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Fluid and Electrolytes
  Acid and Base Balance


              Reference: Pathophysiology by Kathryn McCance




                                                      Mindy Milton, MPA, PA-C
                                                                   July 1, 2010
                                                                        1
Mosby items and derived items © 2006 by Mosby, Inc.
Distribution of Body Fluids
       Total body water (TBW)
                Intracellular fluid                  Total body water aprox 42L
                                                      Rest is fat, fat free solids, bones.
                Extracellular fluid                  Mostly intracellular.
                          Interstitial fluid
                                                      Adipose tissue has less water, so obese
                          Intravascular fluid        have less total body water, and more
                                                      risk of dehydration.

                                                      age also effects, probably due to more
                                                      fat.




                                                                                  2
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Fluid Compartment




                                                      3
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Electrolyte Distribution
    Major Cations:
            Extracellular fluid
                  Plasma: Na
                  Interstitial Fluid: Na

            Intracelluar fluid
                     K, Mg
    Major Anions
            Extracellular Fluid
                  Plasma: Cl, HCO3, Protein
                  Interstitial: Cl, HCO3, HPO4, SO4

            Intracellular Fluid
                     HPO4, Proteins, HCO3, CL,, SO4
                                                       4
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Principles of Fluid and Electrolytes
 Homeostatic mechanisms respond to changes
  in the extracellular fluid
 Cellular receptors respond to changes in
  volume and osmotic concentration
 Water is moved by osmotic gradients and not
  by active transport
 Water follows sodium



                                                      5
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Water Movement Between
the Plasma & Interstitial Fluid
       Osmolality represent Na consentration
       Osmotic forces (hydrostatic pressure)              due to heart
                                                           contraction
       Aquaporins H2O can also diffuse through memb.
       Starling hypothesis
                Net filtration = forces favoring filtration –
                 forces opposing filtration (oncotic)
                     capillary bed



                                                                 6
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Net Filtration
              Forces favoring filtration
                       Capillary hydrostatic pressure (blood pressure)
                       Interstitial oncotic pressure (water-pulling)
              Forces favoring reabsorption
                       Plasma oncotic pressure (water-pulling)
                       Interstitial hydrostatic pressure


                                                                  7
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Water Movement Between                                Be able to do equation to
                                                      figure out force. In
                                                      edema, hypertension,
the ICF and ECF                                       obstruction.




                                                              8
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Edema
        Factors that increase Capillary Hydrostatic Pressure
                Venous obstruction THink Kinking.
                         Thrombophlebitis, tight clothing, prolonged sitting or standing
                Salt and water retention Think osmosis drawing fluid in to make more volume.
                         CHF
                         Renal failure
                         Cirrhosis
        Factors that decrease Capillary Oncotic Pressure
                Decreased plasma proteins Less fluid in vessels
                         Cirrhosis
                         Nephrotic syndrome - centralized edema.
                         Malnutrition
                         Burns - lose proteins through skin.
        Factors that increase capillary permeability
                Inflammation and Immune response as a result of:
                         Trauma: burns, crush injury, neoplastic disease, allergic Rnx
                         Proteins escape from plasma
                                 ↓ capillary oncotic pressure & ↑interstitial oncotic pressure
        Factors that decrease absorption of interstitial fluids
                Lymph obstruction
                             Infection
                             Tumor                                                               9
                             Surgical re-section
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Water Balance - two main factors
              Thirst perception - stim water drinking
               behavior.
                       Osmolality receptors
                                 Hyperosmolality and plasma volume depletion
                                 decrease in actual H2O
              ADH secretion
                       Increase thirst sensation
                       Increase permeability of Renal distal tubule to
                        water = increased water retention. sensor in atrea, aorta,
                                                                     sensing 10
                                                                              pressure. Used to
Mosby items and derived items © 2006 by Mosby, Inc.
                                                                     sense water.
Other Regulatory Hormones
   Aldosterone
     Released by the adrenal cortex
     Stimulates the retention of NA and excretion of K
      by the distal tubule of the kidney - therefore water
      follows.
     Aldosterone released in response to:
           Increasingserum K (hyperkalemia)
           Decreasing serum NA (hyponatremia)
           Low renal perfusion                                            Renin, from JGA, sensing
                            Renin - Angiotensin- Aldosterone System (RAAS) in the kidney.
                                                                           low flow
                                                                           Start RAAS,
                                     Increase volume (Na) and increase BP Angiotensin 2 is a

                                                                           vasoconstrictor.
                                                                                     11
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                                                                           Normal is 136 - 145 Na
                                                                           per L
Other Regulatory Hormones
         Natriuretic peptides
                  Atrial natriuretic peptide (heart)
                  Brain natriuretic peptide (heart)
                  Urodilantin (kidney)
                  ANP (& BNP) is released by the cardiac muscle fibers in
                   response to abnormal stretching of the atrial walls
                  Abnormal stretching can be caused by increased blood
                   pressure or increased blood volume
                  Effects: reduces thirst, decreased release of ADH and
                   Aldosterone
                  Will cause diuresis – water and sodium


                                                                  12
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Alterations in Na+, Cl–, and Water
              Total body water change with proportional
               electrolyte and water change
                       Isotonic volume depletion -- proportional exchange.
                                 Hemorrhage
                                 Excessive diaphoresis               Cl- is the bitch, follows
                                 Decrease fluid intake               Na+.

                                 Intestinal losses
                       Isotonic volume excess
                                 Excessive NS IV - iatrogenically.
                                 Hyperaldosteronism
                                 cortisone - steroid
                                                                                        13
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Decreased water -
                                                                         Diabetes Insipitus. Loss
                                                                         of ADH: unable to
Hypertonic Alterations                                                   concentrate urine. Fine,
                                                                         as long as they can
                                                                         drink.
          Hypernatremia                                                 Conn


                   Serum sodium >147 mEq/L
                   Related to sodium gain or water loss
                   Water movement from the ICF to the ECF
                             Intracellular dehydration (cell shrinks)
                   Manifestations
                             Intracellular dehydration, convulsions, pulmonary
                              edema, hypotension, tachycardia


                                                                                  14
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Hypotonic Alterations
          Decreased ECF osmolality
          Caused by:
                   Sodium deficit (Hyponatremia) or
                   Fee water excess (water intoxication)
          Hyponatremia will cause water movement from ECF to
           ICF
                   Intracellular overhydration (cell swells)
                             Cerebral edema – irritability, confusion, HA, depression, systemic
                              edema, weakness, anorexia, nausea, diarrhea
                   Plasma hypovolemia
                             Hypotension, tachycardia, decrease urine output

          Free water Excess both ICF and ECF volume increase
                   Intracellular overhydration (cell swells)
                   Plasma hypervolemia
                             Cellular and systemic edema as above
                                                                                         15
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Hyponatremia
              Serum sodium level <135 mEq/L
              Sodium deficits cause plasma hypoosmolality and cellular
               swelling
              Causes:                                    addisons disease, not
                       Pure sodium deficits                                                enough cortisol or aldo.
                                 Vomiting, diarrhea, overuse diuretics, burns              Innapropriate secretion
                                                                                            of ADH - page 104 in
                       Low sodium intake                                                   text.
                                 Rare
                       Dilutional hyponatremia
                                 Excessive ½ NS IV (.45) - hypotonic saline
                                 Mannitol (shift from ICF to ECF) - not low sodium, just being diluted
                       Hypoosmolar hyponatremia
                                 ARF (oliguric), severe CHF, Liver Cirrhosis
                       Hypertonic hyponatremia
                                 Hyperlipidemia, hyperglycemia, hyperproteinemia
                                                                                                    16
                                           Displace water volume and decrease Na concentration
Mosby items and derived items © 2006 by Mosby, Inc.
orthostatic vitals:BP
Water Deficit                                                        drop, pulse goes up.




               Dehydration - common
                         Isotonic (loss of water and sodium)
               Pure water deficits - rare
                         Hypertonic dehydration
               Renal free water clearance - common
                         Impaired tubular function or inability to concentrate urine
               Manifestations
                   HA, thirst, dry skin/mucous membranes, wt loss, fever, conc urine*
                   Tachycardia, weak pulses, and postural hypotension
                   Elevated hematocrit and serum sodium level
                 * Not with diabetes insipidus
                                                                                     17
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Water Excess
       Compulsive water drinking
                Psychogenic
       Decreased urine formation
                Intrinsic renal disease or decreased renal blood flow
       Syndrome of inappropriate secretion of ADH (SIADH)
                ADH secretion in the absence of hypovolemia or hyperosmolality
                Hyponatremia with hypervolemia
       Manifestations
                Rapid loading - cerebral edema, confusion, seizures
                Slow loading - weakness, nausea, muscle twitching, headache, and
                 weight gain

                                                                          18
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Potassium
       Major intracellular cation
       Concentration maintained by the Na+/K+
        ATPase pump
       Regulates intracellular electrical neutrality in
        relation to Na+ and H+
       Essential for transmission and conduction of
        nerve impulses, normal cardiac rhythms, and
        skeletal and smooth muscle contraction
                                                      19
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Potassium Levels
       Changes in pH affect K+ balance
                Hydrogen ions accumulate in the ICF during
                 states of acidosis. K+ shifts out to maintain a
                 balance of cations across the membrane.
       Aldosterone, insulin, and catecholamines
        influence serum potassium levels
                                                      ECF acidodic, casue H to be
                                                      pumped into the cell,
                                                      exchanging K out.



                                                                                    20
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Hypokalemia
       Potassium level <3.5 mEq/L
       Etiology
                Reduced intake
                Shifts of potassium from the extracellular to intracellular
                 space (alkalosis)
                Loss of potassium from body stores: GI losses with
                 vomiting, diarrhea, fistulas, laxative abuse. Renal losses
                 from overuse of diuretics, increased aldosterone.
       Manifestations
                Membrane hyperpolarization causes a decrease in
                 neuromuscular excitability, skeletal muscle weakness,
                 smooth muscle atony, and cardiac dysrhythmias
                                                                    21
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Renal failure is the most
                                                      common cause


Hyperkalemia
       Potassium level >5.5 mEq/L
       Hyperkalemia is rare due to efficient renal
        excretion -
       Caused by increased intake, shift of K+ from
        ICF, decreased renal excretion, insulin
        deficiency, or cell trauma         K goes into the cells with
                                                          glucose.




                                                                      22
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Hyperkalemia
       Mild attacks
                Hypopolarized membrane, causing neuromuscular
                 irritability
                          Tall peaked T waves with shortened QT on ECG - rapid
                           repolarization, poor propigation of AP.
                          Tingling of lips and fingers, restlessness, intestinal cramping, and
                           diarrhea
       Severe attacks
                The cell is not able to repolarize, resulting in muscle
                 weakness, loss or muscle tone, and flaccid paralysis
                          Depressed ST segment, prolonged PR interval, widened QRS
                                                                                    23
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Usually inverse
                                                                  relationship.



Calcium and Phosphate
            Most calcium is stored in bone (99%)
            Necessary for structure of bones and teeth, blood
             clotting, hormone secretion, and cell receptor
             function
            Like calcium, most phosphate (85%) is also located
             in the bone
            Necessary for high-energy bonds located in creatine
             phosphate and ATP and acts as an anion buffer
            Calcium and phosphate concentrations are rigidly
             controlled
                     Increase in one will require a decrease in the other
                                                                         24
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Calcium and Phosphate
       Regulated by three hormones - tight control.
                Parathyroid hormone (PTH)
                          Increases plasma calcium levels
                          Renal activation of Vitamin D
                Vitamin D
                          Fat-soluble steroid; increases calcium absorption from
                           the GI tract - epidemic due to sunscreen.
                Calcitonin - parafollicular cells (c cells) in
                 pancreas.
                          Decreases plasma calcium levels - “tone down”.
                                                                        25
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Hypocalcemia and Hypercalcemia
       Hypocalcemia                                               Hypercalcemia
                < 8.5 mg/dl                                           > 12 mg/dl
                Increased                                             Decreased
                 neuromuscular                                          neuromuscular
                 excitability                                           excitability
                 (partial depolarization)                              Muscle weakness
                Muscle cramps                                         Increased bone
                Think of as partial                                    fractures!!!Wierd
                 depolarization                                        Kidney stones
                                                                       Constipation - hard to
                                          be able to compare/
                                          contrast                      depolarize
                                                                                        26
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pH
       Inverse logarithm of the H+ concentration
       If the H+ are high in number, the pH is low
        (acidic). If the H+ are low in number, the pH
        is high (alkaline).
       The pH scale ranges from 0 to 14: 0 is very
        acidic, 14 is very alkaline. Each number
        represents a factor of 10. If a solution moves
        from a pH of 6 to a pH of 5, the H+ have
        increased 10 times.
                                                      27
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pH
       Acids are formed as end products of protein,
        carbohydrate, and fat metabolism
       To maintain the body’s normal pH (7.35-7.45)
        the H+ must be neutralized or excreted
       The bones, lungs, and kidneys are the major
        organs involved in the regulation of acid and
        base balance

                                                      28
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pH
       Body acids exist in two forms
                Volatile - can blow off.
                          H2CO3 (can be eliminated as CO2 gas)
                Nonvolatile
                          Sulfuric, phosphoric, and other organic acids
                          Eliminated by the renal tubules with the regulation of
                           HCO3–




                                                                         29
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Buffering Systems
       A buffer is a chemical that can bind excessive H+ or
        OH– without a significant change in pH
       A buffering pair consists of a weak acid and its
        conjugate base
                Ex: H2CO3 ; HCO3- see the kidney work with both of these.
                HHb ; Hb- - in plasma. (Hemoglobin system)
       The most important plasma buffering systems are the
        carbonic acid–bicarbonate system and hemoglobin
       The most important intracellular buffering systems
        are phosphate and protein
                                                                             30
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Carbonic Acid–Bicarbonate Pair
       If the amount of bicarbonate decreases, the
        pH decreases, causing a state of acidosis
       The pH can be returned to normal if the
        amount of carbonic acid also decreases
                This type of pH adjustment is referred to as compensation
       The respiratory system compensates by increasing or
        decreasing ventilation
       The renal system compensates by producing acidic
        or alkaline urine                           Renal compensatio
       H2O + CO2 <-->H2CO3 <--> HCO3- + H+ take days. Lungs in
                                                    minutes to hours.
                                                                  31
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Other Buffering Systems
       Protein buffering
         Proteins have negative charges, so they can serve
          as buffers for H+
       Renal buffering
         Secretion of H+ in the urine and reabsorption of
          HCO3–
       Cellular ion exchange
         Exchange of K+ for H+ in acidosis and alkalosis


                                                      32
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Acid-Base Imbalances
       Normal arterial blood pH
                7.35 to 7.45
                Obtained by arterial blood gas (ABG) sampling
       Acidosis
                Systemic increase in H+ concentration
                          < 7.35
       Alkalosis
                Systemic decrease in H+ concentration
                          > 7.45
                                                         33
Mosby items and derived items © 2006 by Mosby, Inc.
Acidosis and Alkalosis
        Four categories of acid-base imbalances:
                 Respiratory acidosis—elevation of pCO2 due to
                  ventilation depression
                 Respiratory alkalosis—depression of pCO2 due
                  to alveolar hyperventilation
                 Metabolic acidosis—depression of HCO3– or an
                  increase in non-carbonic acids
                 Metabolic alkalosis—elevation of HCO3– usually
                  due to an excessive loss of metabolic acids
                                                      lactic acidosis - shock,
                                                      DKA,
                                                                        34
Mosby items and derived items © 2006 by Mosby, Inc.   Met Alk - diarrhea/
                                                      vomiting.
Metabolic Acidosis
                                                      SLower.




                                                            35
Mosby items and derived items © 2006 by Mosby, Inc.
Metabolic Alkalosis                                    Have alk urine.




Depression of breathing.




                                                                   36
     Mosby items and derived items © 2006 by Mosby, Inc.
Respiratory Acidosis

    etiology: depression of
    respiration. Can be acute
    and chronic. pCO2 will
    triggar compensation.




head trauma and drug OD,
compensation will not
happen.

Chronic - will cause
respiration to adapt,
changing set pint.
Kidneys are the one.
                                                            37
      Mosby items and derived items © 2006 by Mosby, Inc.
Respiratory Alkalosis

  Cause: ICU ventilated
  patients, anxiety,
  anemia (less Hb), pulm/cv
  disorders. Happens
  rapidly. Kidneys
  compensate for chronic.




                                                      38
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Acid Base Response




   Issue is either a production or excretion problem.
   Buffering systems in the plasma (RBC). bicarb/carbonic acid system and Hb.


                                                                   39
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Approach to Acid Base Disturbances




                                                      40
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Questions?


                                                      41
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Fluids and electrolyte

  • 1. Fluid and Electrolytes Acid and Base Balance Reference: Pathophysiology by Kathryn McCance Mindy Milton, MPA, PA-C July 1, 2010 1 Mosby items and derived items © 2006 by Mosby, Inc.
  • 2. Distribution of Body Fluids  Total body water (TBW)  Intracellular fluid Total body water aprox 42L Rest is fat, fat free solids, bones.  Extracellular fluid Mostly intracellular.  Interstitial fluid Adipose tissue has less water, so obese  Intravascular fluid have less total body water, and more risk of dehydration. age also effects, probably due to more fat. 2 Mosby items and derived items © 2006 by Mosby, Inc.
  • 3. Fluid Compartment 3 Mosby items and derived items © 2006 by Mosby, Inc.
  • 4. Electrolyte Distribution  Major Cations:  Extracellular fluid  Plasma: Na  Interstitial Fluid: Na  Intracelluar fluid  K, Mg  Major Anions  Extracellular Fluid  Plasma: Cl, HCO3, Protein  Interstitial: Cl, HCO3, HPO4, SO4  Intracellular Fluid  HPO4, Proteins, HCO3, CL,, SO4 4 Mosby items and derived items © 2006 by Mosby, Inc.
  • 5. Principles of Fluid and Electrolytes  Homeostatic mechanisms respond to changes in the extracellular fluid  Cellular receptors respond to changes in volume and osmotic concentration  Water is moved by osmotic gradients and not by active transport  Water follows sodium 5 Mosby items and derived items © 2006 by Mosby, Inc.
  • 6. Water Movement Between the Plasma & Interstitial Fluid  Osmolality represent Na consentration  Osmotic forces (hydrostatic pressure) due to heart contraction  Aquaporins H2O can also diffuse through memb.  Starling hypothesis  Net filtration = forces favoring filtration – forces opposing filtration (oncotic) capillary bed 6 Mosby items and derived items © 2006 by Mosby, Inc.
  • 7. Net Filtration  Forces favoring filtration  Capillary hydrostatic pressure (blood pressure)  Interstitial oncotic pressure (water-pulling)  Forces favoring reabsorption  Plasma oncotic pressure (water-pulling)  Interstitial hydrostatic pressure 7 Mosby items and derived items © 2006 by Mosby, Inc.
  • 8. Water Movement Between Be able to do equation to figure out force. In edema, hypertension, the ICF and ECF obstruction. 8 Mosby items and derived items © 2006 by Mosby, Inc.
  • 9. Edema  Factors that increase Capillary Hydrostatic Pressure  Venous obstruction THink Kinking.  Thrombophlebitis, tight clothing, prolonged sitting or standing  Salt and water retention Think osmosis drawing fluid in to make more volume.  CHF  Renal failure  Cirrhosis  Factors that decrease Capillary Oncotic Pressure  Decreased plasma proteins Less fluid in vessels  Cirrhosis  Nephrotic syndrome - centralized edema.  Malnutrition  Burns - lose proteins through skin.  Factors that increase capillary permeability  Inflammation and Immune response as a result of:  Trauma: burns, crush injury, neoplastic disease, allergic Rnx  Proteins escape from plasma  ↓ capillary oncotic pressure & ↑interstitial oncotic pressure  Factors that decrease absorption of interstitial fluids  Lymph obstruction  Infection  Tumor 9  Surgical re-section Mosby items and derived items © 2006 by Mosby, Inc.
  • 10. Water Balance - two main factors  Thirst perception - stim water drinking behavior.  Osmolality receptors  Hyperosmolality and plasma volume depletion  decrease in actual H2O  ADH secretion  Increase thirst sensation  Increase permeability of Renal distal tubule to water = increased water retention. sensor in atrea, aorta, sensing 10 pressure. Used to Mosby items and derived items © 2006 by Mosby, Inc. sense water.
  • 11. Other Regulatory Hormones  Aldosterone  Released by the adrenal cortex  Stimulates the retention of NA and excretion of K by the distal tubule of the kidney - therefore water follows.  Aldosterone released in response to:  Increasingserum K (hyperkalemia)  Decreasing serum NA (hyponatremia)  Low renal perfusion Renin, from JGA, sensing  Renin - Angiotensin- Aldosterone System (RAAS) in the kidney. low flow Start RAAS,  Increase volume (Na) and increase BP Angiotensin 2 is a vasoconstrictor. 11 Mosby items and derived items © 2006 by Mosby, Inc. Normal is 136 - 145 Na per L
  • 12. Other Regulatory Hormones  Natriuretic peptides  Atrial natriuretic peptide (heart)  Brain natriuretic peptide (heart)  Urodilantin (kidney)  ANP (& BNP) is released by the cardiac muscle fibers in response to abnormal stretching of the atrial walls  Abnormal stretching can be caused by increased blood pressure or increased blood volume  Effects: reduces thirst, decreased release of ADH and Aldosterone  Will cause diuresis – water and sodium 12 Mosby items and derived items © 2006 by Mosby, Inc.
  • 13. Alterations in Na+, Cl–, and Water  Total body water change with proportional electrolyte and water change  Isotonic volume depletion -- proportional exchange.  Hemorrhage  Excessive diaphoresis Cl- is the bitch, follows  Decrease fluid intake Na+.  Intestinal losses  Isotonic volume excess  Excessive NS IV - iatrogenically.  Hyperaldosteronism  cortisone - steroid 13 Mosby items and derived items © 2006 by Mosby, Inc.
  • 14. Decreased water - Diabetes Insipitus. Loss of ADH: unable to Hypertonic Alterations concentrate urine. Fine, as long as they can drink.  Hypernatremia Conn  Serum sodium >147 mEq/L  Related to sodium gain or water loss  Water movement from the ICF to the ECF  Intracellular dehydration (cell shrinks)  Manifestations  Intracellular dehydration, convulsions, pulmonary edema, hypotension, tachycardia 14 Mosby items and derived items © 2006 by Mosby, Inc.
  • 15. Hypotonic Alterations  Decreased ECF osmolality  Caused by:  Sodium deficit (Hyponatremia) or  Fee water excess (water intoxication)  Hyponatremia will cause water movement from ECF to ICF  Intracellular overhydration (cell swells)  Cerebral edema – irritability, confusion, HA, depression, systemic edema, weakness, anorexia, nausea, diarrhea  Plasma hypovolemia  Hypotension, tachycardia, decrease urine output  Free water Excess both ICF and ECF volume increase  Intracellular overhydration (cell swells)  Plasma hypervolemia  Cellular and systemic edema as above 15 Mosby items and derived items © 2006 by Mosby, Inc.
  • 16. Hyponatremia  Serum sodium level <135 mEq/L  Sodium deficits cause plasma hypoosmolality and cellular swelling  Causes: addisons disease, not  Pure sodium deficits enough cortisol or aldo.  Vomiting, diarrhea, overuse diuretics, burns Innapropriate secretion of ADH - page 104 in  Low sodium intake text.  Rare  Dilutional hyponatremia  Excessive ½ NS IV (.45) - hypotonic saline  Mannitol (shift from ICF to ECF) - not low sodium, just being diluted  Hypoosmolar hyponatremia  ARF (oliguric), severe CHF, Liver Cirrhosis  Hypertonic hyponatremia  Hyperlipidemia, hyperglycemia, hyperproteinemia 16  Displace water volume and decrease Na concentration Mosby items and derived items © 2006 by Mosby, Inc.
  • 17. orthostatic vitals:BP Water Deficit drop, pulse goes up.  Dehydration - common  Isotonic (loss of water and sodium)  Pure water deficits - rare  Hypertonic dehydration  Renal free water clearance - common  Impaired tubular function or inability to concentrate urine  Manifestations  HA, thirst, dry skin/mucous membranes, wt loss, fever, conc urine*  Tachycardia, weak pulses, and postural hypotension  Elevated hematocrit and serum sodium level * Not with diabetes insipidus 17 Mosby items and derived items © 2006 by Mosby, Inc.
  • 18. Water Excess  Compulsive water drinking  Psychogenic  Decreased urine formation  Intrinsic renal disease or decreased renal blood flow  Syndrome of inappropriate secretion of ADH (SIADH)  ADH secretion in the absence of hypovolemia or hyperosmolality  Hyponatremia with hypervolemia  Manifestations  Rapid loading - cerebral edema, confusion, seizures  Slow loading - weakness, nausea, muscle twitching, headache, and weight gain 18 Mosby items and derived items © 2006 by Mosby, Inc.
  • 19. Potassium  Major intracellular cation  Concentration maintained by the Na+/K+ ATPase pump  Regulates intracellular electrical neutrality in relation to Na+ and H+  Essential for transmission and conduction of nerve impulses, normal cardiac rhythms, and skeletal and smooth muscle contraction 19 Mosby items and derived items © 2006 by Mosby, Inc.
  • 20. Potassium Levels  Changes in pH affect K+ balance  Hydrogen ions accumulate in the ICF during states of acidosis. K+ shifts out to maintain a balance of cations across the membrane.  Aldosterone, insulin, and catecholamines influence serum potassium levels ECF acidodic, casue H to be pumped into the cell, exchanging K out. 20 Mosby items and derived items © 2006 by Mosby, Inc.
  • 21. Hypokalemia  Potassium level <3.5 mEq/L  Etiology  Reduced intake  Shifts of potassium from the extracellular to intracellular space (alkalosis)  Loss of potassium from body stores: GI losses with vomiting, diarrhea, fistulas, laxative abuse. Renal losses from overuse of diuretics, increased aldosterone.  Manifestations  Membrane hyperpolarization causes a decrease in neuromuscular excitability, skeletal muscle weakness, smooth muscle atony, and cardiac dysrhythmias 21 Mosby items and derived items © 2006 by Mosby, Inc.
  • 22. Renal failure is the most common cause Hyperkalemia  Potassium level >5.5 mEq/L  Hyperkalemia is rare due to efficient renal excretion -  Caused by increased intake, shift of K+ from ICF, decreased renal excretion, insulin deficiency, or cell trauma K goes into the cells with glucose. 22 Mosby items and derived items © 2006 by Mosby, Inc.
  • 23. Hyperkalemia  Mild attacks  Hypopolarized membrane, causing neuromuscular irritability  Tall peaked T waves with shortened QT on ECG - rapid repolarization, poor propigation of AP.  Tingling of lips and fingers, restlessness, intestinal cramping, and diarrhea  Severe attacks  The cell is not able to repolarize, resulting in muscle weakness, loss or muscle tone, and flaccid paralysis  Depressed ST segment, prolonged PR interval, widened QRS 23 Mosby items and derived items © 2006 by Mosby, Inc.
  • 24. Usually inverse relationship. Calcium and Phosphate  Most calcium is stored in bone (99%)  Necessary for structure of bones and teeth, blood clotting, hormone secretion, and cell receptor function  Like calcium, most phosphate (85%) is also located in the bone  Necessary for high-energy bonds located in creatine phosphate and ATP and acts as an anion buffer  Calcium and phosphate concentrations are rigidly controlled  Increase in one will require a decrease in the other 24 Mosby items and derived items © 2006 by Mosby, Inc.
  • 25. Calcium and Phosphate  Regulated by three hormones - tight control.  Parathyroid hormone (PTH)  Increases plasma calcium levels  Renal activation of Vitamin D  Vitamin D  Fat-soluble steroid; increases calcium absorption from the GI tract - epidemic due to sunscreen.  Calcitonin - parafollicular cells (c cells) in pancreas.  Decreases plasma calcium levels - “tone down”. 25 Mosby items and derived items © 2006 by Mosby, Inc.
  • 26. Hypocalcemia and Hypercalcemia  Hypocalcemia  Hypercalcemia  < 8.5 mg/dl  > 12 mg/dl  Increased  Decreased neuromuscular neuromuscular excitability excitability (partial depolarization)  Muscle weakness  Muscle cramps  Increased bone  Think of as partial fractures!!!Wierd depolarization  Kidney stones  Constipation - hard to be able to compare/ contrast depolarize 26 Mosby items and derived items © 2006 by Mosby, Inc.
  • 27. pH  Inverse logarithm of the H+ concentration  If the H+ are high in number, the pH is low (acidic). If the H+ are low in number, the pH is high (alkaline).  The pH scale ranges from 0 to 14: 0 is very acidic, 14 is very alkaline. Each number represents a factor of 10. If a solution moves from a pH of 6 to a pH of 5, the H+ have increased 10 times. 27 Mosby items and derived items © 2006 by Mosby, Inc.
  • 28. pH  Acids are formed as end products of protein, carbohydrate, and fat metabolism  To maintain the body’s normal pH (7.35-7.45) the H+ must be neutralized or excreted  The bones, lungs, and kidneys are the major organs involved in the regulation of acid and base balance 28 Mosby items and derived items © 2006 by Mosby, Inc.
  • 29. pH  Body acids exist in two forms  Volatile - can blow off.  H2CO3 (can be eliminated as CO2 gas)  Nonvolatile  Sulfuric, phosphoric, and other organic acids  Eliminated by the renal tubules with the regulation of HCO3– 29 Mosby items and derived items © 2006 by Mosby, Inc.
  • 30. Buffering Systems  A buffer is a chemical that can bind excessive H+ or OH– without a significant change in pH  A buffering pair consists of a weak acid and its conjugate base  Ex: H2CO3 ; HCO3- see the kidney work with both of these.  HHb ; Hb- - in plasma. (Hemoglobin system)  The most important plasma buffering systems are the carbonic acid–bicarbonate system and hemoglobin  The most important intracellular buffering systems are phosphate and protein 30 Mosby items and derived items © 2006 by Mosby, Inc.
  • 31. Carbonic Acid–Bicarbonate Pair  If the amount of bicarbonate decreases, the pH decreases, causing a state of acidosis  The pH can be returned to normal if the amount of carbonic acid also decreases  This type of pH adjustment is referred to as compensation  The respiratory system compensates by increasing or decreasing ventilation  The renal system compensates by producing acidic or alkaline urine Renal compensatio  H2O + CO2 <-->H2CO3 <--> HCO3- + H+ take days. Lungs in minutes to hours. 31 Mosby items and derived items © 2006 by Mosby, Inc.
  • 32. Other Buffering Systems  Protein buffering  Proteins have negative charges, so they can serve as buffers for H+  Renal buffering  Secretion of H+ in the urine and reabsorption of HCO3–  Cellular ion exchange  Exchange of K+ for H+ in acidosis and alkalosis 32 Mosby items and derived items © 2006 by Mosby, Inc.
  • 33. Acid-Base Imbalances  Normal arterial blood pH  7.35 to 7.45  Obtained by arterial blood gas (ABG) sampling  Acidosis  Systemic increase in H+ concentration  < 7.35  Alkalosis  Systemic decrease in H+ concentration  > 7.45 33 Mosby items and derived items © 2006 by Mosby, Inc.
  • 34. Acidosis and Alkalosis  Four categories of acid-base imbalances:  Respiratory acidosis—elevation of pCO2 due to ventilation depression  Respiratory alkalosis—depression of pCO2 due to alveolar hyperventilation  Metabolic acidosis—depression of HCO3– or an increase in non-carbonic acids  Metabolic alkalosis—elevation of HCO3– usually due to an excessive loss of metabolic acids lactic acidosis - shock, DKA, 34 Mosby items and derived items © 2006 by Mosby, Inc. Met Alk - diarrhea/ vomiting.
  • 35. Metabolic Acidosis SLower. 35 Mosby items and derived items © 2006 by Mosby, Inc.
  • 36. Metabolic Alkalosis Have alk urine. Depression of breathing. 36 Mosby items and derived items © 2006 by Mosby, Inc.
  • 37. Respiratory Acidosis etiology: depression of respiration. Can be acute and chronic. pCO2 will triggar compensation. head trauma and drug OD, compensation will not happen. Chronic - will cause respiration to adapt, changing set pint. Kidneys are the one. 37 Mosby items and derived items © 2006 by Mosby, Inc.
  • 38. Respiratory Alkalosis Cause: ICU ventilated patients, anxiety, anemia (less Hb), pulm/cv disorders. Happens rapidly. Kidneys compensate for chronic. 38 Mosby items and derived items © 2006 by Mosby, Inc.
  • 39. Acid Base Response Issue is either a production or excretion problem. Buffering systems in the plasma (RBC). bicarb/carbonic acid system and Hb. 39 Mosby items and derived items © 2006 by Mosby, Inc.
  • 40. Approach to Acid Base Disturbances 40 Mosby items and derived items © 2006 by Mosby, Inc.
  • 41. Questions? 41 Mosby items and derived items © 2006 by Mosby, Inc.

Notas do Editor

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  8. The Starling Equation:\n\nJv = Kf [ (Pc-Pi) - (Pic-Pii) ] \n\nWhere:\nJv = fluid movement\nKf = Huraulic conductance\nPc = capillary Hydrostatic Pressure\nPi = interstitial hydrostatic pressure\nPi c = capillary oncotic pressure\nPi i = interstitial oncotic pressure\n
  9. Flow = [ (pressure of Cap - Pressure of interstitium) - (oncotic P of Cap - Oncotic P of interstitium) ]\n\n+ Pc: art dilation, venous constriction, venous pressure, Heart failure, EC volume expansion, Dependant limb edema\n- Pi c: - plasma protein, liver disease, protein starving, nephrotic syndrom, \n+ Kf: Burn, Inflammation\n
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  26. Perhaps because,\n- Ca outside cell makes cell relatively positive and closer to threshold.\n
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  38. You are basically forced to blow off all your CO2.\n
  39. \n
  40. 1 - look at pH\n2 - look at pCO2. (see it as bicarb on chem 7) See if it is metabolic or respiratory. If outside of normal, than it is not \nthe lung&amp;#x2019;s fault.\n3 - Ex:(Acid)If pCO2 is normal, then it is acute metab. If decreased, then chronic. \n4 - Look at ion gap: Na - (CO2 + Cl) = ion gap. 10-12 = normal. \n Normal, means loss. \n Gap = DKA, LA, ingestion of antifreeze, methanol, aspirin OD, RF, \n If pCO2 elevated, its the lung. Then look at bicarb, see if acute or chronic, see if the kidneys have kicked in.\n*** do the same on the basic side. \n
  41. \n