Ewl, HU,lWl DrN~/0/wwn/. 27 ( I99 I ) l-7 Els&ier Scientific Publishers Ireland Ltd.
EHD 01 I95
Extracellular volume in preterm infants: influence of gestational age and colloids Henrik Ekblad”, Pentti Keroa, Stanley G. Shafferb and Heikki Korvenrantaa ‘Department of Pediatrics, University of Turku. Turku (Finland) and ‘Perinatal Pediatrics, St. Luke’s Hospitul. Universit~~of’Missouri S~~/IOO/ of Metiicitw. Ktrmtrs Cif~,. MO ( L’.S. A. , (Received
5 May 1991; revision
received
30 June
1991; accepted
2 July 1991)
Summary We assessed the effect of fresh frozen plasma (FFP) on extracellular volume (ECV) during the first few days of life in two groups of preterm infants, group 1 (gestational age < 30 weeks) and group 2 (gestational age 30-34 weeks). The infants were randomly assigned to one of two treatment groups, one receiving FFP, the other not; group 1 infants receiving no treatment (n = 8) and group 1 infants receiving FFP (n= ll), and group 2 infants receiving no treatment (n = 9) and group 2 receiving FFP (n = 10). FFP was given at a dose of 10 ml/kg daily during a two-hour period for the first three days of life. ECV was measured on day 1 before FFP was given and on day 4 by the distribution of bromide. There was a significant correlation between birth weight and initial ECV (r = 0.85, P C 0.001). In group 1 ECV was significantly higher than in group 2 (P c 0.02). In group 1 receiving no treatment mean weight loss and mean decrease in ECV were equal (84 g/kg and 78 ml/kg, respectively), but no correlation between the two parameters could be found (r = 0.68, P = 0.06). In the other study groups, mean weight loss was higher than mean decrease in ECV, with no correlation between weight loss and change in ECV. In group 1, no treatment, ECV reduction was 78 f 79 ml/kg (mean f S.D.), whereas in group 1, FFP, ECV increased (13 f 96 ml/kg), indicating that FFP may attenuate ECV reduction in infants with a gestational age < 30 weeks. However, the difference was not significant (P = 0.056). The finding of the present study stresses the importance of careful assessment of hydration, including consideration of sodium balance and alterations of plasma osmolality, and body weight changes, in preterm infants during the first few days of life. Correspondence to: H. Ekblad, SF-20520 Turku. Finland.
Department
0378-3782/91/$3.50 0 1991 Elsevier Published and Printed in Ireland
of Pediatrics
Scientific
Turku
Publishers
University
Ireland
Ltd
Hospital
Kiinamyllynkatu
4-8
2
premature infant; extracellular volume; bromide space; colloids
Introduction In newborn infants great adaptative changes in hemodynamics and water balance take place postnatally. In preterm infants the allowed limits for the changes are not clarified [ 13,161. Postnatal weight loss is usually accepted as physiologic [ 1, 10,131. Weight change may not, however, be a specific enough guideline to define optimal hydration, because of possible volume transfer between intracellular and extracellular compartments as well as between intravascular and extravascular compartments [15]. A stable water and sodium balance is the precondition for a stable intravascular volume and a normal tissue perfusion and oxygenation. In sick preterm infants disturbances in water and sodium balance are common. Fresh frozen plasma (FFP) has been used to prevent intraventricular hemorrhage and the preventive effect has been attributed to a stabilizing effect on the blood circulation [5]. The aim of our study was to evaluate the effects of FFP as a part of the initial fluid therapy on water balance and extracellular volume (ECV) during the first few days of life in two groups of preterm infants, group 1 (gestational age < 30 weeks) and group 2 (gestational age 30-34 weeks). Material and Methods A total of 38 preterm infants, born at the Turku University Hospital between September 1988 and June 1989, was studied. All infants were appropriate for gestational age. The infants were divided into two groups, group 1, gestational age < 30 weeks (19 infants) and group 2, gestational age 30-34 weeks (19 infants). In the two groups the infants were randomly assigned to one of two treatment groups, one receiving FFP, the other not, yielding four study groups, group 1, no treatment (8 infants), group 1, FFP (11 infants), group 2, no treatment (9 infants) and group 2, FFP (10 infants) (Table I). The infants in the two FFP groups received 10 ml/kg FFP daily during a two-hour period for the first three days of life. The first FFP infusion was started before five hours of age. All infants were treated in incubators with maximal air humidity. The diagnoses of the infants are shown in Table I. Fluid intake consisted of intravenous infusion of 10% glucose in all groups. In addition, small oral amounts of 10% glucose and human milk were given from the second day of life. FFP was included in the total daily fluid allowance. Infants in group 1 received more fluid than infants in group 2 according to current recommendations (group 1, 80 ml/kg on day 1 and 150 ml/kg on day 4; group 2, 60 ml/kg on day 1 and 125 ml/kg on day 4) [4]. Sodium input was equal in all study groups; 2 mmohkg daily during days 1 to 3 and 3 mmol/kg daily during days 4 and 5. Infants receiving FFP did not receive additional sodium during days 1 to 3, as FFP contains sodium. Packed red cells were infused to compensate for blood sampling whenever samples were between 5 and 10% of the presumed blood volume (80 ml/kg).
-1eaJI ou ‘1 dnoJ8 UI .sdnoH III?u! [mba SEM @!aM 30 a8mq3 uI?aK ‘E ‘By UTu~oys am (Iqii!aM ql.nq Zy/ltu) ~83 pue (@!aM ql.nq By/S) @!!aM u! a%ueq3 ‘2 dno_B JO 1 dnoJ% u! laq?a p Lap dq a%ay~ IOU pip v@aM lcpoq “03 pavalJo3 ~83 ‘(~0’0 > d) 2 dnoB u! ueyj .‘aqEig ICpuex@~s SBM ~83 ‘1 dnol8 UI ‘i: dnol% JO 1 dnok! u! .Iaq]!a ~83 axIanvu! IOU ptp d+J ‘v hp put? 1 h?p uo qloq sdnol2 mo3 \]I? us a1q”!.ll?A@.@q SBM S83 ‘Z ‘%!J U! UMOIjS S! sdnoA!i /CpI-QS alJJ U! p h?p PUE 1 @I UO ~q@aMdpoq JOJ palDa.LIoDpue ~83 se pamwaur ~33 ‘(1 %J) (100.0 > d Q.0 = A ‘8~ = U) ~83 IE!~U! pue lq$aM qwq uaaMlaq uogelaJlo3 wwy~!u%~st? smt alaqL
‘a’s F uxzam am satyeA ‘aIt! -!.rdolddt! aJaqM suopm~asqo pa.yedun PUBpa.yed 103 ISI-I pm ‘s~s6pm~uoIssa&!a.I .Ieauq ‘SanNXXU paleadar qj!M axIe~.NA30 s~s~~eu~30 pa)s!suo:, ys@me [txysgal~ .[ 1[‘E] lualuo:, lawhi txusyd ‘03 uo!)aaUoD t? ~~6.0 pm ‘wn!Jqg!nba ueuuoa ‘03 uo!valloD E se.0 ‘ap!uroJq 30 uognqgs!p .te~rq~axx~u~~03 uoyamo:, t! s! 06.0 aIaqm ‘ZE6.0 x S6.0 x 06’0 x (a%ueq3 (~/~O”“) ap!tuolq musa~d/(~oum) palayu!tupe apyolq) = sfi3 :SMOIIO~st? pawln3le3 SAM (saa) amds ap!tuolq palDa.kIoD.laylmu aql 30 uogw~s!u!mpe .rai3c u!tu 0~1 pue aJo3aq IClare!paum~ pams~aur S’I?M uog -eJluaxIo~ ap!uIo.Iq etustqd put! @nouaAwu! pa_IaJsgwpe SBM (lav&Mu! uoyyos ~/~ouu.uEPZ f! 30 By/ltu s’z) ap!woJq umpoc; ‘[6‘~‘9] ap!t.uolq umpos 30 uognqgwp aql 6q paWU~~S3 SBM 1233 ‘p hp UO PUE UaA!% Sl?M ddd XOJaq 1 &.I UO ‘%!MJ pamwaw SI?M ~32 .~azLleue ajLIoq3ala zg ueury~aa e q+ki paz@xnz SBM EN-d ‘/(pep pamseaw aJaM (EN-d) suo!wiuamo~ umpos museId pm Iq8iaM lCpoa .p?)!dsoH hyar\yun ny.InL 30 aa~~yxuo~ sxqJ3 aql Lq pahoJdde SBM kpnls aql30 lo3o1old aqL wasuo3 Iwuamd pamo3ur la)3e pauuo3lad alaM sa!pn)s 11~
L s SO’0 ?= IE’L 2’8 8’L
(6-8) (6-L)
855 7 0811 S’I =f 8’IE
E 9 SO’0 7 PZ’L (8-E) 9’9 (8-l) 9’S
SIP =i 18LI 0‘1 F L’IE (6 = “) juaurigaJl ON
60’0
11 11 7 8Z’L (6-Z) (8-l)
80’0
S’S S’P
r (6-I) (6-l)
9 8 IE’L P’9 S’S
(8 = U) luaurleaJ$ ON
iuauma4 dtId
OSE =F EL01 9’1 F 9’LZ
z9z T= LOO1 L’1 -F 8’LZ (II
= 4
Vad saN
Hd vn U!U s U!W I (a8tm) saIo3s .m%dy maw (8) l@‘M
qU!Cj
(=F’M)
Vf)
1 dnoJf)
z dnoJ9
‘snso!lalJe snlmp JO hualod ‘vad fauxolpuds ssam!p Llolw!dsal ‘saa :Hd [~!JaI.Ie [m[!quJn ‘Hd vn :lL&aM qwq ‘Ma %E? pOgElSa8 ‘~9 xqaam Pf-()E a% pXIO!lL?~Sa8 ‘Z dno@ :slaaM 0~ > a% pmo!lelsaP *1 dnoJ9 ,(.a.s r maw) s~ugu! aql JO sasou%xp pw samleaJ pxg13
600 r=0.85 p
EHD 01 I95
Extracellular volume in preterm infants: influence of gestational age and colloids Henrik Ekblad”, Pentti Keroa, Stanley G. Shafferb and Heikki Korvenrantaa ‘Department of Pediatrics, University of Turku. Turku (Finland) and ‘Perinatal Pediatrics, St. Luke’s Hospitul. Universit~~of’Missouri S~~/IOO/ of Metiicitw. Ktrmtrs Cif~,. MO ( L’.S. A. , (Received
5 May 1991; revision
received
30 June
1991; accepted
2 July 1991)
Summary We assessed the effect of fresh frozen plasma (FFP) on extracellular volume (ECV) during the first few days of life in two groups of preterm infants, group 1 (gestational age < 30 weeks) and group 2 (gestational age 30-34 weeks). The infants were randomly assigned to one of two treatment groups, one receiving FFP, the other not; group 1 infants receiving no treatment (n = 8) and group 1 infants receiving FFP (n= ll), and group 2 infants receiving no treatment (n = 9) and group 2 receiving FFP (n = 10). FFP was given at a dose of 10 ml/kg daily during a two-hour period for the first three days of life. ECV was measured on day 1 before FFP was given and on day 4 by the distribution of bromide. There was a significant correlation between birth weight and initial ECV (r = 0.85, P C 0.001). In group 1 ECV was significantly higher than in group 2 (P c 0.02). In group 1 receiving no treatment mean weight loss and mean decrease in ECV were equal (84 g/kg and 78 ml/kg, respectively), but no correlation between the two parameters could be found (r = 0.68, P = 0.06). In the other study groups, mean weight loss was higher than mean decrease in ECV, with no correlation between weight loss and change in ECV. In group 1, no treatment, ECV reduction was 78 f 79 ml/kg (mean f S.D.), whereas in group 1, FFP, ECV increased (13 f 96 ml/kg), indicating that FFP may attenuate ECV reduction in infants with a gestational age < 30 weeks. However, the difference was not significant (P = 0.056). The finding of the present study stresses the importance of careful assessment of hydration, including consideration of sodium balance and alterations of plasma osmolality, and body weight changes, in preterm infants during the first few days of life. Correspondence to: H. Ekblad, SF-20520 Turku. Finland.
Department
0378-3782/91/$3.50 0 1991 Elsevier Published and Printed in Ireland
of Pediatrics
Scientific
Turku
Publishers
University
Ireland
Ltd
Hospital
Kiinamyllynkatu
4-8
2
premature infant; extracellular volume; bromide space; colloids
Introduction In newborn infants great adaptative changes in hemodynamics and water balance take place postnatally. In preterm infants the allowed limits for the changes are not clarified [ 13,161. Postnatal weight loss is usually accepted as physiologic [ 1, 10,131. Weight change may not, however, be a specific enough guideline to define optimal hydration, because of possible volume transfer between intracellular and extracellular compartments as well as between intravascular and extravascular compartments [15]. A stable water and sodium balance is the precondition for a stable intravascular volume and a normal tissue perfusion and oxygenation. In sick preterm infants disturbances in water and sodium balance are common. Fresh frozen plasma (FFP) has been used to prevent intraventricular hemorrhage and the preventive effect has been attributed to a stabilizing effect on the blood circulation [5]. The aim of our study was to evaluate the effects of FFP as a part of the initial fluid therapy on water balance and extracellular volume (ECV) during the first few days of life in two groups of preterm infants, group 1 (gestational age < 30 weeks) and group 2 (gestational age 30-34 weeks). Material and Methods A total of 38 preterm infants, born at the Turku University Hospital between September 1988 and June 1989, was studied. All infants were appropriate for gestational age. The infants were divided into two groups, group 1, gestational age < 30 weeks (19 infants) and group 2, gestational age 30-34 weeks (19 infants). In the two groups the infants were randomly assigned to one of two treatment groups, one receiving FFP, the other not, yielding four study groups, group 1, no treatment (8 infants), group 1, FFP (11 infants), group 2, no treatment (9 infants) and group 2, FFP (10 infants) (Table I). The infants in the two FFP groups received 10 ml/kg FFP daily during a two-hour period for the first three days of life. The first FFP infusion was started before five hours of age. All infants were treated in incubators with maximal air humidity. The diagnoses of the infants are shown in Table I. Fluid intake consisted of intravenous infusion of 10% glucose in all groups. In addition, small oral amounts of 10% glucose and human milk were given from the second day of life. FFP was included in the total daily fluid allowance. Infants in group 1 received more fluid than infants in group 2 according to current recommendations (group 1, 80 ml/kg on day 1 and 150 ml/kg on day 4; group 2, 60 ml/kg on day 1 and 125 ml/kg on day 4) [4]. Sodium input was equal in all study groups; 2 mmohkg daily during days 1 to 3 and 3 mmol/kg daily during days 4 and 5. Infants receiving FFP did not receive additional sodium during days 1 to 3, as FFP contains sodium. Packed red cells were infused to compensate for blood sampling whenever samples were between 5 and 10% of the presumed blood volume (80 ml/kg).
-1eaJI ou ‘1 dnoJ8 UI .sdnoH III?u! [mba SEM @!aM 30 a8mq3 uI?aK ‘E ‘By UTu~oys am (Iqii!aM ql.nq Zy/ltu) ~83 pue (@!aM ql.nq By/S) @!!aM u! a%ueq3 ‘2 dno_B JO 1 dnoJ% u! laq?a p Lap dq a%ay~ IOU pip v@aM lcpoq “03 pavalJo3 ~83 ‘(~0’0 > d) 2 dnoB u! ueyj .‘aqEig ICpuex@~s SBM ~83 ‘1 dnol8 UI ‘i: dnol% JO 1 dnok! u! .Iaq]!a ~83 axIanvu! IOU ptp d+J ‘v hp put? 1 h?p uo qloq sdnol2 mo3 \]I? us a1q”!.ll?A@.@q SBM S83 ‘Z ‘%!J U! UMOIjS S! sdnoA!i /CpI-QS alJJ U! p h?p PUE 1 @I UO ~q@aMdpoq JOJ palDa.LIoDpue ~83 se pamwaur ~33 ‘(1 %J) (100.0 > d Q.0 = A ‘8~ = U) ~83 IE!~U! pue lq$aM qwq uaaMlaq uogelaJlo3 wwy~!u%~st? smt alaqL
‘a’s F uxzam am satyeA ‘aIt! -!.rdolddt! aJaqM suopm~asqo pa.yedun PUBpa.yed 103 ISI-I pm ‘s~s6pm~uoIssa&!a.I .Ieauq ‘SanNXXU paleadar qj!M axIe~.NA30 s~s~~eu~30 pa)s!suo:, ys@me [txysgal~ .[ 1[‘E] lualuo:, lawhi txusyd ‘03 uo!)aaUoD t? ~~6.0 pm ‘wn!Jqg!nba ueuuoa ‘03 uo!valloD E se.0 ‘ap!uroJq 30 uognqgs!p .te~rq~axx~u~~03 uoyamo:, t! s! 06.0 aIaqm ‘ZE6.0 x S6.0 x 06’0 x (a%ueq3 (~/~O”“) ap!tuolq musa~d/(~oum) palayu!tupe apyolq) = sfi3 :SMOIIO~st? pawln3le3 SAM (saa) amds ap!tuolq palDa.kIoD.laylmu aql 30 uogw~s!u!mpe .rai3c u!tu 0~1 pue aJo3aq IClare!paum~ pams~aur S’I?M uog -eJluaxIo~ ap!uIo.Iq etustqd put! @nouaAwu! pa_IaJsgwpe SBM (lav&Mu! uoyyos ~/~ouu.uEPZ f! 30 By/ltu s’z) ap!woJq umpoc; ‘[6‘~‘9] ap!t.uolq umpos 30 uognqgwp aql 6q paWU~~S3 SBM 1233 ‘p hp UO PUE UaA!% Sl?M ddd XOJaq 1 &.I UO ‘%!MJ pamwaw SI?M ~32 .~azLleue ajLIoq3ala zg ueury~aa e q+ki paz@xnz SBM EN-d ‘/(pep pamseaw aJaM (EN-d) suo!wiuamo~ umpos museId pm Iq8iaM lCpoa .p?)!dsoH hyar\yun ny.InL 30 aa~~yxuo~ sxqJ3 aql Lq pahoJdde SBM kpnls aql30 lo3o1old aqL wasuo3 Iwuamd pamo3ur la)3e pauuo3lad alaM sa!pn)s 11~
L s SO’0 ?= IE’L 2’8 8’L
(6-8) (6-L)
855 7 0811 S’I =f 8’IE
E 9 SO’0 7 PZ’L (8-E) 9’9 (8-l) 9’S
SIP =i 18LI 0‘1 F L’IE (6 = “) juaurigaJl ON
60’0
11 11 7 8Z’L (6-Z) (8-l)
80’0
S’S S’P
r (6-I) (6-l)
9 8 IE’L P’9 S’S
(8 = U) luaurleaJ$ ON
iuauma4 dtId
OSE =F EL01 9’1 F 9’LZ
z9z T= LOO1 L’1 -F 8’LZ (II
= 4
Vad saN
Hd vn U!U s U!W I (a8tm) saIo3s .m%dy maw (8) l@‘M
qU!Cj
(=F’M)
Vf)
1 dnoJf)
z dnoJ9
‘snso!lalJe snlmp JO hualod ‘vad fauxolpuds ssam!p Llolw!dsal ‘saa :Hd [~!JaI.Ie [m[!quJn ‘Hd vn :lL&aM qwq ‘Ma %E? pOgElSa8 ‘~9 xqaam Pf-()E a% pXIO!lL?~Sa8 ‘Z dno@ :slaaM 0~ > a% pmo!lelsaP *1 dnoJ9 ,(.a.s r maw) s~ugu! aql JO sasou%xp pw samleaJ pxg13
600 r=0.85 p
