Fluid and electrolyte balance

Anthony P. Olalia Jr.

 FUNDAMENTAL CONCEPTS
• GIVE PRETEST
 NICE TO KNOW
• Skeleton = low water content
• Muscle, skin, and blood = highest amount of
water
• Fats = low water content
 Amount and Composition of Body
Fluids
• Approximately 60% of an adult body weight consists of
fluid (H2O and Electrolytes)
• Factors that influence body fluid are
a. Age – younger people have higher % of body fluid
than older people (infants have 78-80% )
b. Gender – Men have proportionately more body fluid
than women
 Male = 70ml/kg
 Female = 65 ml/kg
c. Body fat – Obese people have less water since fat
cells contain less water
 Amount and Composition of Body
Fluids
• Fluid compartments
a. Intracellular fluid (ICF) – fluid in cells
b. Extracellular fluid (ECF) – fluid outside the
cells
Q. Which has more fluid content?
A. ICF -- approximately 2/3rds
-- primarily located in skeletal muscles
 Amount and Composition of Body
Fluids
• Fluid compartments
Extracellular fluid (ECF) – fluid outside the cells
- 1/3rd of body fluids
- Divided into
a. Intravascular – the fluid within the blood vessel
(plasma/fluid portion of the blood)
- Approximately 3L of the average 6L of blood
volume is made up of plasma
- Other 3L = erythrocytes, leukocytes,
thrombocytes
 Amount and Composition of Body
Fluids
• Fluid compartments
Extracellular fluid (ECF) – fluid outside the cells
- 1/3rd of body fluids
- Divided into
b. Interstitial–fluid that surrounds the cells
- 11-12L in an adult
- E.g. lymph
 Amount and Composition of Body
Fluids
• Fluid compartments
Extracellular space (ECF) – fluid outside the cells
- 1/3rd of body fluids
- Divided into
c. Transcellular space – smallest division of ECF, is
the portion of total body water contained within
epithelial lined spaces
- e.g. cerebrospinal fluids, pericardial, synovial,
intraocular, pleural fluids, sweat and digestive
secretions
• Body fluids shifts between the two
compartments to maintain
equilibrium/homeostasis
• Loss of ECF into a space that doesnot
contribute to homeostasis = third space fluid
shift / third spacing
• E.g. Ascitis secondary to portal hypertension
due to liver cirrhosis, Burns, Peritonitis
• Evidence of fluid shift
- Decrease in urine output despite adequate fluid intake
- Related to
a. Low intravascular blood volume
b. Low kidney blood supply

Signs of hypovolemia
- Increased RR, PR
- Decreased BP
- Edema
- Weight gain
 ELECTROLYTES
• Active chemicals
 Cations- carry positive charges
e.g. Na, Ca, Mg, H…
 Anions- carry negative charges
e.g. Cl, Bicarb, Phosphate, sulfate…
Laboratory
• Electrolytes expressed in milliequivalent (mEq) /L vs
Mg
• mEq = measure of chemical activity
• Mg = measure of weight
• Sample blood is taken from the plasma
 ELECTROLYTES
• Sodium – major electrolytes in the ECF
• Potassium – major electrolytes in the ICF
The ECF has a low concentration of potassium
and can tolerate only small changes in
potassium concentration
Release of large stores of potasium (ff.
trauma) can be extremely dangerous… Why?
 Regulation of Body Fluid
Compartments
• Hydrostatic pressure
- pressure exerted by the fluid on the walls of
the blood vessel
- Normal movement of fluid through capillary
wall depends on this
- Direction of fluid movement depends on the
differences in hydrostatic and osmotic
pressure
 Regulation of Body Fluid
Compartments
• Osmosis and Osmolality
- Membrane is impermeable
- Fluid shifts through the membrane from the region of low
solute concentration to the region of high solute
concentration until the solution are of equal concentration
- Osmolality – the number of dissolved particles contained in
a unit of fluid
- Tonicity – ability of all solutes to cause an osmotic driving
force that promotes water movement from one
compartment to another
- Examples of effective osmoles = mannitol (relate with
diuretic) glucose (relate with diabetes)
 Regulation of Body Fluid
Compartments
• Osmosis and Osmolality
Terms associated with osmosis
 Osmotic pressure – amount of hydrostatic
pressure needed to stop the flow of water by
osmosis
 Oncotic pressure – pressure exerted by proteins
 Osmotic diuresis – increase in urine output
caused by the excretion of substances such as
glucose, mannitol, or contrast agents in the urine
 Regulation of Body Fluid
Compartments
• Diffusion
- Natural tendency of a substance to move from
an area of higher concentration to one of
lower concentration
- E.g. exchange of o2 and co2
 Regulation of Body Fluid
Compartments
• Filtration
- Hydrostatic pressure in the cappilaries tends to
filter fluid out of the intravascular compartments
into the interstitial fluid
- Movement of water and solutes occurs from an
area of high hydrostatic pressure to an area of
low hydrostatic pressure
- E.g. filtration allows the kidneys to filter 180L of
plasma everyday
- Include development of edema r/t high
hydrostatic pressure
 Regulation of Body Fluid
Compartments
• Sodium-potassium pump
- Sodium and potassium goes in and out of the
cell via active transport through sodium
potasium pump locate on cell walls
- Active transport = needs energy
 Major Electrolytes
Sodium (chemical notation = Na+)
• Major positive ion (cation) in fluid outside of cells.
• Na+ + chloride = NaCl/table salt.
• Excess sodium is excreted in the urine.
• Regulates the total amount of water in the body (where sodium
goes water follows)
- Retention of sodium = fluid retention
- Excessive loss of sodium = decreased volume of body fluids
• Necessary for the proper electrical signals transmission.
• Too much or too little can cause cells to malfunction, and can be
fatal
• A Normal blood sodium level is 135 - 145 milliEquivalents/liter
(mEq/L)
 Major Electrolytes
Sodium (chemical notation = Na+)
• Increased sodium (hypernatremia) occurs whenever there is excess
sodium in relation to water.
- causes of hypernatremia
 kidney disease
 too little water intake
 loss of water due to diarrhea and/or vomiting
• A decreased concentration of sodium (hyponatremia) occurs
whenever there is a relative increase in the amount of body water
relative to sodium
- Causes of hyponatremia
 Diseases of the liver and kidney
 congestive heart failure,
 burn victims,
 Major Electrolytes
Sodium (chemical notation = Na+)
• Increased sodium (hypernatremia) occurs
whenever there is excess sodium in relation to
water.
- S/Sx
• A decreased concentration of sodium
(hyponatremia) occurs whenever there is a
relative increase in the amount of body water
relative to sodium
- S/Sx
 Major Electrolytes
Potassium (chemical notation for potassium is K+)
• Major positive ion (cation) found inside of cells
• The The proper level of potassium is essential for normal cell
function.
• Major functions of potassium
 regulation of the heartbeat
 Proper muscles contractitlity
• abnormal increase in potassium or decrease in potassium can
profoundly affect the nervous system and increases the chance
of irregular heartbeats (arrhythmias), which can be fatal.
• The normal blood potassium level is 3.5 - 5.0 milliEquivalents/liter
(mEq/L)
 Major Electrolytes
Potassium (chemical notation for potassium is K+)
• Increased potassium is known as hyperkalemia.
 Potassium is normally excreted by the kidneys, so disorders
that decrease the function of the kidneys can result in
hyperkalemia.
 Certain medications may also predispose an individual to
hyperkalemia (e.g.)
• Hypokalemia, or decreased potassium
 can arise due to kidney diseases (e.g.)
 excessive loss due to heavy sweating, vomiting, or diarrhea,
eating disorders, certain medications, or other causes.
 Major Electrolytes
Potassium (chemical notation for potassium is
K+)
• Increased potassium is known as
hyperkalemia.
S/Sx
• Hypokalemia, or decreased potassium
S/Sx
 Major Electrolytes
Chloride (Cl-)
• Is the major anion (negatively charged ion) found in the
fluid outside of cells and in the blood.
• Sea water has almost the same concentration of
chloride ion as human body fluids.
• Chloride also plays a role in helping the body maintain
a normal balance of fluids.
• Significant increases or decreases in chloride can have
deleterious or even fatal consequences
• The normal serum range for chloride is 98 - 108
mmol/L
 Major Electrolytes
• Increased chloride (hyperchloremia):
 Elevations in chloride may be seen in diarrhea,
certain kidney diseases, and sometimes in
overactivity of the parathyroid glands.

• Decreased chloride (hypochloremia):

 Chloride is normally lost in the urine, sweat, and
stomach secretions.
 Excessive loss can occur from heavy sweating,
vomiting, and adrenal gland and kidney disease.
 Major Electrolytes
• Increased chloride (hyperchloremia):
S/Sx

• Decreased chloride (hypochloremia):

Chloride is normally lost in the urine, sweat,
and stomach secretions.
S/Sx
 Major Electrolytes
Bicarbonate ion
• The bicarbonate test is usually performed
along with tests for other blood
electrolytes.Disruptions in the normal
bicarbonate level may be due to diseases that
interfere with respiratory function, kidney
diseases, metabolic conditions, or other
causes.
 Routes of gain and Losses
• When fluid balance is critical, all routes of gain
and all routes of loss must be recorded and all
volumes compared. Organs of fluid loss
include the
- Kidneys
- Skin
- Lungs
- GI tract
 Routes of gain and Losses
• Kidneys
- usual daily urine volume in the adult is 1-2L
- General rule – approximately 1ml of urine per
kilogram of body weight per hour (1ml/kg/hr)
in all age group
- Normal = 30ml/hr
 Routes of gain and Losses
• Skin
- Sensible perspiration = visible water and electrolyte
loss through the skin (sweating)
- Actual sweat losss can vary from 0-1000 ml or more
every hour, depending on the environmental
temperature
- Insensible perspiration = continuous water loss by
evaporation (approximately 600/ml)
- Invisible
- E.g. fever greatly increases insensible water loss
through the lungs and the skin as does loss of the
natural skin barrier (burns)
 Routes of gain and Losses
• Lungs
- Normally eliminate water vapor (insensible
loss) at a rate of 400ml/day
- Loss is greater with increased RR or depth, or
a dry climate
 Gastrointestinal tract
• Usual loss = 100-200 ml/day
Why?
 LABORATORY TESTS
What is being tested?
• Osmolality is a measure of the number of particles
dissolved in a kilogram of fluid.
• Osmolarity is the number of particles in a litre of fluid and
is approximately the same.
• osmolality and osmolarity values are approximately the
same.
• Osmolality is measured in the laboratory using an
osmometer.
How is the sample collected for testing?
• A blood sample is taken by needle from a vein in the arm.
You may be asked to provide a urine sample too.
 LABORATORY TESTS
How is it used?
• Osmolality is often measured when the doctor finds an
abnormally low sodium (hyponatraemia) which is
difficult to interpret.
• Osmolality may also be measured if you are drinking
lots of fluids, when diabetes insipidus or other
disorders are being considered.
• Measurement of osmolality can also help in patients
treated with the osmotic diuretic, mannitol.
• A high plasma osmolality may indicate the presence of
a drug or toxin (e.g. alcohol) in the blood.
 LABORATORY TESTS
• When is it requested?
• Your doctor may request the test if
- other results (eg a high blood sodium) suggest a diagnosis of
diabetes insipidus or the syndrome of I
- nappropriate antidiuretic hormone (SIADH) secretion.
- Diabetes insipidus is a condition very different to diabetes mellitus
(sugar diabetes) in which an excessive and inappropriate volume of
water is lost in the urine and the blood becomes too concentrated.
- Osmolality may also be measured in a Water Deprivation test, if the
doctor needs to distinguish between two different types of diabetes
insipidus or a condition called psychogenic polydipsia in which a
patient drinks water compulsively.
- It may also be measured when intake of a toxin is suspected and to
assess how much is present in the blood
 LABORATORY TESTS
• What does the test result mean?
• the plasma osmolality increases, meaning that the blood is too
concentrated, water is retained by the kidneys so that a concentrated
urine is produced and the blood is diluted to normalise the plasma
osmolality.
• if plasma osmolality decreases, the blood is too dilute, water is eliminated
by producing a dilute urine and the plasma osmolality then increases.
• A head injury, or disease of part of the brain, may result in overproduction
of anti-diuretic hormone (ADH) by the hypothalamus resulting in a dilute
plasma (low osmolality).
• This is normally detected by finding a persistently low plasma sodium in
the presence of an inappropriately concentrated urine (syndrome of
inappropriate ADH secretion (SIADH)). Disease of the adrenal cortex can
also result in a low osmolality due to decreased production of other
hormones (aldosterone, cortisol) involved in water (osmolality)
regulation.
 LABORATORY TESTS
• Diabetes Insipidus (“water diabetes”) is a condition in
which the urine is always very dilute, leading to water loss
from the body and possible dehydration. It results from too
little antidiuretic hormone or failure of the kidneys to
respond to it, results in a high plasma osmolality in the
presence of an inappropriately dilute urine.
• In uncontrolled Diabetes Mellitus (the more common
“sugar diabetes”), a high plasma glucose and the water loss
associated with glucose excretion by the kidneys, causes a
high plasma osmolality.
• Water intoxication may also decrease plasma osmolality
and dehydration or intake of toxins will increase it.
 LABORATORY TESTS
• Is there anything else I should know?
• An abnormally high plasma osmolality may result from water depletion
(dehydration). Toxins including alcohol, can increase plasma osmolality because
they contribute to the number of particles of solute in the plasma. Similarly sugas
diabetes (diabetes mellitus), if uncontrolled, will increase plasma osmolality, both
from high plasma glucose concentration and from the water loss resulting from
excretion of excess water with the glucose excreted via the kidneys.
Classical diabetes insipidus, in which there is a deficiency of antidiuretic hormone,
and nephrogenic diabetes insipidus, where the kidneys do not respond to
antidiuretic hormone, also cause a rise in plasma osmolality as a result of excess
water loss via the kidneys. These diseases may require a water deprivation test (in
response of the body ia studied) to distinguish them from each other and from
excess water intake (psychogenic polydipsia).
Kidney disease may result in an abnormally high or low plasma osmolality,
depending on the stage or type of disease.
Interpretation of an abnormal plasma osmolality often requires measurement of
urine osmolality to ascertain whether the body is producing an appropriately
concentrated or dilute urine. The diseases causing abnormalities of osmolality are
usually treatable.
 FLUID REGULATION CYCLE
• SEE PATHOPHYSIOLOGY