UNIT II- FLUID AND

HEMODYNAMIC
DERANGEMENTS
• Edema
Edema
 Hyperemia and Congestion
 Hemorrhage
 Hemostasis & Thrombosis
 Embolism
 Infarction
 Shock
EDEMA

Fluid extravasations and

accumulation in the
interstitial spaces
EDEMA
Increased fluid in the interstitial tissue spaces
 Fluid may also accumulate in body cavities:
1. Hydrothorax
2. Hydropericardium
3. Hydroperitoneum is also called Ascites

 Massive generalized edema is called Anasarca

Fluid Homeostasis

Homeostasis is maintained by
the opposing effects of: Lymphatics

1. Vascular Hydrostatic
Pressure

and

2. Plasma Colloid Osmotic

Pressure
Edema Fluid = TRANSUDATE

 A transudate is protein-poor (specific gravity <1.012)

 An exudate is protein-rich (specific gravity >1.020)

= (inflammatory edema)
Pathophysiologic Categories of Edema
I.I. Increased Hydrostatic
Increased Pressure
Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation
IV. Others
 Pathophysiologic Categories of Edema

Increased Hydrostatic Pressure

1. Due to impaired venous return

A) Localized:
 Venous Thrombosis

B) Generalized:
 Congestive Heart Failure

2. Due to increased arteriolar dilatation

 Increased Hydrostatic Pressure

Congestive Heart Failure:

“Generalized increase in venous pressure,

with resultant SYSTEMIC EDEMA occurs

MOST COMMONLY in CONGESTIVE HEART FAILURE”

{*** Thus, Congestive Heart Failure is the most common cause of EDEMA due to
Increased Hydrostatic Pressure}
Congestive Heart Failure

Overall, there are TWO main effects...

1. Increased Central Venous Pressure

2. Decreased Renal Perfusion

Increased Hydrostatic Pressure:
Congestive Heart Failure

Mechanism:
 The Pump is FAILING!!!   Cardiac output
 Blood backs up, first into the lungs

 then into the venous circulation

 increasing Central Venous Pressure (CVP)

 increased capillary pressure (Hydrostatic Pressure)

 Leading to Edema
Congestive Heart Failure:
& Decreased Renal Perfusion

 Congestive heart failure 

Decreased Cardiac Output 
Decreased ARTERIAL blood volume 

“Less arterial blood…Less renal perfusion...

The Kidney doesn’t see enough blood coming
through …….
Congestive Heart Failure:
& Decreased Renal Perfusion

Decreased Renal Perfusion activates

the Renal Defense Mechanisms:
1. Renin-Angiotensin-Aldosterone axis 
 Na & H2O retention
2. Renal Vasoconstriction
3. Increased Renal Anti-diuretic Hormone (ADH)
Congestive Heart Failure - Summary

Central Renal
Venous Perfusion
Pressure
Renin ADH

Renal
Vasoconstriction
Pathophysiologic Categories of Edema

I. Increased Hydrostatic Pressure

II. Reduced
II. Reduced Plasma
Plasma Oncotic
Oncotic Pressure
Pressure
III. Inflammation
IV. Other
Reduced Plasma
Osmotic Pressure

 “…Albumin:
is the serum protein MOST responsible for the
maintenance of colloid osmotic pressure.”

 A decrease in osmotic pressure can result from:

1.  Protein Loss
or
2.  Protein Synthesis
 Reduced Plasma
Osmotic Pressure

1. Increased albumin loss:

 Nephrotic Syndrome
 Increased permeability of the glomerular capillary wall 
loss of protein

2. Reduced albumin synthesis

 Cirrhosis
 Protein malnutrition
Pathophysiologic Categories of Edema
I. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III.III.Inflammation
Inflammation
IV. Other
Pathophysiologic Categories of Edema
I. Increased Hydrostatic Pressure
II. Reduced Plasma Oncotic Pressure
III. Inflammation
IV. :Others
IV. Others
- Lymphatic Obstruction
- Sodium & water retention
Lymphatic Obstruction
 Impaired lymphatic drainage with resultant
lymphedema
 usually localized
 usually due to:
 INFLAMMATION

or
 NEOPLASTIC OBSTRUCTION
 Lymphatic Obstruction

 Filariasis –
 A parasitic infection affecting
inguinal lymphatics resulting
in elephantiasis
Lymphatic Obstruction
Neoplastic

 Resection and/or radiation to axillary lymphatics in

breast cancer patients can lead to -- arm edema

 Carcinoma of breast with obstruction of superficial

lymphatics can lead to edema of breast skin -- --with an

unusual appearance:

“peau d’orange” (orange peel)

EDEMA - Summary

INCREASED DECREASED
HYDROSTATIC  HEART ONCOTIC
PRESSURE PRESSURE
Congestive Heart Failure
 LIVER
Nephrotic Syndrome
Ascites
Venous Obstruction
 KIDNEY Cirrhosis
Protein Malnutrition

LYMPHATIC
INCREASED OBSTRUCTION
PERMEABILITY Inflammatory
Inflammation Neoplastic
GENERALIZED EDEMA

 HEART
 LIVER
 KIDNEY
 Edema
Morphology
Subcutaneous Edema
 Edema of the subcutaneous tissue is most easily detected Grossly (not microscopically)
 Push your finger into it
 and a depression remains

 Dependent Edema is a prominent

feature of Congestive Heart Failure

 Facial Edema is often the initial

manifestation of Nephrotic
Syndrome
 Edema

Clinical Correlation:
Subcutaneous Edema
 Annoying but Points to Underlying Disease
 However, it can impair wound healing or
clearance of Infection
Edema
Morphology

Pulmonary Edema

is most frequently seen in Congestive Heart Failure

 May also be present in renal failure, adult respiratory
distress syndrome (ARDS), pulmonary infections and
hypersensitivity reactions
 Pulmonary Edema
Gross:

 The Lungs are typically 2-3 times the normal weight

 Cross sectioning causes an outpouring of frothy,
sometimes blood-tinged fluid
Normal

Pulmonary Edema
Edema

Clinical Correlation:
Pulmonary Edema
 May cause death by interfering with Oxygen and
Carbon Dioxide exchange
 Creates a favorable environment for infection
 THINK it resembles “Culture Media”!!!
Edema of the Brain

 Trauma, Abscess, Neoplasm, Infection

(Encephalitis due to say… West Nile Virus), etc
Clinical Correlation:
Edema of the Brain

 The big problem is: There is no place for the fluid to go!
 Herniation into the foramen magnum will kill