FOR LEARNING AND TEACHING PURPOSE

1. BY DR QIRAT SIDDIQUI

2. • Total body fluid
• Fluid compartment composition
• Important Terminologies
• Approximate value of daily input and output
• Normal daily fluid loss
• Abnormal Fluid Loss
• Volume Changes
• Concentration Changes
• Composition Changes

4. •BASIC
PHYSIOLOGY

6. • Example for a healthy 70 kg man,
• TBW=0.6x70=42L
• ICF=2/3 TBW = 0.66x42=28L
• ECF=1/3 TBW = 0.33x42= 14L
• Intravascular compartment= 0.25x 14 = 3.5L
• Interestitial compartment = 0.75x 14= 10.5 L

7. ECF ICF
MAJOR CATION SODIUM POTASSIUM AND
MAGNESSIUM
MAJOR ANION CHLORIDE AND
BICARBONATE
PHOSPHATE,
SULPHATE AND
PROTEIN

8. • Osmolarity:
• It is fluid capability to create osmotic pressure.
• It is concentration of osmotically active substance.
• Osmolality:
• It is number of particles/L of solution.
• Tonicity:
• Way of expressing effective osmolarity

9. • Fluid balance is an aspect of
the homeostasis of organisms in which the amount
of water in the organism needs to be controlled,
via osmoregulation and behavior, such that
the concentrations of electrolytes (salts in solution) in
the various body fluids are kept within healthy ranges.

11. WATER GAIN ROUTE AVERAGE
DAILY
VOLUME (ml)
MINIMUM (ml) MAXIMUM (ml)
SENSIBLE ORAL FLUIDS 800-1500 0 1500/h
SOLID FOOD 500-700 0 1500
INSENSIBLE METABOLIC
WATER
250 125 800

12. WATER LOSS ROUTE AVERAGE
DAILY
VOLUME(ml)
SENSIBLE URINE 800-1500
INTESTINE 0-250
SWEAT 100
INSENSIBLE LUNGS 400
SKIN 500-1000

13.  Insensible fluid input=300ml due to oxidation of water
 Insensible fluid loss=500ml through skin
400ml through lungs
100ml through stool
Fluid loss –fluid input=1000-300=700ml
NORMAL DAILY INSENSIBLE FLUID
LOSS=700ML

14. DAILY FLUID REPLACEMENT=
URINE OUTPUT+700

15. There are seven means of abnormal means of fluid loss
which are:
• Vomiting
• Diarrhea
• Prespiration(moderate=500ml, severe=1-1.5L)
• Burns and open body cavity(laprotomy)=0.5-3 L
• Gastric suction
• Bleeding
• Diuretic drugs
• Fever:100ml/degree fever/day
• Tracheostomy (unhumidified air) :m ore than 1.5 litres

16. • VOLUME CHANGES
• CONCENTRATION CHANGES
• COMPOSITION CHANGES

17. Hypovolemia
Hypervolemia

19. • Volume depletion generally results from a deficit in total
body Na+ content. This may result from renal or
extrarenal losses of Na+ from the ECF. Water losses
alone can also cause volume depletion, but the quantity
required to do so is large, as water is lost mainly from the
ICF and not the ECF, where volume contraction can be
assessed.

20. • Thirst
• Fatigue
• weakness,
• muscle cramps,
• and postural dizziness.
• Sometimes, syncope and coma can result with severe
volume depletion

21. • low jugular venous pressure,
• postural hypotension,
• postural tachycardia,
• and the absence of axillary sweat
• Diminished skin turgor and dry mucous membranes are
poor markers of decreased interstitial fluid. Mild degrees
of volume depletion are often not clinically detectable,
whereas larger fluid losses can lead to mental status
changes, oliguria(less than 0.5 L), and hypovolemic
shock.

22. • Laboratory studies are often helpful but must be used in
conjunction with the clinical picture
• Urine sodium
• Urine osmolality and serum bicarbonate -elevated.
• Hematocrit and serum albumin -increased

23. • Isotonic fluid, such as NS (0.9% NaCl), contains a Na+
content similar to that of plasma fluid in the ECF.
• BOLUS ADMINISTRATION:
• An initial bolus of lactated Ringer solution or normal
saline of 250-500ml (over 5-7 mins) of is given in an
adult (20 mL/kg in a pediatric patient), and the patient's
response is assessed.
• Hemorrhage or GI bleeding, blood transfusion.

25. SIGNS:
• Expansion of the interstitial compartment may result in
peripheral edema, ascites, and pleural effusions.
Expansion of the intravascular compartment may result
in pulmonary rales, elevated jugular venous pressure,
hepatojugular reflux, an S3 gallop, and elevated blood
pressures.
• SYMPTOMS:
• dyspnea
• abdominal distention
• swelling of extremities

26. • Laboratory studies are generally not needed, and
hypervolemia is primarily a bedside diagnosis.
• The urine [Na+]
• CXR may show pulmonary edema or pleural effusions,
but clear lung fields do not exclude volume overload.

27. Medications:
• Diuretics
• Dialysis can be option in severe cases.

28. Sodium is the major extracellular cation in plasma and
its concentration is closely related to osmotic
homeostasis.
HYPERNATREMIA
HYPONATREMIA

29. • Hyponatremia is defined as a plasma [Na+] <135 mEq/L

30. Acute hyponatremia:
• In acute hyponatremia (i.e., developing in <2 days),
approximately 125 mEq/L—NAUSEA AND MALAISE
• . As the plasma [Na+] falls further- headache, lethargy,
confusion, and obtundation.
• Stupor, seizures, and coma -below 115 mEq/L if falls
acutely.
• Chronic Hyponatremia (>3 days in duration)

31. • Diuretic use
• Diarrhea
• Heart failure
• Liver disease
• Renal disease
• SIADH

32. • Three laboratory analyses, when used with a clinical
assessment of volume status, can narrow the differential
diagnosis of hyponatremia:
• (a) the plasma osmolality (<275 mOsm/L)
• (b) the urine osmolality (urine osmolality <100 mOsm/L
and specific gravity <1.003).
• (c) the urine [Na+]: discriminate between extrarenal
and renal losses of Na+

35. • Hypernatremia is defined as a plasma [Na+] >145 mEq/L
and represents a state of hyperosmolality.
• • Asymptomatic
• • Symptomatic (Na>160 meq/L)
• CNS manifestations : due to dehydration of brain cells

36. Body system Signs & symptoms
Central nervous system Restlessness, lethargy, ataxia,
irritability, tonic spasms, delirium,
seizures, coma
Musculoskeletal Weakness
Cardiovascular Tachycardia, hypotension, syncope
Tissue Dry sticky mucous membranes, red
swollen tongue,
decreased saliva and tears
Renal Oliguria
Metabolic Fever

37. Etiology &
treatment
of
hypernatremia

38. • Acid/Base Balance
• Potassium Abnormalities
• Calcium Abnormalities

39. • Increased renal excretion
• Administration of potassium free fluids
• Parentral nutrition without potassium
• Fistulas
• Direct loss of potassium from gastrointestinal fluid
(diarrhea), (gastric fluid, either as vomiting or high
nasogastric output)

40. Body system Signs & symptoms
Gastrointestinal Paralytic Ileus, constipation
Neuromuscular Decreased reflexes, fatigue, weakness,
paralysis, rhabdomyolysis, hyporeflexia
Cardiovascular U-waves
T-wave flattening
ST-segment changes
Arrhythmias
Tissue Dry sticky mucous membranes, red swollen
tongue,
decreased saliva and tears
Renal Polyuria & polydypsia

41. • Oral therapy. Oral doses of 40 mEq are generally well
tolerated and can be given as often as every 4 hours.
Traditionally, 10 mEq of potassium salts are given for
each 0.10mEq/L decrement in serum [K+].
• IV THERAPY : The maximum concentration of
administered of K+ should be no more than 40 mEq/L
via a peripheral vein or 100 mEq/L via a central vein.
• Kdeficit (in mmol) = (Knormal lower limit − Kmeasured) × kg body
weight × 0.4.

42. Etiology :
1. Increased intake : Potassium supplementation & Blood
transfusions
2. Endogenous load/destruction: hemolysis,
rhabdomyolysis, crush injury, gastrointestinal hemorrhage
3. Increased release : Acidosis
4. Rapid rise of extracellular osmolality (hyperglycemia or
mannitol) : Impaired excretion of potassium & Renal
insufficiency/failure.

43. Body system Signs & symptoms
Gastrointestinal Nausea/vomiting ,colic diarrhea
Neuromuscular weakness, paralysis, respiratory
failure
Cardiovascular Arrhythmia, arrest
ECG changes Peaked T waves (early change)
Flattened P wave
Prolonged PR interval (first-degree
block)
Widened QRS complex
Ventricular fibrillation

45. • Majority of the 1000 to 1200g of calcium in the average-
sized adult is found in the bone .
• Normal daily intake of calcium is 1 to 3 gm.
• Normal serum level = 8.8-10.5 mg/dl
• Albumin Bound = 40-60%
• Ionized portion (1.2 mg/dl) is responsible for
neuromuscular stability
• Most is excreted via the GI tract
Corrected calcium = 4 – albumin x 0.8 + serum calcium

46. Hypocalcemia Hypercalcemia
Serum calcium level <8.8
mg/dl
Causes:
-acute pancreatitis,
-massive soft-tissue
infections
(necrotizing fasciitis),
-acute and chronic renal
failure,
-pancreatic and small-bowel
fistulas,
-Hypoparathyroidism
• Serum calcium level >10.5
mg/dl
• Causes:
-hyperparathyroidism
-cancer
PTH-like peptide in
malignancies

47. Hypocalcemia S/S Hypercalcemia S/S
1. Hypotension
2. Anxiety
3. Psychosis
4. Paresthesia
5. Laryngeal spasm
6. Numbness and tingling of the
circumoral region and the tips of
the
fingers and toes
7. tetany with carpopedal spasm,
convulsions (with severe deficit),
8. Chvosteck & trousseau’s signs
1. Hypertension
2. Bradycardia
3. Constipation
4. Anorexia
5. nausea, vomiting
6. Nephrolithiasis
7. Pain
8. Psychosis
9. Pruritis
10. weight loss, thirst, polydipsia,
and
polyuria
11. easy fatigue, weakness,
stupor,and
coma

48. HYPOCALCEMIA HYPERCALCEMIA
• (IV) calcium gluconate-
ACUTE
• oral calcium and vitamin
D supplements-CHRONIC
• 0.9% NORMAL SALINE
THEN FUROSEMIDE.