A young woman requires dialysis for acute renal failure.

Examine the
diagram, Describe the principles involved in the system for moving
solvent and solute across the semi-permeable membrane.
Blood

Urea 40 mmol/L
Osmolarity 320 mosm/L
Pressure 100 mmHg

------------SEMI-PERMEABLE MEMBRANE--------------Dialysate

Urea 0
Osmolarity 346 mosm/L
Pressure 10 mm Hg

Answer.
SOLUTE MOVEMENT
1. Diffusion of Urea down a Concentration gradient.
2. Hydrostatic Pressure forcing fluid through membrane by a difference of
hydrostatic pressure - Filtration.
3. Solvent drag solute molecules move with solvent. convective
forces

SOLVENT MOVEMENT
1. Osmosis from blood into dialysate to equilibrate osmotic pressure

Outline the physiological effects of acute hypoglycaemia

Answer
Define acute hypoglycaemia.
Time and criteria or level of blood sugar for hypoglycaemia
Mechanisms for hunger and nausea role of hypothalamus
State tissues that are dependent totally on glucose as a substrate
Alternative substrates in tissues not dependent solely on glucose
Neurohumoral effects
Metabolic reserves

What are the physiological effects of the evaporative loss of 2 litres

of water in a 60kg man.
1. Reduction in total body water
750ml
from ECF
1250ml
from ICF
2. blood vol decreased VR and atrial filling CO via
Frank-Starling mechanism
3. Reduced CO

BP
heart rate
vasoconstriction
venoconstriction

4. Baroreceptor stimulated

both of which tend to restore BP

5. atrial wall stretch

ADH
ANP

6. Increased osmolarity

ADH

7. thirst

lends to drinking

8. ADH

effects on kidney

Explain the mechanism for the maintenance of oxygen supply to organs

during isovolaemic haemodilution.
Haemodilution

Oxygen flux equation

=
cardiac x
output

oxygen carrying capacity

arterial O2
content

cardiac output

[ sat x Hb x 1.34]

Normally blood loses 25% O2 content so that remaining 75% forms

reserve supply
1. ORGAN BLOOD FLOW by
a) increased cardiac output
by blood viscosity venous stroke volume
by afterload
return
b) cardiac output via sympathetic drive
increasing heart rate & stroke volume
c) regional blood flow by viscosity
d) vasodilation of organ circulation
2. O2 EXTRACTION increased
3. Haematocrit = heart & brain will receive preferential blood supply
Decreased viscosity-therefore better flow and distribution
to tissues.

Briefly describe the functions of proteins in cell membranes.

Many types of proteins within cell membrane
Located at (i) outer surface
(ii) through thickness or integral proteins
(iii) inner surface
Hydrophobic part of protein orientated towards cell interior
Hydrophilic part orientated towards exterior of cell
May be Lipoproteins (proteins that contain lipids) or Glycoproteins (contain
carbohydrates)
Role:
1. Structural proteins
2. Active transport mechanisms
3. Ion channels for passive ion transport
4. Receptors for transmitters or hormones
5. G proteins
6. Surface proteins as receptors eg Glycoprotein receptors
As antigens eg Rh factor

Factors that control intra-ocular pressure

1. Intraocular Blood Volume
Venous pressure eg coughing and straining, posture
Carbon dioxide
Posture improve drainage
2. Volume of Aqueous humour
Produced by ciliary body (thickened anterior part of choroid) by
DIFFUSION
Role of Carbonic anhydrase intraocular pressure is reduce by CA
inhibitors e.g acetazolamide
Drainage of aqueous humour via canal of Schwlem

Describe the effects of 100ml of 8.4% sodium bicarbonate

administered intravenously in a 70kg man during CPR at an asystolic
arrest
Composition of Sodium bicarbonate
Na 1 mmo;l per ml
HCO3 1 mmol per ml
Tonicity 2 mosmol per ml
Effects:
1. Alkali load K+ flux; H+
2. Na load
hypertonicity in intravascular volume
3. CO2 load clue to dissociation of HCO34. Effects on O2 dissociation curve
5. CO2 diffusion intracellularly leading to intracellular acidosis
6. Effects on respiratory control

An elderly lady with bowel obstruction has nasogastric losses >

1000ml/day for 5 days.
Explain the mechanism of the development of metabolic alkalosis
and justify your choice of replacement fluid.
NG fluid composition
Na50
K 10
H 100
Mg 2

(mmol/L)

Metabolic alkalosis
loss of H+ ions
maintained and persist because:
1) Hypovolaemic
Na+ reabsorbed in preference to H+ at distal tubule
2) Hypochloraemia
HCO3 reabsorbed with Na+ reabsorption
More K+ and H+ loss at distal tubule
Choice of fluid
0.9% NaCl with 30mmol K+

Define basal metabolic rate. How does the metabolic rate of a child with
abdominal sepsis in the OR differ from that of a sleeping adult.
Definition
BMR = rate of energy utilisation in awake subject 12 hours
after meal in a comfortable or thermoneutral environment
Factors affecting BMR of child
a) Age
- neonate
b) Additonal factors
pain
sepsis
pyrexia
anxiety
if rigors present
OR temperature
? starvation
GA
Sleeping Adult
Age
sleep

Order

BMR higher
approx. 2 x adult
)
) metabolic
)
rate
)
)
) metabolic
)
rate

Outline the control of body water by the kidneys.

1. 180L fluid filtered through the glomeruli/day
2. Approx. 90% water filtered is reabsorbed
3. Proximal tubule
70% passive reabsorption via osmotic forces following (secondary to) active Na
reabsorption.
4. Loop of Henle
passive osmotic reabsorption of water in descending limb because:
a) descending limb is permeable to H2O
b) ascending limb is not permeable
countercurrent multiplier system produces hyperosmotic medullary
interstitium which enhance H2O reabsorption. Occurs at juxtamedullary
nephrons.
5. Distal tubule - passive H2 reabsorption
Collecting ducts - site of ADH free H2O reabsorption
Regulated by ECF osmolarity Ant Pit ADH
6.

Osmotic diuresis

Briefly explain how alveolar hypoventilation reduces the systemic arterial partial
pressure of oxygen (PaO2)
1. Alveolar hypoventilation
< 3600ml/min
2. Alveolar
Conc of gas + inspired gas conc output / uptake of gas
alveolar ventilation
3. With CO2 ; Insp CO2 = O
PACO2 = K (output)

VA PAO2

4. Apply Alveolar Air Equation

PAO2 = P1O2 - PACO2
R
PA P1 in a non-linear manner (i.e. rectangular hyperbola)
5. O2 cascade

Pa PA

6. PAO2 = PIO2 - V. O2
VA

Briefly describe the mechanisms that control the distribution of body water
between the plasma, interstitial and cellular compartments.
1. Distribution of body H2O
ICF / ECF
factors: age, sex, obese
2. Forces that determine distribution
membrane permeability
membrane pumps
osmotic forces
Gibb-Donnan effect
colloid osmotic forces
3. total body osmolarity
Na
Other osmotic forces

Sugar
blood urea

With regard to an invasive arterial blood pressure monitoring, briefly describe

the role of
i.
frequency response
ii.
resonant frequency
iii.
optimal damping
of the measuring system (ie cannula, tubing and transducer) in
achieving an accurate waveform.
Frequency response: range of frequencies to reproduce the Fourier components
of the waveform ie without distortion. X10 hormones
180 beats/m = 3H2 x 10
Resonant frequency:
frequency at which the signal is magnified due to
oscillation and hence distort the signal
Optimal damping

df = resist (friction)
2ms
damping. coef 0.7 produces the least attenuation of a wide range of
frequencies and minimum change in frequency response Also calle optimal
damping.
Transducer

f. S/M
fo = R
2 TTpl

mass =

Connecting tube:
fo short length, large diameter
stiff
air; blood clots
Cannula:site, size, kinks, etc

Briefly describe the acid base changes which arise in a hypoxic person,
including the compensatory processes which may restore the
status to normal.
1. Definition:

Clinical hypoxia
Decrease PaO2 from capillary (90mmHg) to mitochondria
( 1mmHg)

2. Biochemical Effects:
Mitochondria:
stop oxidative phosphorylation
Glycolytic pathway
Glucose Pyruvate Lactic Acid + 2 ATP
2 ATP ADP + AMP - retard Ca ATP pump
3. Cellular Buffering

HPO4; Protein

4. Interstitial buffers
5. Vascular Buffers:

PaO2 : Buffers
HbO2 dissociation shifts
K+

6. Acute Compensatory
s
Resp: Hyperventilation V/Q
Sympathetic N. Syst
Cardiac Output
7. Long Term Compensatory
Renal
EPO

Draw and label a left atrial pressure trace. Briefly describe the factors that
affect LAP.
Diagram A, C and V waves
X Y descent
Values on axes
Factors:
Blood volume
Sympathetic tone
Posture
LV contractibility (systolic)
LV compliance (diastolic)
LV impedance / afterload
Intrathoracic pressure
Pericardial pressure
RV output