1. ANATOMY OF BODY FLUIDS &NORMAL EXCHANGE OF FLUIDS &ELECTROLYTES 2.

CLASSIFICATION OF BODY FLUID CHANGES

DR. S. K. JHA

INTRODUCTION
Fluid

& electrolyte changes can occur pre, intra or post operatively Recognition & management of these changes are paramount to the care of surgical patients

TOTAL BODY WATER (TBW)

50 to 60% of total body wt Obese individuals have less TBW In new born approx. 80% of total body wt is water

MEASUREMENT OF TBW

By indicator dilution methods Using D2O,tritium ,H20(18) A known mass of D2O is taken and after 3 hrs the conc. of isotope in plasma is used to estimate its Vd Bioimpedence spectroscopy or bioelectrical impedence analysis is a clinically applicable method for measuring TBW

FLUID COMPARTMENTS
1. 2. 3. 4. 5.

Multiple fluid compartments separated by biological membranes To major compartments are ICF and ECF ICF comprises of 55% of TBW ECF comprises 45% and divided into Lymphatic and interstitial fluid 20% Water in bones 7.5% Water in dense connective tissue 7.5% Water in plasma 7.5% Transcellular water 2.5%

MEASUREMENTS

ECW can be measured by delayed gamma neuron activation for total body chloride ICW=TBW-ECW ECF and plasma fluid can be measured by indicator dilution method

COMPOSITION OF FLUID COMPARTMENTS

1.
2. 3. 4. 5. 6.

ECF Na+ K+ ClHCO3InorganicGlucose

mmol/kg H2O 142 4 110 24 12 3

1.
2. 3. 4. 5. 6.

ICF Na+ K+ ClHCO3OrganicGlucose

mmol/kg H2O 10 140 3 10 137(meq/kg) 2.5

Total osmolality ECF=ICF=300 Ethanol and urea can freely diffuse Osmolality is a measure of total no. of solutes / mass of water measured as mmol/kg H2O 2 Na+ + Glu/18 + BUN/2.8 Normal 290 to 310 Organic anions are DNA, RNA,creatine phosphate, ATP , ADP, Phospholipid

A fundamental principle of body fluids homeostasis is that TBW moves across CM and distributes betn ICF and ECF until osmolality is same in both compartments. Active transport moves electrolytes across CM Renal function regulates the size of ICF and ECF by producing urine with osmolality range 100 - 1200 mmol/kg H2O

ARGININE VASOPRESSIN (AVP)

ADH is a peptide made in hypothalamus and stored in pituitary Released when osmolality of ICF & ECF is >285 At bedside urine sp. gr is used to measure osmolality Sp. Gr of 1010 or less means dilute urine or decreased ADH Sp. Gr >1030 means urine is of max . Osmolality

NORMAL FLUID BALANCE

1. 2. 3.

Avg water consumption per day 2000ml 75% from oral intake 25% from solid food Loss Urine 1 L Stool 250 ml Insensible loss 600 ml To clear the products of metabolism kidney must excrete a min of 500 to 800 ml of urine per day

VOLUME CONTOL

Volume changes are sensed by osmoreceptors and baroreceptors Osmoreceptors are specialized sensors that detect even small changes in fluid osmolality through osmoreceptor driven changes in thirst and diuresis. Baroreceptors are pressure sensors located in aortic arch and carotid sinus Baroreceptor responses are neurohormonal in nature. Net result is alt in renal Na+ levels and water reabsorption inorder to restore vol to normal.

ROLE OF KIDNEY

A normal GFR of 125 ml/min would generate 180 L/day of filtrate containing 27000 mmol Na+ 2/3 rd filtered Na+ is absorbed in PCT 20% in LOH 7% in DCT 3% in CD The net excretion of urinary Na+ / day as a fraction of total Na+ filtered is less than 1 %

REGULATION OF BODY SOLUTE COMPOSITION

The diff. in electrolyte composition betn ICF & ECF is sustained by activity of Na+,K+ ATPase by active transport It moves 3 Na+ out of the cell while concurrently 2 K+ enter into the cell. A net result is a negative intracellular charge This neg charge in ICF is called RMP The voltage of RMP is essential for cell function It is the basis for nerve cond & muscle contraction In cases of decreased O2 availability, as in shock, ATP level falls & Na+,K+ ATPase funct is impaired leading to intracellular Na+ accumulation and dec. RMP causing cell death.

HYPONATREMIA

1. 2.

3.

Occurs when there is excess of extra cellular water relative to Na+ Volume status may be high , normal , low High volume Increased water intake Post op increase in ADH Drugs like antipsychotic, ACEI, TCAs, mannitol etc

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2.

3. 4.

5.

Normal volume Hyperglycemia Increase in lipids/proteins SIADH Water intoxication diuretics

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2. 3. 4.

Low volume Decreased Na+ intake G.I loses Renal loss Diuretics

HYPERNATREMIA

Symptomatic hypernatremia occurs in pts with impaired thirst or restricted acess to fluids Symptoms occur when Na+ is >160 mEq/L

CAUSES HIGH VOLUME 1. Iatrogenic Na+ administration 2. Increased mineralocorticoid 3. Aldosteronism 4. Cushings disease 5. CAH

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2.

NORMAL VOLUME Non renal water loss through g.i loss & skin Renal water loss Renal disease Diuretics DI

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2.

LOW VOLUME Nonrenal water loss Renal water loss Renal tubular dis Osmotic diuresis DI Adrenal failure

Potassium abnormalities

Avg dietary K+ intake is 50 to 100mEq /d Only 2% of total body K+(about 63 mEq)is located in extracellular compartment. This small amount is critical for cardiac & neuromuscular function

HYPERKALEMIA

1.

Serum K+ > 3.5 to 5 mEq /L Etiology Increased intake Supplementation Blood transfusion Haemolysis Crush injury

INCREASED RELEASE 1. Acidosis 2. Hyperglycemia 3. Mannitol (K+ dec by 0.3 mEq/l for every 0.1 inc in pH)

IMPAIRED EXCRETION
1.

2.

K+ sparing diuretics Renal insufficiency

TYPICAL ECG CHANGES

Peaked T waves Flat p waves Prolonged PR Wide QRS Sine wave pattern VF

HYPOKALEMIA

1. 2. 1. 2.

ETIOLOGY Decreased intake IVF without K+ K+ deficient TPN Increased excreation Hyperaldosteronism Amphotericin, cisplatin, amonoglycoside

TYPICAL ECG CHANGES

U waves Flat T waves ST changes arrhythmias

MAGNESIUM ABNORMALITY

1. 2. 3.

4th most common mineral in body Mainly intracellular 1/3rd extracellular Mg2+ is bound to albumin Increased Mg2+ Renal failure TPN Laxatives or antacids ECG changes are same as hyperkalemia

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2. 3. 4. 5. 6. 7.

Decreased Mg2+ ICU patients Alcohol Starvation Prolonged IV fluids Malabsorption Acute pancreatitis DKA

CALCIUM ABNORMALITY

Serum Ca2+ has three forms :protein bound 40%, complexed to phosphate 10% & ionised Ca2+ 50%

For every 1 gm/dl dec in serum albumin, total serum Ca2+ decreases by 0.8 mg/dl Normal serum level is 8.5 to 10.5 mEq/L

HYPERCALCEMIA

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2. 3.

Common causes Primary hyperparathyroidism Malignancy Milk alkali syndrome

HYPOCALCEMIA

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2. 3. 4. 5. 6.

Common causes Pancreatitis Necrotising fascitis Small bowel fistula Pancreatic fistula Breast and prostate CA Massive blood transfusion

PHOSPHORUS ABNORMALITY

It is present abundantly intracellulary in metabolically active cells Responsible for ATP production Most cases of hyperphosphatemia is seen pts with renal impairment Mostly asymptomatic May lead to metastatic Ca2+ - phosphorus complexes Hypophosphatemia mainly occurs due to intracellur shift of phosphorus in ass. with respiratory alkalosis,insulin therapy .