Fluid and Electrolyte Mgt in

Pediatric Surgical Patients

Moderator: Dr. Maru
(consultant pediatric surgeon)
Presenter: Dawit. A (GSR III)
Aug. 2021
SPHMMC
 Outline

• Introduction
• Fluid and electrolyte homeostasis
• Fluid management
• Electrolyte management
• Acid-base disorders
• References

2
 Introduction
• Understanding fluid & electrolyte physiology and mgt of
pediatric surgical patients is very important ... !
• “children are not little adults”
• The margin between dehydration and fluid overload is
small. So it needs meticulous attention to their
hydration status.
• Surgical conditions that predisposes patients to
dehydration.
• IHPS, Gastroschisis, Short-gut syndrome, Congenital
diaphragmatic hernia and associated PHT
3
Fluid compartments
• TBW; in 2 main compartments
‘ECF & ICF’.
• TBW as a % of body wgt & its
ECF/ICF ratio vary with age, sex &
fat content.
• Fetus at 12 wks’; ~ 94% of
body wgt
• Infants at;
• full term; ~ 80% of body wgt
• 1st wk; ~ 75% of body wgt
• 1 year; ~ 60 – 65% of body
wgt 4
5
Electrolyte composition

• The serum
concentration of an
electrolyte, w/c is
measured clinically,
doesn’t always
reflect the body
content.
• Example; K and
Ca

6
 Fluid and electrolyte homeostasis

• The ICF & ECF are in osmotic equilibrium. Clinically,

the primary process is usually a change in the
osmolality of ECF (Plasma Osmolality).
Osmolality = 2 × [Na] + [glucose]/18 + [BUN]/2.8
• The plasma osmolality is tightly regulated within 285–
295 mOsm/kg. Osmoreceptors in the hypothalamus
sense the plasma osmolality and regulate; ADH and
RAAS.
• Na balance is considered the main regulator of volume
status. The most important determinant of renal Na
excretion is the volume status. 7
 Fluid and electrolyte
homeostasis in Sources of water loss
newborn’s; factors … !
• Gestational age • Sensible water loss;
• Physiologic diuresis (renal)
• Immaturity of neonatal • Insensible water loss;
kidney • Skin (70%); excess in
• Insensible water losses; preterm & LBW infants
Factors: GA, radiant for 2 reasons .. !
warmers, fever, ↑ RR. • RT(30%); ~ ½ of
• Inability to independently insensible losses in term
access H2O. infants
• Other fluid losses; stool, 8
 Fluid management
• In pediatric surgical patients, fluid administration is
necessary
• to maintain adequate tissue perfusion and cellular
metabolism,
• to acutely replete GI, renal, blood losses and
• to compensate for insensible losses.
• The 3 phases of pediatric fluid Mgt;
• Deficit Rx; Mgt of fluid losses that occur before
patients presentation
• Maintenance Rx; those needed for neutral water
balance 9
 Deficit therapy

• Estimate the severity of dehydration; Mild, Moderate, Severe

• Determine the type of fluid deficit; Isotonic, Hypotonic,
Hypertonic
• Restoration of deficit; restoration of CVS, CNS, & renal
perfusion.
• Severe dehydration; give 10-20 mL/kg NS IV bolus (20-40
mL/kg for pts with low UOP due prerenal causes). Repeat as
needed. Reevaluate Q 15-30min. Once stable, the remaining
deficit corrected slowly (over ~1-2 days).
• Moderate and mild dehydration; PO or IV
• Monitoring; by frequent assessment of fluid status … !
10
• The ideal type of for resuscitation remains unclear;
• Crystalloid (NS, LR) vs Colloids (albumin, dextran); Both
are widely used in the fluid resuscitation of critically ill
children. No evidence suggested that resuscitation with
colloids has mortality benefit … !
• NS vs RL; the most commonly used for resuscitation.
• Hypertonic (3%) saline is effective in the mgt of Burns,
Seizures due to severe hyponatremia and elevated ICP (in
TBI)

11
 Maintenance therapy
• Maintenance therapy; replacing the losses under ordinary
conditions (sensible and insensible losses). Urinary losses; ~ 2/3rd
of total MF.
• MF requirements are calculated based on the lean body weight.
• 1st wk of life;

• Then after; Holliday and Segar formula (100-50-20 rule and/or

4-2-1 rule)
12
 MF requirement; 1st week of life (in
mL/kg/day)
• The recommended initial IV fluid: D10W. (4-6 ml/kg/min).
• Term babies and babies with birth wgt > 1500 grams.
• Day 1: 60-70 ml/kg/day D10W. Day 2-7: increase by 15-20 ml/kg/day till a
max. of 150 ml/kg/day. Add Na after 48 hrs of age & K? (2/3rd D10W + 1/3rd
NS).
• Preterm babies and babies with birth wgt 1000-1500 grams.
• Day 1: 80 ml/kg/day D10W. Day 2-7: increased by 10-15 ml/kg/day till a max.
of 150 ml/kg/day. Add Na after 48 hrs of age & K? (2/3rd D10W + 1/3rd NS)
• If the neonate is: Febrile, Under radiant warmer, Under
phototherapy.
• Add 10-30ml/kg/day on top of MF

13
 Maintenance requirement; > 7th day
• For infants >32 wks or >1.5 kg wgt GA, For neonates
>1 wk of age; For children > 2 months of age and
beyond, the daily fluid requirements can be calculated
using Holliday and Segar formula
•Body
The weight
recommended
Fluid initial IV fluidper
requirement is day
NS/RL.

0-10 kg 100 mL/kg/day

Or (4 mL/kg/hr)
11-20kg 1000 mL/day + 50 mL/kg/day for each kg b/n
11 - 20 kg
Or (40 mL/hr + 2 mL/kg/hr for each kg b/n 11 -
20 kg)
>20kg 1500 mL/day + 20 mL/kg/day for each kg b/n 14
 Replacement therapy

• Replacement therapy; part of perioperative care.

• Blood losses; replace max. ABL with crystalloid in a 3:1
ratio.
• Allowable blood loss … !
• 3rd space losses; fluid replacement based on anticipated
amt of fluid loss;
• Superficial and minor surgeries (e.g. hernia operation); 1-
2ml/kg/hr
• Intrathoracic surgery; 4-7 mL/kg/hr
• Abdominal surgery; elective bowel resection; 6-10 mL/kg/hr,
Emergency surgeries; 15-20 mL/kg/hr, Laparotomy for NEC; 15
50 mL/kg/hr.
 Specific clinical scenarios

• Pyloric stenosis;
• In cases of clinical dehydration, rehydration before
surgery. Defer the surgery until the child is adequately
rehydrated.
• MF ~ 1.5×. Slow resuscitation … ! Then When UOP is
adequate, add 10-20 mEq/L of KCl.
• Abdominal wall defects; Gastroschisis VS
Omphalocele
• Eviscerated bowel covered with moist nonadherent
sponges & plastic bag.
• Initial resuscitation; 10 - 20ml/kg bolus NS/LR + MF (~
2.5×). Additional fluid until UOP is established. Ongoing16
 Perioperative care
• Preoperatively; In general, preoperative IV fluid is
seldom necessary.
• Assess the patient hydration status
• Recommended preop. NPO times; 2 hrs clear liquids, 4
hrs breast milk, 6 hrs non-human milk or infant formula,
8 hrs solid food.
• Intraoperatively; give calculated fluid (NS/RL); MF +
anticipated 3rd space loss + Estimated blood loss +
Insensible losses.
• Postoperatively;
• Early oral intake; to avoid dehydration. If delayed give 17
fluid.
 Electrolyte management
• Electrolytes account for ~ 95% of the solute molecules
in body water. It is usually gained and lost in a
relatively equal amount to maintain balance.
• For infants receiving IV fluids, these electrolytes
generally are not given during the first 48 hours after
birth because of the relatively volume-expanded state,
and normal isotonic losses during the first days of life.
• Urine flow should be adequate before potassium is
added.

18
19
• Depending on the volume, electrolyte losses from
gastric or ileostomy drainage can be large, with
electrolyte composition:
• Because the
constituents of these
losses often
substantially differ
from the composition of
MF; it is recommended
to replace large-volume
stoma or other fluid
losses with a
physiologic equivalent
fluid.
20
• Gastric …
 Normal daily electrolyte requirements
Normal serum RR
• Sodium = 136-145 mEq/L
(136-145 mmol/L)
• Potassium = 3.5-5.0
mEq/L (3.5-5.0 mmol/L)
• Magnesium = 1.8-3.0
mg/dl (0.8-1.2 mmol/L)
• Calcium = 8.5-10.5 mg/dl
(2.2-2.6 mmol/L)
• Phosphorus = 3.0-4.5
mg/dl (1.0-1.4 mmol/L)
• Chloride = 98-106 mEq/L
(98-106 mmol/L)

• Generally maintenance requirements for Na, K, & Cl is

~2-3 mEq/kg/day. 21
 Electrolyte disturbance

• Electrolyte imbalances could be caused by:

• Abnormal losses (vomiting/diarrhea)
• Disproportionate IV supplementation
• Disease states: renal diseases
• Common electrolyte disturbances;
• Sodium
• Potassium
• Calcium
• Magnesium
22
 Sodium
Hyponatremia
• Sodium is unique among electrolytes because water
balance, not Na balance, usually determines its
concentration. RR: 136-145 mEq/L
• Hyponatremia; Na <135 mEq/L. (Mild 130–135, Mod. 125–
129, Sev. <125)
• Hyponatremia can be classified based on serum
osmolality and volume states (extracellular fluid
volume).
• Hypertonic hyponatremia (high serum osmolality);
23
Hyperglycaemia, mannitol
• Causes; of Hypotonic hyponatremia
• Hypovolemic; RF with high UOP, Diuretics, Addison
disease, Cerebral salt wasting syndrome, Diarrhea,
Burn, 3rd space loss (peritonitis, ascites).
• Euvolemic; SIADH, Iatrogenic excess adm. of hypotonic
fluids.
• Hypervolemic; RF with low UOP, CHF, Cirrhosis, NS
• Symptoms; depends on mainly the onset
hyponatremia.
• Acute drops vs Gradually drop
• N, V, muscle weakness, lethargy, headache 24
 Mgt
Hyponatremia
• Treatment ranges from fluid restriction (asymptomatic)
to hypertonic saline administration (severe cases).
• Na deficit=(desired Na-measured Na) x TBW (TBW = 0.6
x Wgt in Kg)
• Acute, Severe symp. hyponatremia, ICP; Give 5
mL/kg 3% NS (bolus);
• ↑ serum Na by 1–2 mEq/L/hr, until an ↑ of 4–6 mEq/L
has been reached within 6 hrs. No recommended max.
correction rate in the first 24 hrs
• Chronic hyponatremia; Give 5 mL/kg of 3% NaCl
(infusion);
• ↑ serum Na by no > 0.5 mEq/L/hr, until an ↑ of 4–6 25
mEq/L has been reached within 24 hrs with max.
 Hypernatremia

• Serum Na >145 mEq/L. Serum osmolality is always

increased.
• Causes;
• Water deficit; hypovolemic hypernatremia (hypotonic
fluid loss) or Euvolemic hypernatremia (pure water
deficit).
• Diarrhea, Excessive sweating, Dehydration, Insufficient
water intake/poor feeding in newborn’s; DI (central or
nephrogenic).
• Sodium excess; hypervolemic hypernatremia
26
• Symptoms; Acute Vs Chronic hypernatremia.
• Acute hypernatremia; Excessive thirst, decreased
salivation, dry sticky mucous membrane,
• Irritability, restlessness, weakness, lethargy, muscular
twitching, fever, a high pitched cry, tachypnea, low BP
• With Na >160 mEq/L; intracranial hemorrhage
(confusion, seizures coma)
• Chronic hypernatremia; Sxs are usually less severe
and nonspecific, due cerebral adaption to chronic
hypernatremia.
27
 Mgt
Hypernatremia
• Replacing free water deficit (FWD) with sterile water
PO or D5W IV.
• FWD (L) = ((measured Na/desired Na)-1) x TBW (L)
• In hypovolemic pts restore hypovolemia with isotonic
solutions (NS) before correcting hypernatremia.
• Acute hypernatremia; replace FWD within < 24 hrs.
• ↓ serum Na+ by no > 1–2 mEq/L/hr. Max. 15 mEq/L/day; to
prevent cerebral edema.
• Chronic hypernatremia; replace FWD over 48-72
hours. 28
 Potassium
Hypokalemia
• Potassium is an important electrolyte in maintaining
RMP of excitable tissues (heart and skeletal muscles).
RR: 3.5–5 mEq/L.
• Hypokalemia; K+ < 3.5 (Mild: 3.0-3.5; Mod: 2.5-2.9;
Sev. <2.5)
• Causes;
• GI losses; Diarrhea, Vomitting ... !
• Renal losses: RTA type I, Genetic tubular disorders
(Bartter & Gitelman syndrome), Diuretics,
Glucocorticoids, Hyperaldosteronism,
29
Hypercortisolism, Hypomagnesemia.
• Symptoms; rarely seen with K+ levels >3.0 mEq/L.
• Muscle weakness; progress from lower extremities to the
trunk, upper extremities ultimately leading to paralysis and
respiratory failure.
• Others; cramps, fasciculations, rhabdomyolysis, ileus.
• Cardiac arrhythmia; premature atrial and ventricular
beats, and ventricular fibrillation, worsens digitalis-induced
arrhythmias.
• ECG changes; T wave flattening, ST depression, QT
prolongation, U waves, "torsades de pointes".
30
 Mgt
Hypokalemia
• Severe hypokalemia, acute setting, high risk of recurrence:
• High-dose IV KCl (max. 0.3 mEq/kg/hr or max. of 10mEq/L through
peripheral line; or 0.5-1 mEq/kg/hr or max. of 40mEq/L through a
central line)
• Appropriate monitoring in ICU
• Moderate hypokalemia: Oral or IV repletion.
• Mild hypokalemia: Rx underlying conditions (GI fluid losses),
dietary K+ intake, Oral supplementation (2 - 4 mEq/kg/day)
• In refractory hypokalemia think of concurrent
hypomagnesemia.
31
 Hyperkalemia

• Serum K+ > 5.5 mEq/L.

• Causes:
• Excessive K+ intake (iatrogenic IV overload, blood
transfusion), rapid cell death (exercise, massive
trauma, rhabdomyolysis), hemolytic crisis, tumor
lysis syndrome.
• Prolonged diarrhea (metabolic acidosis), DM, RF.
• Rarer causes; congenital adrenal hyperplasia,
adrenal insufficiency, medications (K+sparing
diuretics).
32
•
• Symptoms; The heart and skeletal muscle are
especially vulnerable to hyperkalemia, due to the role
of K+ in membrane polarization.
• Muscle weakness or paralysis; paresthesia and tingling.
• Cardiac conduction abnormalities; ECG changes:
• Peaked T waves, shortened QT interval (mild)
• PR prolongation, flattened P wave, wide QRS complex
• BBB, ventricular fibrillation and asystole (in severe cases)
• Hyperkalemia should be considered in the setting of
cardiac arrest of unknown etiology in a child.
33
 Mgt
Hyperkalemia
• Cardiac membrane stabilization; 10% Ca gluconate
• 100 mg/kg IV over 5-10 mins. Rpeate after 5 mins if ECG
changes persist.
• Intracellular K+ shifting; Short acting insulin ±
glucose, SABA
• RI 0.05 IU/kg IV + D10W 2ml/kg load; then 0.1 IU/kg/hr + 2-
4 ml/kg/hr).
• Nebulized albuterol (10 mg); as an adjunct to insulin
• Enhanced K+ elimination; Na polystyrene sulfonate
“kayexalate”, Na bicarbonate (1-2 mEq/kg IV over 5-10
minutes), Loop diuretics, Hemodialysis 34
 Calcium
Hypocalcemia
• Ca is the most abundant mineral in the body. Relatively
common … !
• Hypocalcemia; total < 8.5 mg/dl or ionized/free < 4.65 mg/dl.
• Causes;
• 24-48 hrs: asphexia, maternal hyperparathyroidism,
anticonvulsant Rx, DM
• 1st wk postnatal: Hypoparathyroidism (autoimmune, congenital),
hyperphosphatemia, Hypomagnesemia, Vit. D deficiency
(malnutrition & malabsorbtion, lack of sunlight exposure, RF)
• Others; multiple blood transfusion, Acute necrotizing pancreatitis
• Factitious hypocalcemia … !
35
• Symptoms; in the acute situations; due increased
muscular excitability: tetany + Chvostek’s sign +
Trousseau’s sign.
• Mild and/or chronic hypocalcemia; mild NM irritability;
• Muscle twitches and cramping, tingling around
mouth or fingers (paresthesia)
• Apnea, irritability, lethargy, feeding intolerance, abd.
distention
• Severe and/or symptomatic hypocalcemia;
• Carpal/pedal spasms.
• Seizure, hyperreflexia, jitteriness, laryngospasm, 36
 Mgt
Hypocalcemia
• Severe or symptomatic hypocalcemia (serum Ca < 7.5 mg/dl)
• Patients should be placed on an ECG monitor as
arrythmias or cardiac arrest can occur during calcium
replacement.
• IV Ca (10% Ca gluconate or 10% CaCl2); 1 mL/kg/dose
over 5-10 mins. Once seizure subsides Ca replaced in 200-
500 mg/kg/day as a continues infusion or in 4 divided
doses.
• Mild and/or chronic hypocalcemia (7.6-8.4 mg/dl)
• Oral Ca supplementation (Ca citrate, Ca gluconate).
• Treat underlying cause.
37
 Hypercalcemia
• Hypercalcemia; total > 10.5 mg/dL or ionized > 5.25
mg/dl. Mild (10.5-12), moderate (12-15), severe (>15).
It is very uncommon … !
• Causes; iatrogenic (vitamin D overdose, deficient
dietary PO4 intake); inborn error of metabolisms; less
common causes (tertiary hyperparathyroidism,
hypercalcemia of malignancy), diuretic therapy.
• Symptoms; mostly asymptomatic but can present with
GI Sxs (N, V, poor feeding), failure to thrive,
dehydration, lethargy, hypotonia, psychological &
emotional Sxs (confusion, delirium, emotional changes,38
 Mgt
Hypercalcemia
• Focus on treating underlying cause; by eliminating
possible causes such as thiazide diuretics and
hypervitaminosis
• Serum PO4 should be checked and corrected first.
• Increase urinary excretion: Hydration with NS 10-20
mL/kg bolus ± Lasix
• Decrease intestinal absorption: Increased dietary PO4
• Decrease bone resorption; calcitonin or bisphosphonates.
• Dialysis; in severe cases.

39
 Magnesium
Hypomagnesemia
• Hypomagnesemia; serum Mg < 1.5 mg/dl. It is unusual … !
• Causes; may be GI or renal losses, dietary deficiency,
chronic diuretic use.
• Symptoms; often reflective of associated electrolyte
abnormalities (hypocalcemia & hypokalemia). Anorexia,
weakness, lethargy, tremor.
• ECG changes; T wave flattening, long QT syndrome and "torsades
de pointes," esp. in conjunction with hypokalemia, VF.
• Treatment; Oral or IV Mg adminstration.
• Oral (1st line Rx); 6-15 mg/day of elemental Mg in 4 divided doses.
• IV; 0.2-0.4 mEq/kg/dose slowly over every 4-6 hrs (if symptomatic).
40
 Hypermagnesemia
• Hypermagnesemia; serum Mg > 3 mg/dL.
• Causes; usually 2° to maternal Mg Rx (for pre-
eclampsia, preterm labor)
• Symptoms; usually appear at Mg level > 4.5 mg/dl.
Hypermagnesemia inhibits acetylcholine release at the
NMJ
• Hypotonia, weakness, hyporeflexia, hypotension,
apnea and vasodilatation with marked flushing.
Paralysis in severe cases.
• Treatment; Usually supportive until Mg level
41
gradually falls.
 Acid-base disorders
• Acid-base disorders are a group of conditions
characterized by changes in the concentration of H+ or
HCO3-, which lead to changes in the arterial blood pH
(acidosis or alkalosis and have a respiratory or
metabolic origin)
• Acidosis caused by a primary ↓ in HCO3- conc.; metabolic
acidosis
• Alkalosis caused by a primary ↑ in HCO3- conc.; metabolic
alkalosis
• Acidosis caused by a primary ↑ in PCO2; respiratory
acidosis 42
 ABG analysis interpretation

1. Blood pH (RR: 7.35-7.45); pH < 7.35: acidosis; pH > 7.45:

alkalosis
2. PaCO2 level (RR: 33–45 mm Hg)
• pH and PaCO2 change in the opposite direction: respiratory
disorders
• pH and PaCO2 change in the same direction: metabolic
disorders. In metabolic acidosis, anion gap calculation helps
to reach to a precise diagnosis.
3. HCO3- level (RR: 22–28 mEq/L): Low, Normal, High
4. Mixed acid-base disorder if:
• pCO2 or HCO3- is abnormal and pH is normal
• pCO2 and HCO3- shift towards acidosis or alkalosis 43
 ABG
analysis
interpreta
tion

44
 Compensatory response

• The lungs play a compensatory role in the cases of metabolic acidosis

and alkalosis
• In metabolic acidosis, hyperventilation occurs to blow off excess CO2
and thus carbonic acid, although this cannot completely compensate for
the acidosis.
• In metabolic alkalosis, hypoventilation occurs to retain CO2 and thus
carbonic acid, although this cannot completely compensate for the
alkalosis.
45
 Respiratory acidosis

• Alveolar hypoventilation → ↑ CO2 retention → ↑ PaCO2

• Renal compensation: Increased excretion of H+ and
NH4+ and increased reabsorption of HCO3–.
• Acute respiratory acidosis: Renal compensation has
not yet occurred (intracellular fluid buffering only).
Each 10 mmHg ↑ in Paco2 leads to a 1 mEq/L ↑ in
HCO3– and a 0.08 ↓ in pH.
• Chronic respiratory acidosis: Renal compensation
has occurred. Each 10 mmHg ↑ in Paco2 leads to a 3.5
mEq/L ↑ in HCO3– and a 0.03 ↓ in pH.
46
• Causes;
• Decreased CO2 exchange; Airway obstruction, COPD,
asthma, ARDS, acute lung diseases (pneumonia,
Pulmonary edema, empyma, PTX);
• Respiratory muscle weakness; MG, GBS, ALS, and MS
• CNS respiratory center depression (due to inhibition
of the medullary respiratory center); Narcotic over
dose, opiates, sedatives, and anesthetics
• Treatment; treat the underlying cause, adequate
ventilation (O2 administration), treatment of secondary
change
47
 Respiratory alkalosis

• Alveolar hyperventilation (↑ RR) → ↑ CO2 washout → ↓

PCO2
• Renal compensation: Decreased excretion of H+ and
NH4+, decreased reabsorption of HCO3–.
• Acute respiratory alkalosis: Renal compensation has
not yet occurred (intracellular fluid buffering only). Each
10 mmHg ↓ in Paco2 leads to a 2 mEq/L ↓ in HCO3 – and
a 0.08 ↑ in pH.
• Chronic respiratory alkalosis: Renal compensation has
occurred. Each 10 mmHg ↓ in Paco2 leads to a 5 mEq/L
↓ in HCO3– and a 0.03 ↑ in pH.
48
• Causes;
• Fever, pulmonary embolism (PE), high altitude (due
to hypoxemia and increased ventilation rate)
• Pain or anxiety, salicylate toxicity, pregnancy,
cirrhosis (due to direct stimulation of the medullary
respiratory center).
• Others; CHF, Sepsis, Hypothalamic lesion
• Treatment; treat the underlying cause, direct
treatment of the hyperventilation as needed, Sedation

49
 Metabolic acidosis

• Loss of HCO3- Or Increased production/ingestion of H+

• Causes;
• Normal anion gap; GI loss of HCO3- (Diarrhea, GI
fistula, intestinal stoma), RTA. HARD-ASS
• Increased anion gap; Lactic acidosis (most common
causes), DKA, Renal insufficiency, Exogenous organic
acids. MUDPILES.
• Treatment; treat the underlying cause, Restore adequate
tissue perfusion with volume resuscitation, Na bicarbonate
… !, Correct electrolyte disturbance.
50
 Metabolic alkalosis

• Loss of H+ Or Increased production/ingestion of HCO3-

• Causes;
• Chloride responsive; Persistent vomiting, Pyloric
stenosis, GOO, Prolonged gastric suction, Diuretics
• Chloride resistant; Hyperaldosteronism, Cushing
syndrome, Genetic tubular disorders (Bartter & Gitelman
syndrome), Cystic fibrosis
• Treatment; treat the underlying cause, volume
replacement with isotonic saline), Acetazolamide (for
bicarbonate excess), Correct electrolyte disturbance (K+
administration once adequate OUP is ensured).
51
 References

• Ashcraft pediatric surgery 5th edition.

• Nelsone pediatrics 20th edition.
• NICU Guideline TAH, AAU; 2021
• UpToDate; 23rd

52
Thanks … !

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