5)

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BODY FLUID

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90
EXCLUSIVE EDUCATION AID

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Dr. Mahira Murshid, MBBS (AFMC)

Resident (Pediatric surgery ), Dhaka Shishu Hospital
FLUID COMPARTMENT OF THE BODY :
Topic 1

Total body fluid (42L) : 60%

Extracellular fluid (ECF) : 1/3rd

5)
• Interstitial fluid (11L) Lymph 75%

13
• Plasma (3L)
• Transcellular fluid (1-2L) :

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Fluid in potential spaces- Fluid in pleural cavity, pericardial cavity, peritoneal cavity,
synovial cavity including joint cavity & bursa, cavity of the tunica vaginalis surrounding

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the testis etc.

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Fluid in Git & respiratory tract
Intraocular fluid CSF

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Intracellular fluid (28L) 2/3rd

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Extracellular fluid: The fluid outside the cells of the body is called ECF is 1/3 of total body fluid.
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In the extracellular fluid are the ions and nutrients needed by the cells to maintain cell life.
n

Thus, all cells live in essentially the same environment—the extracellular fluid. For this reason,
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the extracellular fluid is also called the internal environment of the body, or the milieu
intérieur. The extracellular fluid contains large amounts of sodium, chloride and bicarbonate
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ions plus nutrients for the cells, such as oxygen, glucose, fatty acids and amino acids. It also
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contains carbon dioxide that is being transported from the cells to the lungs to be excreted,
Ed

plus other cellular waste products that are being transported to the kidneys for excretion.
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Intracellular fluid: The fluid inside the cells of the body is called ICF. It is 2/3 of total body fluid.
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It contains large amounts of potassium, magnesium and phosphate ions instead of the sodium
and chloride ions found in the extracellular fluid. Special mechanisms for transporting ions
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through the cell membranes maintain the ion concentration differences between the
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extracellular and intracellular fluids.

Total body water is most in early fetal life. With increase in age, body water decreases due to
increase in fat. In general, TBW is about 72% of lean body mass (LBM).
Among the different organs, brain contains highest water content (84%) and adipose tissue
contains lowest water content (10%). Water content of skeletal muscle is 80%.

In female, TBW is about 5-10% less than that in male of same age became of high fat content
in female compared to male. Fat represent 15% of body weight in non obese male & 21% of

5)
body weight in non obese female.

13
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Transcellular fluid :
It is the part of ECF & formed by transport activity or secretory activity of cells. It is separated

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from plasma by in additional epithelial cell layer along with the capillary epithelium. It is rich in

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mucopolysaccharide and slippery due to glycoprotein.

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Ex : Synovial fluid, peritoneal fluid, pleural fluid, pericardial fluid, gastro intestinal secretion,
intraocular fluid, urine, sweat etc.

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Functions of body water :
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1. Maintenance of metabolic integrity

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2. Transport of different substances

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3. Maintenance of circulatory integrity

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4. Maintenance of by fluid osmolarity

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5. Thermoregulation
6. Maintenance of form and texture of tissues
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ECF osmolarity = ICF osmolarity

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Differences between ECF & ICF: VVI

ECF ICF
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1. Occupies outside the cell. Specially 1. Occupies inside the cells.

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potential spaces of body.

2. Consists 1/3rd of total body water. Is about 2. Consists 2/3rd of total body water. Is about
14L. 28L.
3. Has more sodium, chloride, calcium, 3. Has more potassium, magnesium,
bicarbonate, sulphate and glucose than ICF. phosphate, protein, amino acid, cholesterol,
phospholipids and neutral fat.
 4. PO2 = 35mmHg 4. PO2 =20mmHg
5. PCO2 = 46mmHg 5. PCO2 = 50mmHg
6. PH -7.4 6. PH -7.0

Measurement of body fluid volumes : Topic 2

5)
Methods of measurement :

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Indirect method – indicator dye dilution technique Principle

59
: Have to select a suitable dye or radio-isotope.

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V= Volume of fluid .

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A= Total amount of dye used.

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E= Amount of dye excreted or lost.

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C= Concentration of dye in each ml after dispersed.
Formula : V= ( A-E ) /C
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Total body water bh20, & H2O, antipyrin

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Criteria of suitable dye:

• Must mix evenly throughout the compartment .

• Non toxic.
• Must not have any effects of it’s own on the distribution of water or other substances in

5)
the body.
• Either it must be unchanged during the experiment or if it changes, the amount changed

13
must be known.

59
• The material should be relatively easy to measure.

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90
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Insensible water loss : VVI

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Loss of water through the skin (by diffusion) and from the lungs (by evaporation) is known an
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insensible water loss. This insensible loss amounts to 1000-1200 ml per day in humans. Visible
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sweating is called sensible perspiration and invisible sweating is called invisible perspiration.
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Water loss by lungs is called insensible transpiration. Loss of water from the skin and
respiration is not under control of the body mechanism.
750ml
Water turnover
It is the percentage of ECF volume that is lost and again made up per day.
Water turnover = (Water output per day / ECF volume ) x 100
In adult it is approx 18%. In infant and children it is approx 45-60%.
High water turnover leads to quick dehydration. So infants and children are very much prone
to develop dehydration and after passing 1-2 diarrheal motion.

5)
Osmotic Pressure, osmolarity and osmolality :

13
The osmotic pressure of a solution is directly proportional to the concentration of osmotically

59
active particles in that solution. This is true regardless of whether the solute is a large molecule
or a small molecule.

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Osmolarity is the measure of the concentration of solute particles or osmoles per litre. Thus,

90
the osmotic pressure of a solution is proportional to it’s osmolarity.

17
Expressed mathematically, according to Van’t Hoff’s law, osmotic pressure ( π) can be
calculated as, π = CRT

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Where C is the concentration of solutes in osmoles per liter, R is the ideal gas constant, and T is
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the absolute temperature in degrees kelvin (273° + centigrade°).
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Plasma osmolarity =2[Na+]+[Urea]+[glucose]= 300mosml /litre. Of which, 92% is produced by

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NaCl and rest 8% by others ( 7.5% by other crystalloids and 0.5% by colloids).
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Osmolality is defined as the number of osmoles of solute per kilogram of solvent (osmol/kg )
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In contrast to osmorality, osmolality is independent of temperature and pressure.

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Causes of increased urine osmolality (>150mOsmol/kg):

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• Dehydration
• SIADH
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• Adrenal insufficiency
•
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Glycosuria
•
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Hypernatremia
• High-protein diet

Causes of decreased urine osmolality (<150mOsmol/kg):

• Diabetes insipidus
• Excessive fluid intake / Psychogenic polydipsia
 • Glomerulonephritis
• Acute renal insufficiency

Osmolar gap :

5)
Osmolar gap = Measured osmolarity - calculated osmolarity =0.12 mosml/L It

13
is increased in :

59
Hyperglycemia in DM
• Gross hyperproteinemia

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• Gross hyperlipidemia

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• Chronic renal failure
• Ketoacidosis

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• Lactic acidosis
•

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Mannitol infusion
• Alcohol poisoning
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Importance: Calculation of the osmolar gap can be clinically very useful in the assessment of
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the comatose patients.

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Classification of volume disorders :

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Hypovolemia :
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Isotonic hypovolemia : Clinically common. Here salt loss = water loss. ECF volume decreases
but ICF volume is normal. Osmolarity of both ICF and ECF is normal.
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Common causes :
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Severe hemorrhage, secretory diarrhoea, loss of small intestinal content by fistula,

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gastrostomy , intestinal obstruction, chronic renal failure etc.

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Hypertonic hypovolemia: Occur following hypotonic fluid loss. Water loss > salt loss. Both ECF
and ICF volume decrease. Osmolarity of both ICF and ECF increases.
Common causes:
Severe diarrhoea, profuse sweating, severe burn, persistent vomiting or nasogastric suction,
salt losing nephritis, osmotic diuresis, adrenal deficiency etc.
Hypotonic hypovolemia : Clinically rare. Water loss < salt loss. ECF volume decreases, but ICF
volume increases. Osmolarity in both ICF and ECF decreases.
Common causes:
Occur following treatment of the patients with isotonic or hypertonic hypovolemia by wrongly
selected intravenous fluid without NaCl, haemorrhage, vomiting, diarrrhoea , burn, salt losing

5)
nephritis, adrenal deficiency etc.

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Hypervolemia :
Isotonic hypervolemia : Clinically rare. Body total Na+ content increases but plasma Na+

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concentration is normal. ECF volume increases, but ICF volume is normal. Osmolarity is normal

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in both ICF & ECT ,edema doesn’t develop.

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Common causes:
Excess infusion of normal saline.

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Hypertonic hypervolemia: Clinically rare. Body Na+ content increases with increased plasma
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Na+ concentration. ECF volume increases, but ICF volume decreases. Osmolarity of both ECF &
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ICF increases but no edema develops.
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Common causes :
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Excess infusion of hypertonic saline . eg. 3% NaCl, NaHCO3 solution, Conn's syndrome (primary
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hyperaldosteronism), Cushing syndrome, sea water intake etc.

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Hypotonic hypervolemia: Clinically common. Occur in hypotonic fluid gain. Na+ concentration
of gained fluid is less than that of plasma. Body total Na+ content increases but plasma Na+
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conc is low. Both ECT and ICF volume increase. Osmolarity in both ICF & ECF decreases and
usually associated with edema.
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Common causes:
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Congestive cardiac failure (CCF), nephrotic syndrome, cirrhosis of liver, hepatic failure ,
Kwashiorkor, protein losing enteropathies etc.
 5)
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Laboratory findings : (0
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Hypovolemia :
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Serum sodium concentrations are usually normal in hypovolaemia. The GFR is usually
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maintained unless the hypovolemia is very severe or prolonged, but urinary flow rate is
reduced as a consequence of activation of sodium- and water-retaining mechanisms in the
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nephron. Serum creatinine, which reflects GFR, is usually normal, but serum urea
concentration is typically elevated due to a low urine flow rate, which is accompanied by
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increased tubular reabsorption of urea. Similarly, serum uric acid may also rise, reflecting
increased reabsorption in the proximal renal tubule. The urine osmolality increases due to
increased reabsorption of sodium and water, while the urine sodium concentration falls and
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sodium excretion may fall to less than 0.1% of the filtered sodium load. Hematocrit level and
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specific gravity of urine increases.

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Hypervolemia :
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Is accompanied by an excess of total body sodium, serum sodium concentrations are normal
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due to the accompanying water retention. Serum concentrations of potassium are normal
except in Conn’s syndrome, where there is hypokalemia due to the increased aldosterone
production. Creatinine, GFR and urea are usually normal, unless the underlying cause of
hypervolemia is renal failure. General investigations may reveal evidence of cardiac, renal or
liver disease.
Body water homeostasis :
It is maintained by the following mechanisms:

• Hypothalamic-thirst control mechanism

• Osmoreceptor -ADH mechanism
• Renin-Angiotensin system

5)
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Osmoreceptor-ADH mechanism :

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• Vasopressin (ADH) is stored in the posterior pituitary and released into the bloodstream

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by impulses in the nerve fibers that contain the hormone .
• At 280 mosmole/ kg ADH secretion suppressed but when the effective osmotic pressure

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of the plasma is increased above the normal 285 mosmole/kg, the rate of discharge of

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these neurons increases (osmoreceptors in supraoptic nucleus of hypothalamus is
stimulated) and vasopressin secretion is increased.

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• ADH increases the permeability of the collecting ducts of the kidney, so that water
enters the hypertonic interstitium of the renal pyramids. The urine becomes
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concentrated, and it’s volume decreases.
• The overall effect is therefore retention of water in excess of solute, consequently, the
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effective osmotic pressure of the body fluids is decreased. In the absence of

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vasopressin, the urine is hypotonic to plasma, urine volume is increased, and there is a
net water loss. Consequently, the osmolality of the body fluid rises.
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• ECF volume also affects vasopressin secretion. Vasopressin secretion is increased when
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ECF volume is low and decreased when ECF volume is high.

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 5)
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90
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Renin angiotensin aldosterone system : Topic 3
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Vasopressin
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Thirst mechanism :
As little as a 2% increase in ECF osmolality can trigger thirst and thirst mechanism is stimulated
when circulating ECF volume decrease 10% ( plasma osmolality is about 298mosml/kg).
It is stimulated by :

5)
• Hypovolemia

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• Increased osmolality

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• Angiotensin II in circulation

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Increase in Na+ concentration in ECF due to any cause leads to increase in osmorality, which
stimulates thirst center and thereby intake of water increases ECF volume and decreases Na+

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concentration in ECF and vice versa.

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Water intoxication :
Total body water excess. It may occur in following situation :
 • Excessive amount of water or hypotonic solution administration (over prescription of
5%D/A in postoperative patient though who also conserve water & sodium by the stress
effect of operative trauma--ADH & Aldosterone mechanism.
• Colorectal wash with plain water.
• During TURP-excessive uptake of water.
• SIADH (secretion of inappropriate anti diuretic hormone)- found in lobar pneumonia,

5)
empyema, head injury etc Clinical feature :

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Confusion, drowsiness (serum sodium <120mEq/L) , seizure, coma (serum sodium <

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110mEq/L), cardiac arrhythmia (serum sodium <100mEq/L).

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Consequence of osmotic disequilibrium between ICF and ECF:

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When ECF osmotic pressure< ICF osmotic pressure : (eg. infusion of hypotonic solution)

•
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Cellular overhydration due to water entry into the cells.
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• Increased intracellular hydrostatic pressure.
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• Impairment of cellular metabolic activities
• Cerebral edema leading to coma and even death.
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When ECF osmotic pressure> ICF osmotic pressure: (eg. infusion of hypertonic solution)
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• Cellular dehydration due to water loss from the cells.

• Impairment of cellular metabolic activities.
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• K+ efflux from cells leading to hyperkalemia.

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• Cerebral dehydration leading to coma and even death.

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SIADH : Topic 4 Increase ADH Medicine

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-7
90
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Different I/V fluids and their tonicity :

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 1 question
Volume expanders : Topic 5 vvi
Colloids : Plasma, Dextran, Starch, Albumin etc.
Crystalloids : Normal saline, Ringer’s lactate, Hartmann’s solution, dextrose etc.

5% DA = 50gm dextrose in water

5)
Composition of colloid and crystalloid solution : (mmol/L)

13
Solution Na+ K+ Ca2+ Cl- Lactate Glucose Colloid

59
Hartmann’s 131 5 2 111 29
Normal saline (0.9%Nacl) 154 154

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Dextrose saline (4% 30 30

90
dextrose in 0.18% saline)

17
5% DNS 154 154 50 g/L

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Gelofusine 150 150 d Gelatin 4%
Haemacel 145 5.1 <1 145 Polygelin
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75g/L
Hetastarch Hydroxyethyl
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starch 6%
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Compensatory reactions activated by haemorrhage :

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• Vasoconstriction
• Venoconstriction
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• Tachycardia
• Tachypnea
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• Restlessness
• Increased secretion of vasopressin /ADH
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• Increased movement of interstitial fluid into capillaries

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• Increased secretion of glucocorticoids

• Increased secretion of renin and aldosterone
• Increased secretion of erythropoietin
• Increased plasma protein synthesis
Previous year’s questions :
1. Compared with intracellular fluid, the extracellular fluid has lower (MD, MS, Basic, Paedi
March-2019)
a) Osmolality.

5)
b) Sodium ion concentration .

13
c) Chloride ion concentration.
d) Potassium ion concentration.

59
e) Hydrogen ion concentration.

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FFFTT

90
2. Compared with intracellular fluid, extracellular fluid has a lower -(MS, March-17) a)

17
Osmotic strength.

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b) Sodium ion concentration . d
c) Chloride ion concentration.
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d) Potassium ion concentration.
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e) Hydrogen ion concentration .

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FFFTT
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3. Regarding body fluid compartment (MD March-17)

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a) Extracellular fluid volume is greater than intracellular fluid volume.

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b) Total amount of body water in adult is 42 liters.

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c) Tonicity of extracellular fluid is greater than intracellular fluid.

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d) Crystalloid solutions rapidly equilibrate extra and intracellular space.

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e) Colloids are high molecular weight substances as blood albumin.

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FTFTT

4. Regarding body fluid (Basic, MD, MS March 16)

a) Aldosterone regulates the concentration of body fluid
b) ADH regulates the volume of body fluid
c) Body fluid volume changes determine the state of hydration
d) Osmolar changes determine the type of hydration

5)
e) Total body water can be measured by deuterium oxide

13
TTTTT

59
5. On both sides of a selectively permeable membrane (MS March 16)

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a) Equal concentration of non diffusible ions

90
b) Equal concentration ratio of diffusible ion

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c) Equal concentration of diffusible ions
d) Electrical potential difference
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e) Osmotic gradient
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FTFTF
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6. Compared to the composition of intracellular fluid, the extracellular fluid has a higher
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concentration of (MPhil/Diploma July-16)

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a) Na+
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b) K+
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c) CI
d) non diffusible anions
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e) non diffusible cations

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TFTFT
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7. Extra cellular fluid differs from intracellular fluid in that it’s (Basic, MD, MS March 12) a)
PH is higher
b) Sodium potassium molar ratio is higher
c) Anions are mainly inorganic
d) Tonicity is lower
e) Volume is greater
TTTFF

5)
13
8. Severe hypotonicity of ECF compared to ICF may lead to (July-08)

59
a) Cellular overhydration
b) Cerebral oedema

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c) Cellular dehydration

90
d) Coma and convulsion

17
e) Hyperkalemia
TTFTF
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9. Drinking of 2L of isotonic saline results in (Jan-10)

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a) Decrease in ADH secretion

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b) Increase in aldosterone secretion

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c) Decrease in heart rate

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d) Dilatation of afferent arteriole

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e) Release of ANP
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TFFTT
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10. Features of hypertonic hypovolemia are (Basic, MS March 16)

cl
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a) Decreased osmolarity in both ICF and ECF

b) Sodium concentration of lost fluid is less than that of plasma
c) Decrease ECF volume but increase ICF volume
d) Relatively more water loss than salt
e) Decrease of total sodium content of the body . FTFTT
11. Effects of ECF volume depletion are (Basic, MS March 16)
a) Activation of sympathetic nervous system and renin-angiotensin aldosterone system b)
Increased GFR
c) Decreased aldosterone level

5)
d) Increased ADH secretion

13
e) Decreased atrial natriuretic peptide level

59
TFFTT

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12. In a person deprived of water for 24-hours, there is an increased in (MS March 16) a)

90
Plasma renin activity

17
b) ADH secretion
c)Plasma atrial natriuretic peptide
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d) Vagal tone
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e) Plasma Na+ concentration

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TTFFT
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13. Atrial natriuretic peptide causes (MD, March 13)

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a)Increase GFR
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b)Decrease renin secretion

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c) Enhance secretion of aldosterone

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d) Increase ADH secretion

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e) Decrease NaCl reabsorption by the collecting duct

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TTFFT

14. The following conditions are associated with hypertonic hypovolemia (Basic, MD,
March-13)
a) Severe diarrhoea
b) Persistent vomiting
c) Conn's syndrome
d) Congestive cardiac failure
e) Nephrotic syndrome

5)
TTFFF

13
59
15. Polyuria is commonly seen in (MS March 13)
a) Hypercalcemia

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b) Glycosuria

90
c) Hypokalemia

17
d) Hyperkalemia
e) Renal infarction
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d
TTTFF
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16. Laboratory findings of hypovolemia Include: (MPhil/Diploma July-13)

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a) Elevated hematocrit
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b) Elevated plasma albumin

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c) Urinary Na usually >20 meq/L

Ed

d) High specific gravity

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e) Low urinary osmolarity

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TFTTF
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17. One liter of normal saline contains (Diploma Basic, 2020)

a) nine grams of sodium chloride
b) 140 mmol of sodium ion
c) 154 mmol of sodium ion
d) 105 mmol of chloride ion
e) 154 mmol of chloride ion
TFTFT

18. Crystalloids includes (Diploma July-19, Medicine Faculty, Surgery Faculty, Paediatrics) a)

5)
Plasma

13
b) Sodium

59
c) Chloride
d) Potassium

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e) Albumin

90
TFFTT

17
(0
19. When oral rehydration solution is taken (MD, Basic Science, March-17)
d
a) Sodium mostly enters the cell through active transport
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b) Glucose enters the cell through facilitated diffusion

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c) Potassium enters the cell through active transport

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d) Citrate enters through diffusion

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e) Water enters through diffusion

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TFTFT
Ed
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20. Crystalloid solutions are (MPhil/Diploma July-16)

i

a) Dextrose saline
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b) Gelofusine
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c) Haemocel
d) Hartmann's solution
e) Normal saline
TFFTT
21. Hartmann’s solution contains (MPhil/Diploma July-15)
a) Sodium
b) Potassium
c) Magnesium

5)
d) Calcium

13
e) Bicarbonate

59
TTFTF

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22. Isotonic fluids are (Basic, MD, MS March-15)

90
a) Normal saline

17
b) 5% dextrose in aqua
c) 5% DNS
(0
d
d) Baby saline
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e) Cholera saline
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TTFFT
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23. Urine osmolality is low in (MPhil/Diploma July-16)

u

a) Diabetes Mellitus
Ed

b) Diabetes insipidus
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c) Psychogenic polydipsia
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d) High fever
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e) Dehydration
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FTTFF