The computer at my workplace turned into a disaster and I couldn’t do any work at all. Harddisk rosak, motherboard rosak, everything rosak. And at that point of time, I wonder why I even received the computer as a work computer in the first place when it was so defective.
At this point of my life, I really don’t care if my lines are clean at all. Seeing clean lines of other people’s work looks amazing but drawing clean lines myself gives me a sense of … ickyness? Like its too clean and empty looking.
Also, infant warmers are cozy =)
The number of times I’ve slept like this while waiting for that ‘BABY OUT’ is…. Ugh. I’ve even slept under baby warmers when I was an anesth resident while waiting for the surgeon who forever cannot find the appendix. If I’m not head banging at the ventilator, then I’m hibernating at the open hood infant warmers. I know some will argue that it’s ‘not sterile‘ but you can always discard the layer of napkins for a fresh sterile one.
Also, you think the one doing the surgery is very sterile meh? Look at all these wound breakdowns.
Also, if baby ever gets colonized by my skin flora, I can bet that they will be a super baby – with all this ESBL, MRSA, VRSA, CRE, VRE etc.
This time we’ll talk about infusion feeding and safe increments.
Honestly though, I don’t expect house officers to know about safe increments but if they do, then that’s a thumbs up from me. Because I myself was never taught how to calculate safe increments when I was in residency and I only knew how to calculate it when I become a medical officer.
But it certainly helps if you know the concept.
I’m to lazy to write any more questions but I’ll type it here so that you can practice and understand how to calculate in other settings.
Premature baby at 28 weeks + 2 days. Birth weight of 0.89 kg, current weight: 0.91 kg. Currently at Day 13 of life, corrected age: 30weeks + 0 days. Baby currently on infusion pump feeding: 8 cc/h x3 rest one hour (TF: 158 cc/kg/d). What would be your safe increment for the next day?
Term baby at 38 weeks +6 days, delivery complicated with HIE and has feeding intolerance during the first 3 days. He is currently at 86 HOL and was plan to start feeding gradually. Birth weight is 3.2 kg. How would you start feeding?
Premature second twin baby at 31 weeks + 3 days. Birth weight of 1.1 kg current weight of 0.88 kg at Day 5 of life. Bolus 2 hourly feeding during the early neonatal period was wrought with feeding intolerance. Plan to start infusion pump feeding with SI of 20 cc/kg/d. How long would it take to achieve full feeding of TF 120 cc/kg/d?
Using the same patient from Question (3), it was decided that the feeding will be increased by 1.5 cc every day. Is this feeding considered safe? With a feeding of 1.5 cc/day, how long would it take for the baby to achieve full feeding?
Answer for Question (1): use current weight of 0.91 kg
Increase feeding to 9cc/h x3 rest one hour of infusion pump feeding tomorrow (TF: 178 cc/kg/day)
If plan for a higher SI, then SI 25cc/kg/d =
SI 25cc/kg/d = 1.26cc/day ~ 1.2 cc/day = SI = 23.7 cc/day.
Hence, feeding tomorrow would be: 9.2 cc/h x3,rest one hour = 182 cc/kg/day)
If plan for maximum SI, then SI 30 cc/kg/d =
SI 30cc/kg/d = 1.51 cc/d ~ 1.5cc/d
Hence feeding tomorrow would be 9.5 cc/h x3, rest one hour = 188 cc/kg/day)
Answer for Question (2) – Use birth weight of 3.2 kg
TF at 86 hours of life (Day 4) = TF 150 cc/kg/d (TR = 20 cc/h)
SI 20 cc/kg/d = 20cc/kg/d x3.2 kg /8 feeding = 8 cc/day
Plan: Start feeding 8 cc/3 hourly as extra. If tolerate x3, may include in total fluid (TF).
If include in total fluid, cut down IVD from 20cc/h to 17.3 cc/h 1/5NSD10%
If plan for a higher SI, then SI 25cc/kg/d =
SI 25cc/kg/d = 10cc/day
Start feeding 10 cc/3 hourly as extra. If tolerate x3, may include in total fluid (TF).
If include in total fluid, cut down IVD from 20cc/h to 16.7 cc/h 1/5NSD10%
If plan for maximum SI, then SI 30 cc/kg/d =
SI 30cc/kg/d = 12cc/d
Start feeding 12 cc/3 hourly as extra. If tolerate x3, may include in total fluid (TF).
If include in total fluid, cut down IVD from 20cc/h to 16 cc/h 1/5NSD10%
Answer for Question (3) – Use birth weight of 1.1 kg
SI 20cc/kg/d = 1.22cc/day ~ 1.2 cc/d
TF: 120cc/kg/day (full feeding) = 7.3 cc/hx3 rest one hour
How many days = 7.3 cc/h divided by 1.2 cc/day = 6.1 days
It will take 6.1 days for baby to achieve full feeding to TF 120 cc/kg/d
So in the meantime, you might want to consider inserting PICC for TPN
Answer for Question (4) – Use birth weight of 1.1 kg
1.5cc/day x18 feedings / 1.1 kg = SI: 24.5 cc/kg/day
Yes, it falls within the range of 20 – 30 cc/kg/d – it is considered SAFE
TF: 120cc/kg/day (full feeding) = 7.3 cc/hx3 rest one hour
How many days = 7.3 cc / 1.5 cc = 4.9 days ~ 5 days
It will take roughly ~ 5 days for baby to achieve full feeding to TF 120 cc/kg/d
Again: different centres employ different protocols. Some centres use a range of 15 – 30 cc/kg/day for safe increment, some even go as high as 40 cc/kg/d. It depends on the practice.
Also, in the centre which I used to practice, a feeding of TF 120 cc/kg/d is considered full feeding. Which means, at this amount of milk, the baby is unlikely to get hypoglycemia, so you don’t need to top off the remaining 30cc/kg/d with intravenous fluid. Because placing a baby on intravenous fluid requires canulation for IV access, you will need to poke the baby just for fluids (which will only be used for one day give or take) which is painful and stressful to them! And what are the chances that you can get access with a single attempt? We try to minimize blood taking and line setting as much as possible in babies and children.
In fact, again, in the centre where I used to practice, if the IV line is not working, even at a TF of 100cc/kg/day, we would not recanulate (unless baby requires a line for antibiotics or other medications) but we will prefer to check the serum glucose regularly because it is less painful then attempting cannulation. This is provided that the baby has no previous issues with sugar control.
Again, and I stress it again: Follow your hospital’s protocol.
The fun starts when we begin calculating total parenteral nutrition (TPN).
Let’s move on to something completely different than my usual video games and artsy (lol) stuff.
I used to be a former paeds medical officer. Emphasize on the former. I didn’t like it at all because it’s something that I was forced to do rather than something that I would consider but I would be lying if I told you I didn’t learn a bunch of stuff that was useful.
And it’s appalling each time working with house officers (or even medical officers, for that matter) who enter and then leave paeds without learning anything. Like, I get it – paeds is difficult – I truly believe it is, but it’s not something insurmountable. Sometimes they even courageously go for offtag assessment without knowing how to calculate fluids. If you’ve ever had the experience of working in the paeds department, fluid management is the bread and butter of paeds, especially if you assigned to the NICU. Larger children can feed themselves unless they are fasting, but babies will just cry for milk and unless you know how to calculate how much, you won’t know how much to give.
Please note yeah, cc = mls. Cubic centimetre is the same as milliliter so stop fuming when I use them interchangeably. It’s literally the same measurement.
We’ll proceed with advance fluid calculation in the next episode – where we’ll talk about total parenteral nutrition, tube and cup feeding, infusion feeding, and safe increments.
Later, if this is helpful, I can also describe about inotrope regimes and sedation.
Please understand that this fluid regime is according to my previous hospital policy/protocols– different hospital has a bit of a different policy/protocol. Like my previous hospital that I worked with have a +15 cc/kg/d prem total fluid increment regime (60mls/kg/d, 75 mls/kg/d, 90 mls/kg/d, 105 mls/kg/d, etc). But my latest hospital used +20 cc/kg/d. Honestly, I prefer the latter because you can increase the fluids faster but you need to learn to adapt to different situation when the time calls for it.
Also, my previous hospital absolutely abolished rounding up the fluids. Like say if you calculate the feeding is 42 cc/3hourly cup feeding, you will have to give 42 cc/3 hourly, nevermind the fact that there is no way to measure 42 cc in a cup. But the other hospital that I work with allows you to round up the fluids so long as the baby is not premature or have any gut issues.
You can use whatever I put here but do not claim them as yours and do not sell them. You don’t even need to credit me or anything because this isn’t something novel – all this is common knowledge in paeds. I make these notes for free to help people struggling in paeds in any way I can. Selling stuff that I made or claiming them as yours when you don’t have a shred or artistic taste is the definition of a maggot.
I’d be lying if I told you that while working as a paeds medical officer it wasn’t totally fun and intellectually stimulating. But I guess it was fun because of the company that I kept. Some other factors just deterred me from pursuing paeds.
You know – like crazy, psychotic parents nowadays who like to ride the bandwagon for whatever nonsense fad is going around at the current time.
Okay, bye~ Have a nice day.
I’ll tag this as medic from now on so it’s easier to find rather than shift through all my nonsense.
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