What’s the main fluid in the body?

Fluid and Electrolyte management

Background
♂ The surgical patient is liable to develop numerous
disorders of body fluid volume and composition,
some of which may be iatrogenic

► Understanding the physiologic mechanisms that

regulate the composition and volume of the body fluids
and the principles of fluid and electrolyte therapy is
therefore essential for patient management
 Fluid and Electrolyte management
• Body water and its distribution
• Total body water comprises 50-70% of body weight;

• ►♂the percentage in any individual is influenced by

age and the lean body mass

• But in the healthy individual it remains remarkable

constant from day to day
• Age In male In Female
• 10-18 59 57
• 18-40 61 51
• 40-60 55 47
• Over 60 52 46 (meq/L of water)
•
 Fluid and Electrolyte management

• Body water and its distribution

Total body water is divided into intracellular fluid (ICF) and
extracellular fluid (ECF) compartments

Intracellular water represents about two-thirds of total

body water (30%) and 40% of body weight

The remaining one third of body water is extracellular

 Fluid and Electrolyte management

• Body water and its distribution

• The extracellular is divided into two compartments:

1) Plasma water: comprising approximately 25% of

ECF, or 5% of body weight

2) Interstitial fluid, comprising 75% of ECF, or 15%

of body weight
 Fluid and Electrolyte management

Age (M) Plasma (f) Interstitial (f) ICF Total

70 kg 3. 500cc 10. 500cc 28.000cc 42.000cc

%body weight 5% 15% 40% 60%

• General composition of ECF

• Plasma: contains principally sodium (Na+) 152, chloride (Cl- ) 113 and bicarbonate
HCO- 3) 27

• Other ions in much lower concentrations: K+ (5), Ca2+ (5), Mg2+ (3), HPo4 (2), SO4
2-

2-
(1), organic acid (6), Nonelectrolytes, protein (16) and HHCO3
•
• Interstitial fluid: contains principally sodium (Na+) 143 chloride (Cl- ) 117 and
bicarbonate HCO3 ) 27

• Other ions much lower: K+ (5), Ca2+ (5), Mg2+ (3), HPo4 (2), SO4 (1), organic acid
2- 2-

(6), protein (2), Nonelectrolytes, and HHCO3

 Fluid and Electrolyte management
• General composition of intracellular fluid
• More
• K+: 157
• PO43- : 113
• SO4-2
• Protein: 74
• Mg2+: 26

• Other ions much lower: Na+: 14, HCO3- (10), Cl-, and
HHCO3
 Fluid and Electrolyte management
• General composition

• Even though plasma water and interstitial fluid have similar

electrolyte compositions, plasma water contains more protein
than interstitial fluid

• The plasma proteins, chiefly albumin, account for the high

colloid osmotic pressure of plasma, which is an important
determinant of the distribution of fluid between vascular and
interstitial compartments
 Fluid and Electrolyte management
• Body water and its distribution
• The kidneys
• The kidney maintain constant volume and
composition of body fluids by two distinct but
related mechanism:

• 1) Filtration and reabsorption of sodium, which

adjusts urinary sodium excretion to match changes
in dietary intake

• 2) Regulation of water excretion in response to

changes in secretion of antidiurectic hormone
 Fluid and Electrolyte management
• Body water and its distribution
• These two mechanisms allow the kidneys to keep the volume and
osmolality of body fluid constant within a few percentage points
despite wide variations in intake of salt and water

• The corollary is that analysis of the composition and volume of the

urine provides valuable clues in the diagnosis of disorders of body:
• * fluid volume and
• * composition
 Fluid and Electrolyte management
• Body water and its distribution
•♂ Although the movement of certain ions and
proteins between the various body fluid
compartments is restricted, water is freely diffusible

• Consequently, the osmolality of all body

compartment is identical
• Body water and its distribution
• Example:
• In ECF, Na (+) and its salt account for most of the osmolality
• In ICF, the K (+) are chiefly responsible

• ♂ The control of osmolality occurs through regulation of:

• water intake: thirst, and
• water excretion:
• urine volume
• insensible loss and
• stool water
 Fluid and Electrolyte management
• Body water and its distribution
• The concentration of electrolytes are usually
expressed as equivalent weights:
•
• Osmolality = (Nae + + A- ) + (Ke+ + A-)/TBW

• The plasma sodium concentration (PNa) can be

determined as followed:
• PNa = Nae + + Ke+ / TBW
• NB: e = exchangeable; A= molecular weight
 Fluid and Electrolyte management

• Body water and its distribution

• Remember
• Most people ingest more than 5 g of NaCl per day,
equivalent to about 85 meq of Na+ (1 g NaCl = 17 meq Na+)

• Potassium excretion average 40 – 60 meq/d

• Water Balance
• total water intake = total water loss (output)
• Water intake: average intake is 2500 ml, but this is
extremely variable
• Our water intake is from:
fluids we drink (**thirst) (~60%)
• foods we eat (~30%) and
metabolic production of water (~10%)

Remember
Water output: Water input = water output
Take in ~2500 ml per day, must also lose that much
 Fluid and Electrolyte management
• Water loss occurs through:
• **Urine: ~ 60%
• Feces: ~ 6%
Sweat: ~ 6%
• Insensible loss: ~ 28%

• Insensible loss water loss via evaporation:

• from the skin and
• from lungs during breathing
 Fluid and Electrolyte management
• Remember
• The primary regulation of fluid level is through urine formation

• Regulation of water loss: ADH

Regulation occurs mostly through the distal convoluted tubule and

collecting duct

They are usually impermeable to water so the water that enters

them is excreted
 Fluid and Electrolyte management

►Typical daily solute balances in normal

subjects:
Water intake Concentration total amount
Ingest 2L
Cell metabolism 0.4L
Total solute 600 mosm
Sodium 90 meq
Potassium 54meq

NB: small amounts of Na and K are lost extrarenally (stool,

sweat)
 Fluid and Electrolyte management

• ►Typical daily solute balances in normal

subjects:

• Urine excretion Concentration total Amount

Water 1.5L
Total solute 400 mosmkgwater 600 mosm
Sodium 60 meq/L 90 mosm
Potassium 36 meq/L 54 mosm

NB: small amounts of Na and K are lost extrarenally (stool,

sweat)
 Fluid and Electrolyte management
• OSMOTIC PRESSURE
• The interactions between the various body fluid
compartments is the definition of commonly used
terms

• The differences in ionic composition between ICF

and ECF are maintained by the cell wall, which
functioning as a semipermeable membrane
 Fluid and Electrolyte management

• OSMOTIC PRESSURE
• Remember
• The total number of osmotically active particles is 290
to 310 mosm in each compartment

• Since the cell membranes are completely permeable

to water, the effective osmotic pressure in the two
compartments are considered equal
 Fluid and Electrolyte management
• OSMOTIC PRESSURE
• Any condition that alters the effective osmotic pressure in either
compartment causes redistribution of water between the
compartments

• ►► Example: an increase in effective osmotic pressure in ECF,

which would occur frequently through increased sodium
concentration, causes a net transfer of water from the ICF to the
ECF compartment
 Fluid and Electrolyte management

• OSMOTIC PRESSURE
• ►►Thus, ICF shares in losses a changes in
concentration or composition of ECF, but shares
slowly in changes involving loss of isotonic volume
alone

• ►Remember
• For practical considerations, most losses and gains of
body fluid occur directly from the extracellular
compartment

•
 Fluid and Electrolyte management

Classification of body fluid changes (Disorders)

The disorders in fluid balance may be classified into

three general categories:
Disturbance of volume
Disturbance of concentration
Disturbance of composition
• Disorders of water balance
• Volume Disorders
• Dehydration
• This can be due to:
• increased sweating
• decreased intake with steady output
• vomiting
• diarrhea
• fistula drainage
• nasogastric suction
•
• Volume Disorders
• Dehydration
• Other common cause causes:
• Sequestration of fluid in soft tissue injuries such as:
• * Infection
* Peritonitis
* Intestinal obstruction
* Burns
• Symptoms:
• Volume Disorders
• (include CNS, cardiovascular and tissue signs)
• CNS:
• Sleepiness, apathy, slow responses, anesthesia of distal extremities

• Gastrointestinal: Nausea, vomiting, refusal to eat

• Cardiovascular: Tachycardia, collapse pulse, absence of peripheral pulse

• Tissue signs: Atonic muscles, poor skin turgor, skin mucous membrane
dry, sunken eye
 Fluid and Electrolyte management
• Volume Disorders
• 3) Volume intoxication (Excess or overload)

►1). Antidiuretic hormone, released during

anesthesia and surgical stress, promotes water
conservation by the kidneys ►►►

• Renal vasoconstriction and increased aldosterone activity

reduce sodium excretion

• Consequently, if fluid intake is excessive in the

immediate postoperative period, circulatory overload
may occur
 Disorders of water balance
• Water intoxication
• 2. This is a condition in which the extracellular
become hypotonic
*Drinking more water than the kidneys can
keep up with
*Treating dehydration with pure water
Consequently ► ► cell swelling due to osmosis
Symptoms:
Decreased Na concentration:
* Severe muscle cramps * convulsions
* confusion and * coma
 Disorders of water balance
• Edema
• Swelling; an abnormal accumulation of extracellular fluid in the
interstitial spaces
•
Possible causes include:
a) Hypoproteinemia when decreased plasma protein
e.g.1: in liver disease ►may decrease the production of plasma protein

e.g. 2: in kidneys disease

e.g. 3: In starvation
• Edema
• Possible causes include:
b) Lymphatic obstruction
From:
surgery
infection
Lymphatic vessels cannot drain adequately, so pressure inside
them increases
c) Increased venous pressure
e.g. obstruction between liver and IVC
d) Increased capillary permeability
e.g. during an inflammation response
 Disorders of water balance
• Disturbance of concentration
• Electrolyte Balance:
• As a water electrolyte input should equal to electrolyte
output

• The most important electrolytes are

• Na+, Cl-, K+, Ca++, Mg++, SO4-2, PO3-3, and HCO3-
 Fluid and Electrolyte management
• Specific electrolyte disorders
• Sodium
• Hypernatremia:
• Represents chiefly loss water
• Clinical presentation
• Moderate Severe

• Restlessness Delirium
weakness Maniacal behavior
• Tachycardia Hypotension
• Decrease saliva and tears Dry and sticky mucous membrane
• Red, swollen tongue Flushed skin
• Oliguria Oliguria
• Fever Fever
• Disturbance of concentration
• Specific electrolyte disorders
• Sodium
• Hyponatremia
• Clinical presentation
• Moderate Severe
• Muscle twitching Convulsions
• Hyperactive tendon reflexes Loss of reflexes
Increased intracranial pressure (IIP) IIP
Increase salivation Watery diarrhea
• lacrimation Oliguria
Anuria
 Disorders of water balance
• Disturbance of concentration
• Electrolyte Balance:
• 3.hypokalemia: low potassium from:

• increased aldosterone secretion

• diuretics
• renal dysfunction
• vomiting
• diarrhea.►► Result to:
• muscle weakness
• paralysis
• respiratory difficulty
cardiac arrhythmias
•
 Disorders of water balance

• Disturbance of concentration
• Electrolyte Balance
• 4.hyperkalemia: high potassium can be from:
* renal dysfunction
* drug decreased aldosterone secretion
►► Result to paralysis of:
* skeletal muscles
* cardiac arrest
 Disorders of water balance
• Disturbance of composition
• Acid-Base Balance
• Electrolytes that ionize in water release H+ and are acids.
Substrates that combine with H+ are bases
• Major sources of H+:
1. Aerobic respiration of glucose
Ex: CO2 + H2O = H2CO3 (carbonic acid),
Then H2CO3 H+ + HCO3- (bicarbonate ion)
2. Anaerobic respiration of glucose
lactic acid H+
3. Incomplete oxidation of fatty acids
Acidic ketone bodies H+
 Disorders of water balance
• Disturbance of composition
• Acid-Base Balance
• Electrolytes that ionize in water release H+ and are
acids. Substrates that combine with H+ are bases
• Major sources of H+:
4. Oxidation of amino acids containing sulfur
H2SO4 (sulfuric acid) Õ H+
5. Hydrolysis of phosphates and nucleoproteins
phosphoric acid H+
 Disorders of water balance
• Acid-Base Balance
• Acid-Base pH balance is regulated by:

• 1. respiratory centers in the brain (stem cells)

• NB: (by altering the rate and depth of breathing)

2. the kidneys:
NB: (through ammonia, and ammonium)

3. chemical buffer systems (metabolism)

H+: from different buffer such as :
sulfuric acid
phosphate acid
amino acids (protein)
 Disorders of water balance
• Acid-Base Balance
• Acid-base buffer systems are present in all body fluids

• They usually involve 2 or more chemicals that can combine

with acids and bases when they are in excess

• Buffer systems:
• Bicarbonate buffer system
• Phosphate buffer system
• Protein buffer system
 Disorders of water balance

• Acid-Base Balance
1. Bicarbonate buffer system: in both intra-and extracellular fluids.
Chemicals involved
carbonic acid (H2CO3) and
sodium bicarbonate (NaHCO3)
 Disorders of water balance
• Acid-Base Balance
2. Phosphate buffer system: in intra- and extracellular fluids,
especially important in nephrons where it controls the pH of
tubular fluid and urine

• Chemicals involved:
• sodium monohydrogen phosphate Na2HPO4 (a weak base) and

• sodium dihydrogen phosphate NaH2PO4 (a weak acid)

 Disorders of water balance
• Acid-Base Balance
3. Protein buffer systems: especially located in plasma
and intracellular fluids
This one involves plasma proteins and various proteins
inside the cells, including hemoglobin

Chemicals involved: Each amino acid contains a

carboxyl group (-COOH) and an amine group (NH2)
 Disorders of water balance

• Acid-Base Balance
• In summary:
• these acid-base buffer systems take up H+ as fluid
activity increases, and give up H+ as fluid activity
decreases (or as alkalinity increases)

• They are meant to PREVENT shifts in the

hydrogen ion concentration, and thus the pH
 Disorders of water balance

• Acid-Base Balance
• Blood pH:
• normally 7.4. If it changes more than .4 (7.0 or 7.8),
can’t easily survive

• Acidosis: increased acids or decreased bases/ too

much hydrogen ion, too low pH

• Alkalosis: decreased acids or increased bases/ too

little hydrogen ion, too high pH
 Disorders of water balance
• Acid-Base Balance
1. Respiratory acidosis: increased carbon dioxide in body leads
to increased hydrogen ion
• Causes include
• 1) injury to respiratory center
• 2) obstruction of air passageways
• 3) diseases that decrease gas exchange (pneumonia,
emphysema)
•
Symptoms include
• decreased CNS activity leading to drowsiness, disorientation,
stupor, labored breathing, cyanosis, ►►can lead to coma
and death
 Disorders of water balance
• Acid-Base Balance
2. Metabolic acidosis: accumulation of non-respiratory
acids or a decrease in bases via metabolic processes
• Causes include
• 1) kidney disease impairing hydrogen ion
excretion
• 2) prolonged vomiting with loss of upper small
intestine contents (alkaline)
3) prolonged diarrhea
4) increased acidic ketone bodies metabolism

Symptoms are same as for respiratory acidosis

• Acid-Base Balance
3. Respiratory alkalosis:
• increased clearance of carbon dioxide leading to less
carbonic acid formation
• Causes include
• 1) hyperventilation (anxiety)
• 2) hypoxia high altitude
• 3) fever
Symptoms include
• agitation
• dizziness
• tingling
• Tetanic muscle contractions in severe cases
 Disorders of water balance
• Acid-Base Balance
4. Metabolic alkalosis:
• loss or excessive buffering of acidic gastric
contents
• Causes include
1) gastric drainage during surgery
2) stomach pumping
3) prolonged vomiting of just stomach contents,
4) excessive use of antacids

Symptoms are same as respiratory alkalosis

Thanks