Summary Notes for studying Fluid and Electrolytes Lecture November 8, 2011

Remember: The body is composed of two major fluid compartments: 1. Intracellular fluid space or ICF (fluid in the cells) 40% of body weight (most fluid is kept in cells) Prevalent electrolyte is potassium and phosphate 2. Extracellular fluid space or ECF (fluid in plasma and interstitial spaces which is in lymph & between cells 20% of body weight Prevalent electrolyte is sodium and sodium and chloride Note: that is why NaCl is the most common IV solution given it is what is in the plasma 3. Transcellular space is a minor space which includes cerebrospinal, joint, peritoneal, GI fluid spaces FLUID WITHIN THE COMPARTMENTS IN THE BODY STAY CONSTANT (Homeostasis) Remember: The ICF and ECF maintains the water and the electrolytes concentration appropriate for their compartments ( 2/3 volume in ICF and 1/3 volume in ECF) by the following mechanisms:

1. Diffusion - high concentration to low concentration of molecules or Active transport sodium potassium pump by ATP energy (Electrolyte, gases, urea movement) 2. Osmosis low concentration (more water/dilute) to high concentration (less water/concentrated) (Water movement) Note: Osmolality is a test typically performed to evaluate the concentration of plasma or urine. Plasma osmolality is normally 275-295mOsm/kg. Higher levels >295 indicates water deficit and Lower levels < 275 indicates water excess Think in terms of concentration If you re making Kool-Aid and you add to much powder (solute) the osmolality would is high > 295 and you would need more water If you add too much water (solvent) the osmolality would be low < 275 and you would need less water In the end you want the Kool-Aid (solution) is be balanced. 3 Hydrostatic Pressure force which moves water in and out of capillaries differs at venous vs. arterial ends 4 Oncotic Pressure- Protein molecules attract water move in and out of mostly into plasma

In our bodies Balance is maintained by 1. Water intake (high osmolality triggers hypothalamus to cause thirst and release of ADH from pituitary to kidneys causing water reabsorption) and by excretion or output (low osmolality triggers hypothalamus to stop thirst and stop release of ADH)

Note: In addition to high osmolality ADH is released under stress and with morphine. That is why it is normal for post op patients often have lower serum osmolality (stress and MS) as water is retained Note: SIADH associated with brain tumors and brain injury causes too much ADH water retain and diabetes insipidus too little ADH results water losses (Na losses) 2. Water is balance by adrenal cortical regulation secretion of hormones , glucocorticoids cortisol retains water under stress (along with elevating glucose) Note: this is why patients often have insulin ordered in hospital but are not DM and mineralocorticoid Aldosterone (stimulated by decreased renal perfusion in kidneys causing kidneys to secrete renin causing angiotensinogen (from liver and circulating in blood) to covert to angiotensin I to angiotensin II causing adrenal to secrete aldosterone which causes sodium retention and therefore water retention. 3. Water is balance by pituitary release of ADH and ACTH (also causes aldosterone release) both retain water

4. Water is balance by renals. Note: Kidney reabsorb 99% of filtrate and produce only 1.5 L of urine per day Remember Kidneys also reabsorb electrolytes Note: Renal function is decreased with age therefore elderly persons are at greater risk of fluid and electrolytes imbalances Note: Impaired kidney function results in edema, potassium and phosphorous retention, acidosis and other electrolyte imbalances. 5. Water is balanced by cardiac ANF atrial naturetic factor hormone release with increased cardiac pressures excretes water and Na Note ANF is elevated in CHF patients 6. Water is balanced by GI intake and output and insensible water loss

IMBALANCES 1. IMBALANCES CAUSED BY FLUID VOLUMES IN ECF Hypovolemia deficit Causes: decreased intake (anorexia, nausea , inability to drink, or obtain water) Think of comatose or very elderly patient) Increased loss (GI vomiting diarrhea drainage suction, diuretics, hemorrhage, third spacing, sweating

Hypervolemia - excess Causes: increased intake (IV fluids) ncreased retention (CHF, Cushing s, Liverdisease, corticosteroid, Renal disease)

HYPOVOLEMIA THINK G I PROBLEMS AND HYPERVOLEMIA THINK CARDIAC AND RENAL PROBLEMS

2. IMBALANCES CAUSE FLUIDS SHIFTS Disease, trauma, malnutrition may alter all these mechanisms which maintain homeostasis or balance Result is ABNORMAL SHIFTS Shifts are often within the ECF and between plasma and interstitial fluids 1. Plasma to Interstitial fluids

Ex: CHF, liver failure, venous thrombosis, varicose veins elevate venous hydrostatic pressure shift movement from plasma to interstitial fluid Ex: Malnutrition low protein intake, nephritic syndrome- excess protein loss or liver disease low protein synthesis decrease plasma oncotic pressure shift movement from plasma to interstitial fluid Ex: trauma, burns, and inflammation damage capillary walls and elevate oncotic pressure shift movement from plasma to interstitial fluid RESULT EDEMA!!!!!!! (SECOND SPACING)

2.

Interstitial fluids to plasma Ex. Hypovolemic shock leads to vasoconstriction which lowers hydrostatic pressure shift movement cell to plasma Ex. Compression hose increases tissue hydrostatic pressure shift into plasma Ex. Administration of IV fluids dextran, mannitol, or any hypertonic solution shift from interstitial to plasma

Note: IV fluids are isotonic, hypotonic or hypertonic and are RX with the direct purpose of maintaining or effecting water movement.

Shifts or movement between ECF and ICF are affected by osmolality ICF and ECF normally have same osmolality and are termed as being isotonic no movement of water. If the ECF (plasma) osmolality is high >295 water therefore it is more concentrated water will move into plasma from cell and the cell will shrink. If the ECF (plasma) osmolality is low <275 therefore it is diluted water will move into cell from plasma and the cell with swell. Note: As brain cells shrink cause CNS symptoms and as brain cells swell cause CNS symptoms

ELECTROLYTES Anions Bicarbonate HCO3 Chloride Cl Phosphate PO4 Protein Cations Potassium K Magnesium Mg2 Sodium Na Calcium Ca2

Electrolytes Imbalances Note: Imbalances are always classed as deficit or excess

Na Note: Serum sodium levels reflect the ratio of sodium to water not necessarily the loss or gain of sodium therefore underlying causes of imbalances can be water or sodium loss or gain Remember Na and water go together therefore changes in one effect the other

Hypernatremia: 1. Loss of water results in water deficit therefore increased Na Manifestations: Thirst, restlessness, seizures, weakness, hypotension, weight loss EX: Causes: Increased perspiration from Fever, Diabetes insipidus 2. Gain of Sodium Manifestations: Thirst, restlessness, seizures, edema, increased BP, weight gain EX: Causes: IV hypertonic solutions, IV sodium bicarbonate, Hyperaldosteronism , salt water drowning

Think why weight gain vs weight loss symptoms with hypernatremia (Volume of ECF is more in sodium gain causes Hyponatremia: 1. Gain of water results in low Na Manifestations: Headaches, apathy, weakness, confusion, weight gain increased blood pressure seizures, increased CVP Causes: SIADH, CHF, POLYDIPSIA, IV HYPOTONIC FLUIDS Loss of Na Manifestations: Irritability, confusion, hypotension, tachycardia, decreased CVP weight loss, seizures, and coma Causes: GI- diarrhea, vomiting, fistulas, NG suction, Renal- diuretics, adrenal insufficiency Skin-burns, wound drainage REMEMBER THIS ABOUT NA IMBALANCES PROBLEMS ARE MOST OFTEN NEURO!!!!

2.

K Remember K is the major electrolyte in ICF therefore problems in tissue with cause excess or losses Hyperkalemia Causes can be excess potassium intake (salt substitutes, drugs, IV) or shift of K out of cells (acidosis, fever with tissue catabolism, crush injury, tumor lysis syndrome) OR failure to eliminate K (renal disease, diuretic sparing, adrenal insufficiency, ACE inhibitors Manifestations: Irritability, cramping, paresthesias, Cardiac standstill, irregular pulse, EKG changes Hypokalemia Causes can be potassium loss (GI diarrhea, vomiting, fistulas, NG suction, Renal diuretics, hyperaldosteronism, diaphoresis, dialysis OR shift of K into cells (insulin, alkalosis, tissue repair, stress or epinephrine OR lack of K intake (NPO with no IV) Manifestions: Fatigue, cramps, ileus, soft muscles, paresthesias, decreased reflexes, irregular pulse, bradycardia, arrhythmias, EKG changes

REMEMBER THIS ABOUT K IMBALANCES ARE MOST OFTEN CARDIAC!!!!

Ca Remember calcium found in bone and is 99% combined with phosphorus therefore changes in one causes changes in the other an inverse relationship depends on hormones PTH, VitD, calcitonin

Hypercalcemia Causes: Rare cause of intake usually associated with antacids Main causes are skeletal metastasis, parathyroidism, vitamin D overdose, and immobilization Manifestations: Lethargy, weakness, decreased memory, confusion, bone pain, fx Hypocalcemia Causes: Elevated phosphorus, hypoparathyroidism, vit D deficiency, pancreatitis, alcoholism

Manifestations: fatigue, depressions, numbness, muscle cramps, Chvostek, Trousseau signs, tetany

REMEMBER this about Ca imbalances are mostly Muscular !!!!!!

Hyper and Hypo phosphatemia are similar to calcium imbalances but maybe caused by intake of phosphorus ingestion of laxatives, foods or using Fleets enemas Mg Note Most magnesium is balanced in the kidneys therefore patients with renal failure should not take mg containing products such as Maalox or MOM Hypermagnesemia Causes: Renal patients taking magnesium, eclampsia patient given magnesium, adrenal insufficiency Manifestations: lethargy, drowsiness, nausea deep tendon reflexes loss, cardiac arrest Hypomagnesemia Causes: GI problems, malabsorption syndrome, prolonged malnutrition Manifestations: Confusion, hyperactive deep tendon reflexes, tremors REMEMBER MAGNESIUM IMBALANCES THINK NEUROMUSCULAR HYPERIRRITABILITY!!!! PROTEIN NOTE: PROTEINS DETERMINE PLASMA VOLUME PARTICULARLY ALBUMIN THEY STAY IN PLASMA

HYPOPROTEINEMIA Causes: Intake, massive burns, renal disease, infection, liver disease Manifestations: Ascites, edema, slow healing

Hyperproteinemia Rare

REMEMBER PROTEIN IMBALANCE ARE PROBLMES WITH THIRD SPACING (First spacing is normal distribution of fluids ECF to ICF, second spacing is abnormal accumulation in interstitial fluid = edema and third spacing is when fluid accumulation in areas that do not have fluid normally = ascites

Class assignment is to determine tx for each fluid and electrolyte imbalance discussed Note acid base imbalances with be discussed next week