Body Fluids and Electrolytes

Dr. Mahmoud Al-Balas, MBBS

Higher Specialty Certificate of General Surgery JUST

Jordanian Board of General Surgery
E.C.F.M.G Certificate
MRCS Ireland
 Body Fluids

Total amount of fluid in the human body is approximately 60%

of body weight
Body fluid has been divided into two compartments
Intracellular fluid (ICF)
Inside the cells
60% of total body water
Extracellular fluid
Outside the cells
40% of total body water
PERCENTAGE OF H2O IN TISSUES
Average 70 kg person Total body weight

42 L total H2O 60%

28 L Intracellular fluid (ICF) 40%

14 L Extracellular fluid (ECF) 20%

( ISF and plasma water )

10.5 L Interstitial fluid (ISF) 15%

3.5 L Plasma water 5%
 Body Fluid Compartments

Extracellular fluid includes

Interstitial fluid
Present between the cells
Approximately 75% of ECF
Plasma
Present in blood
Approximately 25% of ECF
Also includes
Lymph * vitreous body
synovial fluid * endolymph
aqueous humor * perilymph
cerebrospinal fluid * pleural, pericardial and
peritoneal fluids
Body Fluid Compartments
Barriers separate ICF, interstitial fluid and
plasma

Plasma membrane
Separates ICF from surrounding interstitial fluid
Blood vessel wall
Separate interstitial fluid from plasma
 Composition of body fluids

Organic substances * Inorganic substances

Glucose * Sodium
Amino acids
* Potassium
Fatty acids
Hormones
* Calcium
Enzymes * Magnesium
* Chloride
* Phsophate
* Sulphate
 Difference

ECF ICF
Most abundant cation - Na+, Most abundant cation - K+
muscle contraction Resting membrane potential
Impulse transmission Action potentials
fluid and electrolyte balance Maintains intracellular volume
Regulation of pH
Most abundant anion - Cl-
Regulates osmotic pressure Anion are proteins and
Forms HCl in gastric acid phosphates (HPO42-)

Na+ /K+ pumps play major role in keeping K+ high inside cells and Na+ high outside
cell
 Sodium Na+

Most abundant ion in ECF

90% of extracellular cations
Plays pivotal role in fluid and electrolyte balance as it accounts
for half of the osmolarity of ECF
 Chloride Cl -

Most prevalent anion in ECF

Moves easily between ECF and ICF because most plasma
membranes contain Cl- leakage channels and transporters
Can help balance levels of anions in different fluids
 Bicarbonate HCO3 -

Second most prevalent extracellular anion

Concentration increases in blood passing through systemic
capillaries picking up carbon dioxide
Chloride shift helps maintain correct balance of anions in ECF
and ICF
 Potassium K+

Most abundant cation in ICF

Establish resting membrane potential in neurons and
muscle fibers
Maintains normal ICF fluid volume
Helps regulate pH of body fluids when exchanged for H+
 Magnesium

Mg2+ in ICF (45%) or ECF (1%)

Second most common intracellular cation
Cofactor for certain enzymes and sodium-potassium pump
Essential for synaptic transmission, normal neuromuscular
activity and myocardial function
 Serum Osmolality

Normal serum osmolality = 280 295 mOsm/kg

Electrolytes Disorders
 Hypernatremia

Na+ level > 145 mEq/L

Causes THE MODEL

M MEDICATIONS (hypertonic saline, TPN), MEALS (excess
intake of Na+)
O Osmotic Diuresis (e.g. Mannitol)
D Diabetes Insipidus
E Excessive H2O Loss (vomiting, diarrhea, diuresis,
sweating)
L Low H2O intake
 Hypernatremia

Sign and Symptoms FRIED

F Fever (low grade), Flushed Skin
R Restless (Irritable, Confusion, Seizures),
Respiratory Paralysis
I increased fluid retention and Blood Pressure
E Edema
D Decrease urine output, Dry mouth
 Hypernatremia

Medical management

Diuretic Therapy
Hydration therapy D5W followed by or N.S
Check underlying cause

Note Avoid rapid correction to avoid Brain Edema

 Treatment recommendations for symptomatic
hypernatremia

Establish documented onset (acute, < 24 h; chronic, >24h)

In acute hypernatremia, correct the serum sodium at an initial rate of 2-3 mEq/L/h
(for 2-3 h) (maximum total, 12 mEq/L/d).
Measure serum and urine electrolytes every 1-2 hours
Perform serial neurologic examinations and decrease the rate of correction with
improvement in symptoms

Chronic hypernatremia with no or mild symptoms should be corrected at a rate not

to exceed 0.5 mEq/L/h and a total of 8-10 mEq/d (eg, 160 mEq/L to 152 mEq/L in 24 h).

If a volume deficit and hypernatremia are present, intravascular volume should be

restored with isotonic sodium chloride prior to free-water administration
 Hyponatremia

Causes

Hypovolemic excess diuretics, Hypoaldosteronism,

vomiting, NG suction, Burns, Pancreatitis, Sweating.

Euvolemic SIADH, CNS abnormalities

Hypervolemic Renal failure, CHF, Liver failure,

Iatrogenic (dilutional)
Hyponatremia
 Hyponatremia

Clinical Manifestations
Symptomatic BUT less impaired
Headache, Irritability, Nausea, Vomiting, Mental
slowing, Unstable Gait, Confusion, Disorientation
Usually seen in Chronic cases

Life Threatening
Coma, Convulsions, Respiratory arrest and death from
cerebral edema and brain herniation
Seen in Acute cases
 Treatment Guidelines of Hyponatremia

1. maximum correction for chronic Hyponatremia:

12 mmol/L in the first 24 h
18 mmol/L in the first 48 h

2. even lower (8 mmol/L in any 24h period) if any of the following are
present:
serum Na 105 mEq/L
hypokalemia
alcoholism and/or malnutrition
liver disease

3. maximum correction for acute hyponatremia: not ascertained, but

much lower risk
 Treatment Guidelines of Hyponatremia

Short term Long term

isotonic saline infusion fluid restriction
hypertonic saline demeclocycline
infusion furosemide + NaCl
vaptan (conivaptan, mineralocorticoids
tolvaptan) urea
vaptan (tolvaptan)

Note vaptans (conivaptan, tolvaptan) are vasopressin receptor antagonist

 Hypertonic Saline Correction

choose desired correction rate of plasma [Na+ ] (e.g.,

1.0 mEq/L/h)

obtain or estimate patients weight (e.g., 70 kg)

multiply weight X desired correction rate and infuse

as ml/h of 3% NaCl (e.g., 70 kg X 1.0 mEq/L/h = 70 ml/h
infusion)
 Cerebral Pontine Myelinolysis

Tremor
Incontinence
Hyperreflexia, pathological reflexes
Quadriparesis, quadriplegia
Dysarthria, dysphagia
Cranial nerve palsies
Mutism, locked-in syndrome
 Hyperkalemia

Normal K+ = 3.5 5.3 mEq/L

Causes

Iatrogenic overdose
Blood transfusion
Renal failure
Diuretics
Acidosis
Tissue injury (e.g. Burn)
hemolysis
 Hyperkalemia

Signs and symptoms ECG Changes

Weakness Peaked T waves

Parasthesia Depressed ST segment
Decreased deep tendon Prolonged PR interval
reflexes Wide QRS
Areflexia Bradycardia
Paralysis Ventricular fibrillation
Respiratory failure
 Treatment of Hyperkalemia

IV calcium (cardioprotective)

IV NaHCO3
Glucose and Insulin
Albuterol

Sodium polystyrene sulfonate (kayexalate)

Furosamide
Dialysis
 Hypokalemia

Causes

Insufficient supplementation
Vomiting
Diarrhea
Intestinal fistula
Insulin
Hyperaldosteronism (Conns) of Steroids (Cushings)
Alkalosis
Amphotericin
Certain antibiotics
 Hypokalemia

Manifestations ECG Findings:

Weakness, Tetany Flat T wave

Nausea and vomiting U wave
Ileus ST depression
Parasthesia PAC, PVC
AF
 Hypokalemia Treatment Guidelines

Hypokalemia Treatment Comments

Mild (3-3.4 mmol/l) Oral Replacement Monitor Daily K+ level
Consider I.V if not tolerated

Moderate (2.5-2.9 Oral Replacement Monitor Daily K+ level

mmol/l) Consider I.V if not tolerated
Asymptomatic
Severe (<2.5 mmol/l) I.V Replacement Check Mg2+ level If
Symptomatic 40mEq in 1L 0.9N.S BID or hypomagnesaemic: initially
TID give 4ml MgSO4 50%
Standard infusion rate (8mmol) diluted to 10ml with
10mmol/hr NaCl 0.9% over 20min
Maximum infusion rate monitor K+ level after each
20mmol/hr 40mmol
 Calcium

Calcium concentration, both total and free, is characterized by a

high physiological variation, depending on age, sex, physiological
state (eg, pregnancy), and even season (owing to the seasonal
variation of vitamin D)

Normal Adult Calcium = 8.9 -10.1 mg/dl

Corrected Ca = [0.8 x (normal albumin - patient's albumin)] + serum Ca level

Note: The normal albumin level is defaulted to 4 mg/dL Standard Units or 40 g/L if
using SI Units
 Hypercalcemia

Causes

Excessive Ca2+ supplementation

Hyperparathyroidism (1 and 3)
Immobility
Milk alkali syndrome
Bone Pagets disease
Neoplasms, Paraneoplastic
Metastasis
Excessive Vitamin D or A
Sarcoid
Thiazides
 Hypercalcemia

Manifestations ECG Changes

Renal Stones Short QT interval

Bone Pain Prolonged PR interval
Abdominal groans
Psychiatric symptoms
Polyuria
Polydipsia
Constipation
 Hypercalcemia

Treatment

Volume expansion with N.S

Furosamide

Others

Steroids
Calcitonin
Bisphosphonate
Dialysis
 Hypocalcaemia

Causes

Acute Pancreatitis
Vit. D deficiency
Sepsis
Osteoplastic metastasis
Diuretics
Renal failure
Short bowel syndrome, intestinal fistula
Hypomagnesaemia
 Hypocalcaemia

Manifestations ECG Findings

Perioral numbness Prolonged QT, ST segment

Confusion, seizures Peaked T wave
Abdominal cramps
Stridor, laryngospasm
Tetany
Depression, hallucinations
Chvosteks, Trousseaus signs
 Hypocalcaemia Treatment

Calcium Gluconate

Calcium PO

Vitamin D
THE END