Fluids and Electrolytes

THE BODY FLUIDS - A solution of solvent and solutes - Our body is made up of fluids and solids - About 50-60% of the body weight is WATE - !n a "0 #g adult male$ 60% % "0& '0-'( )iters - *ote that + ,g body weight& + liter of water - The body has two ma-or .ompartments$ o !ntra.ellular o E/tra.ellular The Proportion of Body Fluids The Intracellular Fluid - 0ound inside the .ell surrounded by a membrane - This is .ompartment with the highest per.entage of water in adults The Extracellular Fluid - 0luid found outside the .ells +1 !*TE 2T!T!A) 0)3!4-0ound in between the .ells (1 !*T A5A263)A 0)3!4- 0ound inside the blood vessels and lymphati. vessels 71 T A*26E))3)A 0)3!4-0ound inside body .avities li,e pleura8 peritoneum8 620 Sources of Fluids Fluid Input +1 E/ogenous sour.es - 0luid inta,e- water from foodstuffs - !50 - 9edi.ations - :lood produ.ts (1 Endogenous sour.es - by produ.ts of metabolism - se.retions

Fluid Losses outes of 0luid output - 3rine - 0e.al losses - 2weat - !nsensible losses- s,in ; lungs as water vapor Fluid Dyna!ics The movement of fluids <solutes and solvents= in the body .ompartment 4iffusion Osmosis 0iltration A.tive transport The "oncept of TO#I"ITY - This is the .on.entration of solutes in a solution - A solution with high solute .on.entration is .onsidered as >?@E TO*!6 - A solution with low solute .on.entration is .onsidered as >?@OTO*!6 - A solution having the same toni.ity as that of body fluid or plasma is .onsidered !2OTO*!6 Helpful Hints - !n a >?@E TO*!6 solution8 fluid will go out from the .ell8 the .ell will shrin, - !n a >?@OTO*!6 solution8 fluid will enter the .ell8 the .ell will swell - !n an !2OTO*!6 solution8 there will be no movement of fluid1 DIFFUSIO# - The movement of SOLUTES or parti.les in a solution from a higher .on.entration to a lower .on.entration

!f a sugar is pla.ed in plain water8 the glu.ose mole.ules will dissolve and diffuse distribute in the solution OS$OSIS - The for.e that draws water or solvent from a less .on.entrated solution into a more .on.entrated solution through a semipermeable membrane - The pressure that draws water inside the vessel whi.h is more .on.entrated is .alled Osmoti. pressure - A spe.ial type of osmoti. pressure is e/erted by the proteins in the plasma1 !t is .alled O*6OT!6 @ E2223 E 0!)T AT!O* - The movement of both solute and solvent by hydrostati. pressure8 ie8 from an area of a higher pressure to an area of a lower pressure - An e/ample of this pro.ess is urine formation - !n.reased hydrostati. pressure is one me.hanism produ.ing edema A.tive transport - This is the movement of solutes a.ross a membrane from a lower .on.entration to a higher .on.entration with utiliAation of energy - E/ample is the 2odium-@otassium pump- a primarily a.tive transport pro.ess egulation of :ody fluid balan.e %& The 'idney egulates primarily fluid output by urine formation eleases E*!* egulates sodium and water balan.e (& Endocrine re)ulation 1

egulates primarily fluid intake by thirst mechanism - ADH in.rease water reabsorption on .olle.ting du.t - Aldosterone in.reases 2odium retention in the distal nephron - ANF @romotes 2odium e/.retion and inhibits thirst me.hanism *& +astro,intestinal re)ulation - The B!T digests food and absorbs water - Only about (00 ml of water is e/.reted in the fe.al material per day The ELE"T-OLYTES - Ele.trolytes are .harged ions .apable of .ondu.ting ele.tri.ity and are solutes in all .ompartment - A*!O*2 are *egatively .harged ions$ :i.arbonate8 .hloride8 @O'- 6AT!O*2 are positively .harged ions$ 2odium8 @otassium8 magnesium8 .al.ium >elpful mnemoni.s PI,SO Potassiu! is inside Phosphate is inside Sodiu! is outside "hloride is outside egulation of Ele.trolyte :alan.e %& -enal re)ulation - O..urs by the pro.ess of glomerular filtration8 tubular reabsorption and tubular se.retion - 3rine formation - !f there is little water in the body8 it is .onserved

- !f there is water e/.ess8 it will be eliminated (& Endocrinal re)ulation - >ormones play a role in ele.trolyte regulation - Aldosterone promotes 2odium retention and @otassium e/.retion - ANF promotes 2odium e/.retion arathormone promotes 6al.ium retention and @hosphate e/.retion - !alcitonin promotes 6al.ium e/.retion and @hosphate e/.retion T>E 6AT!O*2 SODIU$ POT.SSIU$ ".L"IU$ $.+#ESIU$ SODIU$ - The 9O2T A:3*4A*T .ation in the E60 - *ormal range is +75-+'5 mECD) - 9a-or .ontributor of plasma osmolarity 03*6T!O*2 +1 parti.ipates in the *a-# pump (1 assists in maintainin" blood #olume 71 assists in nerve transmission and mus.le .ontra.tion Aldosterone in.reases sodium retention A*0 in.reases sodium e/.retion POT.SSIU$ - 9O2T A:3*4A*T .ation in the !60 - *ormal range is 715-510 mECD) - 9a-or ele.trolyte maintaining !650 balan.e 03*6T!O*2 +1 maintains $!F Osmolality (1 nerve .ondu.tion and mus.le .ontra.tion

71 metabolism of .arbohydrates8 fats and proteins Aldosterone promotes renal e/.retion of #E A.idosis promotes e/.hange of #E for >E in the .ell ".L"IU$ 9a-ority of .al.ium is in the bones and teeth *ormal serum range F15-+0 mgDd) 03*6T!O*2 +1 formation and mineraliAation of bonesDteeth (1 mus.ular .ontra.tion and rela/ation 71 .ardia. fun.tion '1 blood .lotting 51 enAyme a.tivation egulation$ %$T absorbs 6aE in the intestine with the help of 5itamin 4 &idney 6aE is filtered in the glomerulus and reabsorbed in the tubules TH in.reases 6aE by bone resorption8 6aE retention and a.tivation of 5itamin 4 !alcitonin released when 6aE is high8 it de.reases 6aE by e/.retion in the ,idney $.+#ESIU$ 2e.ond to #E in the !60 *ormal range is +17-(1+ mECD) 03*6T!O*2 +1 intra.ellular produ.tion and utiliAation of AT@ (1 protein and 4*A synthesis 71 neuromus.ular irritability T>E A*!O*2 "HLO-IDE PHOSPH.TES BI".-BO#.TES 2

"HLO-IDE - The 9AGO Anion in the E60 - *ormal range is H5-+0F mECD) 03*6T!O*2 +1 ma-or .omponent of gastri. -ui.e aside from >E (1 together with *aE8 regulates plasma osmolality 71 parti.ipates in the .hloride shift '1 a.ts as .hemi.al buffer PHOSPH.TES - The 9AGO Anion in the !60 - *ormal range is (15-'15 mgD) 03*6T!O*2 +1 .omponent of bones (1 needed to generate AT@ 71 .omponents of 4*A and *A TH de.reases @O' in blood by renal e/.retion !alcitonin in.reases renal e/.retion of @O' BI".-BO#.TES - @resent both in !60 and E60 - *ormal range- ((-(6 mECD) 03*6T!O* +1 regulates a.id-base balan.e (1 .omponent of the bi.arbonate-.arboni. a.id buffer system

I$B.L.#"E E/"ESS %& HYPE-#.T-E$I. - 9ore than +'5 mECD) - 0luid moves out of .ell .renation - Etiology$I sodium inta,e8 !508 water loss in e/.ess of water8 diarrhea - 2D2%$ dry' sticky ton"ue' thirst $)!t - sodium restri.tion - water restri.tion - 4iureti.s - isotoni. non saline soln1 <45W= or hypotoni. soln - 4esmopressin A.etate for 4iabetes !nsipidus #s) considerations - >istory J diet8 medi.ation - 9onitor 528 )O68 ! and O8 weight8 lung sounds - 9onitor *a levels - Oral .are - initiate gastri. feedings slowly - 2eiAure pre.aution (& HYPE-'.LE$I. - #E more than 510 mECD) - Etiology$ !50 with #E8 a.idosis8 >yperalimentation and #E repla.ement - E6B$ peaked T (a#es and wide K 2 $)!t - # restri.tion <.offee8 .o.oa8 tea8 dried fruits8 beans8 whole grain breads8 mil,8 eggs= - 4iureti.s - @olystyrene 2ulfonate <#aye/alate=

- !5 insulin - :eta ( agonist - !5 6al.ium glu.onate J >ypotension - !5 *a>6o7 J al,aliniAe plasma - 4ialysis #s) consideration - 9onitor 528 urine output8 lung sounds8 6rea8 :3* - monitor # levels and E6B - observe for mus.le wea,ness and dysrythmia8 paresthesia and B! symptoms *& HYPE-".L"E$I. - 2erum .al.ium more than +015 mgDd) - Etiology$ Overuse of .al.ium supplements8 e/.essive 5itamin 48 malignan.y8 prolonged immobiliAation8 thiaAide diureti. - E6B$ Shortened )T inter#al s0sx - Anore/ia - due to de.reased tone in smooth mus.le - nausea8 vomiting and striated mus.le in.oordination - mus.le wea,ness - 0atigue - )ethargy - @olyuria- due to disturbed renal tubular fun.tion - 2evere thirst- due to polyuria .aused by high solute load - @epti. ul.er li,e symptoms- in.reased se.retion of a.id ; pepsin $)!t - 01H% *a6l- dilutes serum 6a8 in.reased e/.retion by inhibiting tubular reabsorption - !5 @hosphate 3

4iureti.s J 0urosemide- diuresis and in.reased 6a e/.retion - !9 6al.itonin- for patients with .ardia. and renal failure edu.es bone resoprtion - !n.reases 6a and phosphorus deposition in the bones - !n.reased e/.retion of 6a and phosphorus - 6orti.osteroids- to de.rease bone turnover and tubular reabsorption esp1 if the .ondition is .aused by a malignan.y - dietary restri.tion <.heese8 i.e .ream8 mil,8 yogurt8 oatmeal8 tofu= 1& HYPE-$.+#ESE$I. - 2erum magnesium more than (1+ mECD) - Etiology$ use of 9g anta.ids8 enal failure8 9g medi.ations - 2D2%$ depressed tendon refle/es8 oliguria8 L $)!t - dis.ontinue 9g supplements - )oop diureti.s - !5 6a glu.onate - >emodialysis #s) !)!t - monitor 52 - observe 4T Ms and .hanges in )O6 - seiAure pre.autions 2& HYPE-"HLO-E$I. - Seru! chloride !ore than %34 !E50L - Etiolo)y sodiu! chloride excess Dx in. serum 6l de. serum bi.arbonate $)!t - )a.tated ingerMs solution- pres.ribed to

.onvert la.tate to bi.arbonate in the liver--in.rease the base bi.arbonate level and .orre.t the a.idosis1 - 2odium bi.arbonate !5 to in.rease bi.arbonate levels8 whi.h leads to the renal e/.retion of .hloride ions as bi.arbonate and .hloride .ompete for .ombination with sodium1 - 4iureti.s may be administered to eliminate .hloride as well1 - 2odium8 fluids8 and .hloride are restri.ted1 6& HYPE-PHOSPH.TE$I. - Seru! PO1 !ore than 1&2 !)0dL - Etiolo)y Tissue trau!a7 che!otherapy& PO1 containin) !edications7 osteoporosis Dx in. serum phosphorus level de. 6a level /ray J s,eletal .hanges $)!t - diet J limit mil,8 i.e .ream8 .heese8 meat8 fish8 .arbonated beverages8 nuts8 dried food8 sardines - 4ialysis - monitor signs of impending hypo.al.emia and .hanges in urine output I$B.L.#"E DE"-E.SE HYPO#.T-E$I. - *a level is less than +75 mECD) - Water is drawn into the .ell .ell swelling - Etiology$ prolonged diureti. therapy8 e/.essive burns8 e/.essive sweating8 2!A4>8 plain water .onsumption S0S/ - nausea8 vomiting8 seiAures

$)!t - sodium repla.ement - water restri.tion - isotoni. soln for moderate hyponatremia - hypertoni. saline soln for neurologi. manifestations - diureti. for 2!A4> #s)& "onsideration - 9onitor ! and O - )O6 - 52 - serum *a - 2eiAure pre.aution - diet (& HYPO'.LE$I. - #E level less than 715 mECD) - Etiology$ use of diureti.8 vomiting and diarrhea - E6B$ flattened ' depressed T (a#es' presence of *U+ (a#es Dx de. serum # level E6B - flattened 8 depressed T waves8 presen.e of N3O waves A:Bs - metaboli. al,alosis $edical $)!t$ +1 diet- < fruits8 fruit -ui.es8 vegetables8 fish8 whole grains8 nuts8 mil,8 meats= (1 oral or !5 repla.ement #s) !)!t$ +1 monitor .ardia. fun.tion8 pulses8 renal fun.tion (1 monitor serum potassium .on.entration 4

71 !5 # diluted in saline '1 monitor !5 sites for phlebitis *& HYPO".L"E$I. - 6al.ium level of less than F15 mgDd) - Etiology$ removal of parathyroid gland during thyroid surgery8 5it1 4 defi.ien.y8 0urosemide8 infusion of .itrated blood - 2D2%- Tetany8 <E= 6hovste,Ms <E= TrousseausMs - E6B$ prolonged KT interval s0sx - Tetany- neural e/.itability - <E= 6hovste,Ms- .ontra.tion of the fa.ial mus.le in response to tapping near the angle of the -aw - <E= TrousseausMs- .arpopedal spasm - !nflate :@ .uff (0 mm>g above systoli. pressure for (-5 mins - seiAures- dDt in. irritablity of 6*2 and peripheral nerves Dx de. 6a level E6B$ prolonged KT interval $)!t 6al.ium salts 5it 4 diet <mil,8 .heese8 yogurt8 green leafy vegetables= #s) !)!t - monitor .ardia. status8 bleeding - monitor !5 sites for phlebitis - seiAure pre.autions

redu.e smo,ing

."ID,B.SE "O#"EPTS - A.id- substan.e that .an donate or release hydrogen ions o !arbonic acid o Hydrochloric acid - :ase- substan.e that .an a..ept hydrogen ions o ,icarbonate - :uffer- substan.e that .an a..ept or donate hydrogen o Hemo"lobin buffer o ,icarbonate - carbonic acid buffer o hosphate buffer - Helpful Hints o 6arbon dio/ide is .onsidered to be A!$D be.ause of its relationship with .arboni. a.id o pH measures the degree of a.idity and al,alinity1 !t is inversely related to >ydrogen1 *ormal ph "175-"1'5 o 4e.reased p>- A!$D$!-in.reased >ydrogenPp> below "175 o !n.reased p>- AL&ALOS$S-de.reased hydrogenPp> above "1'5 - re!e!8er o a high hydrogen a.idi. p> is low o a low hydrogen al,alosis p> is high o a high 6O(may mean a.idi. o a low 6O( may mean al,alosis Dyna!ics of .cid and 8ases - A.ids and bases are .onstantly produ.ed in

the body - They must be .onstantly regulated - 6O( and >6O7 are .ru.ial in the balan.e - A ratio of (0$+ is maintained <>6O7$>(6O7= espiratory and renal system are a.tive in regulation 9ays to 8alance the acids and 8ases - Excretion o A.id .an be e/.reted8 and >ydrogen .an be e/.reted in A6!4OT!6 .ondition o :i.arbonate .an be e/.reted in A)#A)OT!6 .ondition - Production o :i.arbonate .an be produ.ed in A6!4OT!6 .ondition o >ydrogen .an be produ.ed in A)#A)OT!6 .ondition - The respiratory system .ompensates for metaboli. problems - 6O( <a.id= .an be e/haled from the body to normaliAe the p> in A6!4O2!2 - 6O( <a.id= .an be retained in the body to normaliAe the p> in A)#A)O2!2 - The ,idney .an .ompensate for problems in the respiratory system - The #idney reabsorbs and generates :i.arbonate <al,aline= in A6!4O2!2 - The #idney .an e/.rete >E e/.ess <A.idosis= to normaliAe the p> in A6!4O2!2 - The ,idney .an e/.rete bi.arbonate <al,ali= in .onditions of A)#A)O2!2 - The ,idney .an retain >E <a.id= in .onditions of A)#A)O2!2 5

Ways to balan.e the a.ids and bases 6hemi.al buffers .an also parti.ipate in the balan.e of a.id-base - +1 6arboni. a.id- bi.arbonate buffer - (1 @hosphate buffer - 71 protein buffer- !60 and hemoglobin - The action is immediate but very limited $ET.BOLI" ."IDOSIS - -)ow p> - -!n.reased > ion .on.entration - -)ow plasma :i.arbonate Etiology$ diarrhea T@* wDo :i.arbonate fistulas ,etoa.idosis diureti.s la.ti. a.idosis renal insuffi.ien.y ."UTE .#D "H-O#I" $ET.BOLI" ."IDOSIS S0sx - heada.he .old .lammy s,in - 6onfusion dysrrythmia - 4rowsiness sho., - in. - de. :@ Dx A:B J low :i.arbonate8 low p>8 >yper,alemia8 E6B .hanges -x - :i.arbonate for p> Q "1+ and :i.arbonate level Q +0 - monitor serum # - dialysis $ET.BOLI" .L'.LOSIS

- >igh p> - 4e.reased > ion .on.entration - >igh plasma :i.arbonate Etiolo)y vomiting diureti. hyperaldosteronism hypo,alemia e/.essive al,ali ingestion $ET.BOLI" .L'.LOSIS - >igh p> - 4e.reased > ion .on.entration - >igh plasma :i.arbonate Etiology$ vomiting diureti. hyperaldosteronism hypo,alemia e/.essive al,ali ingestion $ET.BOLI" .L'.LOSIS s0sx tingling of toes diAAiness de. in. @ ventri.ular disturban.es Dx A:B J p> R "1'58 serum :i.arbonate R (6 mECD)8 in. @a6O( -x restore normal fluid balan.e .orre.t hypo,alemia 6arboni. anhydrase inhibitors -ESPI-.TO-Y ."IDOSIS

@h Q "175 @a6O( R '( mm>g Etiolo)y pulmonary edema aspiration Atele.tasis @neumothora/ overdose of sedatives sleep apnea syndrome pneumonia -ESPI-.TO-Y ."IDOSIS sDs/$ sudden hyper.apnia produ.es in. @ 8 in. :@8 mental .loudinesss feeling of fullness in head papilledema dilated .on-un.tival blood vessels Dx A:B J p> Q "175 @a6O( - R '( mm>g /$ improve ventilation pulmonary hygiene me.hani.al ventilation

-ESPI-.TO-Y .L'.LOSIS - p> R "1'5 - @a6O( Q 7F mm>g Etiolo)y e/treme an/iety8 hypo/emia sDs/$ lightheadedness inability to .on.entrate numbness tingling 6

loss of .ons.iousness Dx A:B J p> R "1'5 @a6O( Q 75 de. # de. 6a -x breathe slowly - sedative Interpretin) .B+ results - +16he., the p>1 - (14etermine the @a6O(1 - 71Wat.h the bi.arbonate1 - '1)oo, for .ompensation1 - 514etermine @aO( and 2aO(1 .-TE-I.L BLOOD +.S .#.LYSIS - !nterpreting A:B results - +16he., the p>1 p> & "175 J "1'5 <normal= p> & Q "175 <a.idosis= p> & R "1'5 <al,alosis= .ompensated J normal p> un.ompensated J abnormal p> %& Deter!ine pri!ary cause of distur8ance& , 0igure out whether the .ause is$ espiratory <@a6O(= or 9etaboli. <>6O7= (& Deter!ine the Pa"O(& nor!al or a8nor!al espiratory .omponent *ormal$ 75-'5 mm >g - a1 @a6o( Q 75 mm>g J respiratory al,alosis p> R "1'5 hypo.apnia - a1@a6o( R '5 mm >g J respiratory a.idosis - p> Q "175 hyper.apnia

*& 9atch the 8icar8onate& renal or metaboli. .omponent *ormal$ (( J (6 mECD) - >6O7 Q (( mECD) J metaboli. a.idosis - S p> Q "175 - >6O7 R (6 mECD) J metaboli. al,alosis - S p> R "1'5 1& Loo: for co!pensation loo: at the ;alue <hich does not !atch the acid 8ase status of the patient=s pH a1 Within normal range$ *O .ompensation b1 Above or below normal A*4 the p> itself is outside the normal range$ @A T!A) .1 Above or below normal A*4 the p> is within the normal range$ 6O9@)ETE %&pH >&(3 (&p"O( acidic *&H"O* nor!al? dec 63 (1 inc nor!al acidic

#OTE If pH is nor!al 8ut Pa"O( or H"O* is a8nor!al7 use >&1 as a cut off point "175 - "1'0 "1'0 - "1'5 a.idosis al,alosis al,aline al,aline

+1p> "160 in. (1p6O( (0 de. 71>6O7 +F de. a.idi. -ESPI-.TO-Y .L'.LOSIS partial co!pensation %&pH >&23 inc (&p"O( 63 inc acidic *&H"O* *1 inc al:aline $ET.BOLI" .L'.LOSIS partial co!pensation

al:aline

-ESPI-.TO-Y ."IDOSIS no0 a8sent co!pensation +1p> "1(0 de. (1p6O( 60 in. 71>6O7 70 in. - -ESPI-.TO-Y ."IDOSIS partial co!pensation +1p> "1'0T normal (1p6O( 'F in. 71>6O7 (' normal -ESPI-.TO-Y ."IDOSIS no0 a8sent co!pensation

a.idi. a.idi. al,alineT a.idi.T a.idi. normalT

+1p> "176T normal a.idi. (1p6O( 70 de. al,aline 71>6O7 (0 de. a.idi. $ET.BOLI" ."IDOSIS co!plete0 full co!pensation +1p> "170 de. (1p6O( '0 normal 71>6O7 (0 de. a.idi. $ET.BOLI" ."IDOSIS no0 a8sent co!pensation a.idi. normal

.cid,Base I!8alance "lassifications +1 A.idosis or al,alosis a1 A.idosis$ >ydrogen ion .on.entration in blood in.reases above normal and p> is below "175 b1 Al,alosis$ >ydrogen ion .on.entration in blood de.reases below normal and p> is above "1'5 (1 Origin of the problem a1 0rom the respiratory system b1 0rom the metaboli. system Disorders Si!ple or "o!8ined +1 @rimary disorders a1 2imple b1 One .ause8 either respiratory or metaboli. (1 6ombined disorders a1 9ore severe b1 :oth the respiratory and metaboli. systems are the .ause of the same imbalan.e "o!pensation +1 Only o..urs with primary disorders (1 esponse by the system not .ausing the imbalan.e to .orre.t the p> - E/ample$ with respiratory a.idosis8 the ,idneys would eliminate hydrogen ions in urine to offset the a.idosis .aused by

hypoventilation of lungs1 71 6omplete 6ompensation o..urs if the p> is .orre.ted to the normal range <"175 J "1'5= '1 @artial 6ompensation o..urs if there is improvement in the p> but not to the normal range1 51 6ompensation .an be determined by analysis of the arterial blood gas results1 Treat!ent %& Ur)ency a1 9ental ability and level of .ons.iousness is often affe.ted b1 :rain fun.tion usually affe.tedU brain .ells need proper .onditions to perform .ellular fun.tions .1 6ells .annot fun.tion properly if signifi.ant a.idosis or al,alosis o..urs (& Indirect treat!ent a1 Treating and .orre.ting the pre.ipitating .ondition often .orre.ts the a.id-base imbalan.e b1 4ire.tly treating the a.id-base imbalan.e8 by adding or removing hydrogen or bi.arbonate ions8 may lead to further imbalan.es .1 *ot usually first line of treatment

!tespiriturn!d 3%%>(3%(