Regulatio Functions

osmotic P within cell

n and
neuromuscular activity
related to movement
Moveme
of glucose
nt
acid-base balance
of

K+

Potassium
Major
cation in
intracellula
Normal
r level
(3.5 - 5.0
compartments
mEq/L)

Serum levels
maintained by:

dietary ingestion
renal regulation
the
influence of aldosterone
Basal
requirement
of Potassium

K+ intake ranges from 40-150 mEq daily

Homeostasis (minimum req) 20-30 mEq/day
Increased requirement in heart failure and
hypertension

Potassium

reference range - 3.6 to

5.0 mmol/L
Values < 3.0 or > 6.0 are
potentially dangerous
Cardiac conduction defects
Abnormal neuromuscular excitability
Clinical

Problems are common

Many are iatrogenic and avoidable

Disorders of Potassium

Hypokalemia

(< 3.5 mEq/L)

Major cause: increased renal loss of K+

Clinical conditions associated with hypokalemia
insulin therapy

ketoacidosis

long term diuretic therapy

alcoholism

GI fluid loss

steroid therapy

Manifestations
muscle weakness
flaccid paralysis
decreased reflexes
rapid, irregular pulse
decreased BP

EKG changes (flat T)

hypoactive bowel sounds
polyuria

_ Normal serum K+ 3.55.0 normal ECG; T

wave is much higher than
the U wave.

Hypokale
mia &
ECG
Hypokalemia
prominent U waves;
may have camel hump
effect. It is never
normal for the U wave
to be larger than the T
wave.

Serum K+ 3.0-3.5 ECG may be

normal. If ECG changes are
present, they are most prominent
in the anterior precordial leads
(V2 and V3).
Appearance of U waves. (U
wave also seen with digitalis,
quinidine, epinephrine,
hypercalcemia, exercise,
hyperthyroid.)
T wave may be flat, inverted and
ST may be depressed.

Serum K+ 2.7-3.0

Hypokale
mia &

U waves become taller and

T waves become smaller.
Prolongs repolarization as
indicated by U wave and flat
T which may merge (T-U
fusion). The ratio of the
amplitude of the U wave to
the amplitude of the T wave
frequently exceeds 1.0 in V2
or V3.

ECG
Hypokalemia
prominent U waves;
may have camel hump
effect. It is never
normal for the U wave
to be larger than the T
wave.

Serum K+ <2.6
ST segment depression
associated with tall U waves and
low amplitude TR waves.
May produce PVCs,
tachycardia, ventricular fibrillation
because necessary for polarized
state

Hypokalemia, initial

approach

Hypokalemia
Life threatening?
ECG, PaCO2, hepatic
encephalopathy?

No
___
Excessive K
excretion?

No
___
Previous excretion high?
No
___
Chronic low K intake
GI K loss K shift into cells

Yes
___
Remote vomiting
Remote diuretics

Yes
Immediate treatment

Yes
___
Why is K excretion so high?
High urine [K]
___
High mineralocorticoid and
see next algorithm

High CCD flow rate

___
Diuretics
Osmotic diuresis

Hypokalemi
replace potassium !!!
a
Managemen

t Give Potassium Chloride (KCL)

Prevent low K+ watch lab with diuretic drugs!!!
What foods are high in K+?
______________?
Oral route-Check lab and kidney function
IV route-check lab, validate 30 cc per hour
urine output before adding to IV.
Give in stable IV site.

Hypokalemia
Treatment
Oral supplementation preferred unless
significant symptoms present
Amount of potassium needed
proportional to muscle mass and body
weight

Each 1 mEq/L decrease in K

reflects a deficit of 150-400
m Eq in total body potassium

CLINICAL ALERT
Potassium Administration
Never Push

Dilute
NEVER PUSH
POTASSIUM
DO NOT GIVE> 10
mEq/hour IV
Clinical Alert K+
Rider!!

Perfect
Murder

Standard K+ concentration in i.v.

solutions
< 40mEq/L
KCl

1 Cnc: <40 mEq/L

2 Rate of adm: <20 mEq/hr
3 daily dosage : <100 mEq/day
4 Monitor ECG and serum K+
5 U r i n e output: >0.5 ml/kg/hr

KCl bolus

Vol. 281 No. 23,

June 16, 1999

Preoperative Serum
Potassium Levels and
Perioperative Outcomes in
Cardiac Surgery Patients
Joyce A. Wahr, MD; Reginald Parks, MPH; Denis
Boisvert, MSc; Mark Comunale, MD; Judith Fabian, MD;
James Ramsay, MD; Dennis T. Mangano, MD, PhD; for the
Multicenter Study of Perioperative Ischemia Research
Group

Conclusions

Perioperative arrhythmia and the need for

CPR increased as preoperative serum
potassium level decreased below 3.5 mmol/L .
Although interventional trials are required to determine whether preoperative
intervention mitigates these adverse associations, preoperative repletion is low
cost and low risk, and our data suggest that screening and repletion be considered
in patients scheduled for cardiac surgery.
JAMA. 1999;281:2203-2210

Hyperkalemia
Hyperkalemia
Severe

hyperkalemia is a medical
emergency
Neuromuscular signs (weakness,
ascending paralysis, respiratory
failure)
Progressive ECG changes (peaked T
waves, flattened P waves, prolonged
PR interval, idioventricular rhythm
and widened QRS complex, sine
wave pattern, V fib)

Hyperkalemia
Pseudohyperkalemia

hemolysis
thrombocytosis
>1,000,000
WBC > 200,000

Redistribution

acidosis
digitalis overdose
AD hyperkalemic
periodic paralysis

Impaired potassium
secretion
Aldosterone deficiency
adrenal failure
Syndrome of
hyporeninemic
hypoaldosteronism (SHH)
tubular unresponsiveness

Renal failure
GFR < 10 -20% of normal

Hyperkalemi
a
Treatment

Stop potassium!
Get and ECG
Hyperkalemia with ECG
changes is a medical
emergency

First phase is emergency treatment to counteract

the effects of hyperkalemia
*IV Calcium
Temporizing treatment to drive the potassium into
the cells
*glucose plus insulin
*Beta2
agonist
Therapy directed
at actual
removal of potassium
from the body *NaHCO3
*sodium polystyrene sulfonate
(Kayexalate)
*dialysis
Determine and correct the underlying cause

Daily WATER BALANCE

Water intake
DRINK
DRINK
1500
1500
ml/Day
ml/Day
Insolid
solid
In
food800
800
food
ml/day
ml/day

Water excretion
Vaporization from lungs 400
ml/day
Insensible perspiration
600 ml/day

BODY

METABOLISM
METABOLISM
294ml/day
ml/day
294

( Total 2600 ml ) approx

In feces
100 ml/day

URINE
1500 ml/day

( Total 2600 ml )
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Imbalances
Result
From:

Illness
Altered

fluid intake

Prolonged

vomiting or diarrhea

Imbalances
Affect:
Respiration
Metabolism
Function of Central
Nervous System

Dehydration
Dehydration is loss of
water and important
blood salts like
potassium (K+) and
sodium (Na+).

CAUSES OF DEHYDRATION

GI losses
Vomiting
Diarrhea
Malabsorption
disorders

Increased insensible
loss
Fever
Hyperventilation
High environmental
temperatures

Increased sweating
Medical conditions
High environmental
temperatures

Internal loss - loss of fluids into

various body compartments,
especially from intravascular into
interstitial.
Illness - peritonitis, pacreatitis,
bowel obstruction
Poor nutritional states

Plasma losses
Burns
Surgical drains
Fistulas (Abnormal tubelike
passage from a normal cavity to
another cavity or free standing
surface).
Open wounds

Types of dehydration
Dehydration is classified as mild, moderate, or
severe based on the percentage of body weight
age,
lostDepending
during on
the
acute illness:

Mild dehydration -- a loss of 3-5% of body

weight

Moderate dehydration -- a loss of 6-10% of

body weight

Severe dehydration -- a loss of more than

9-15% of body weight. This is a life-threatening
emergency ! ! !

Signs of Dehydration.
Mild
Thirst
Dry lips
Slightly dry mouth
membranes

Moderate
Very dry mouth
membranes

Severe
All signs of
moderate dehydration

Sunken eyes

Rapid, weak pulse

(> 100 at rest).

Sunken fontanelle (soft

spot) on infants head.

Cold hands and feet

Skin doesnt bounce

back quickly when
lightly pinched and
released (poor skin
turgor)

Rapid breathing
Blue lips
Confusion, lethargy,
difficult to arouse
hypotension

LaboratoryTests include
blood chemistries (to check electrolytes, especially
sodium, potassium, and bicarbonate levels)
urine specific gravity (a high specific gravity indicates
significant dehydration)
BUN (blood urea nitrogen -- may be elevated with
dehydration)
creatinine (creatinine -- may be elevated with dehydration )
Complete Blood Count (CBC) to look for signs of
concentrated blood (hemoconcentration)
Other tests may be done to determine the specific
cause of the dehydration (for example, a blood sugar to
check for diabetes).

Treatme
Treat the cause of the dehydration.!!!
nt
Mild
dehydration.

moderate to
severe
dehydration.

Drinking fluids is often

sufficient

Intravenous fluids and

hospitalization may be
necessary

Daily of
water
and
electroly
te

30 ml / kg B.W.

70 kg adult 2000ml/day
Fever water needs
15% for each 1C rise in
the patient's temperature

requiremen
ts

Adapted from Goldberger,

Water, Electrolyte, Acid base
balance.

Daily of
water
and
electroly
te
requiremen
ts

Na, 100 mEq( 5,9 g

NaCl)
K, 60 mEq daily ( 4,5
g KCl)
Fever or sweating
water needed 500 to 2000 ml (if
the patient's temperature is > 38.3C
or room temperature is >
32C( 101F)
More 4 mEq K , will be needed
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Volum
e
of
Fluid
Neede
There
d are

several
methods of
calculating the
volume of
water needed
to treat water
loss.

remember that,
regardless of the method of
calculating water loss,
additional water must be given
to supply the daily water needs.
For example,
a water loss of 4000 ml is present. How
much the patient needs

The patient needs not only the 4000

an additional 1500
ml or more water daily
ml but

to cover the daily water

losses due to insensible
perspiration, urinary
output, and other causes.

 If thirst is present, but other clinical signs

are minimal, assume that the water deficit is
about 2% of the body weight.
In a 70
kg patient, the water deficit 1400 ml.

Volume of
Fluid If the patient has gone 3 to 4 days without
Needed
water, and if there is marked thirst, a dry

Method 1.
A simple way to
calculate the
water deficit is
the following :

mouth and oliguria, the water

deficit is approximately 6% of the b. w.
In a 70 kg patient, the water deficit 4200 ml.
The above signs are present. In addition, if
there are marked physical weakness and
severe mental changes, such as confusion
or delirium, the water deficit is 7 to
14% of the body weight.
In a 70 kg patient, the water deficit 5 to 10 liters.

Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Method 2.
If the patient has been weighed
daily, and it is known, for
example, that he has lost 4 kg
weight during an acute period of
desiccation, the water deficit

is

approximately
4000 ml, or 4 liters.
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Total body water

0,6 X (TBW)
Body weight
42 L

Extracellular fluid

Intracellular fluid

(ECF)

(ICF)

~ 20% X body weight

~ 40% X body weight

14 L

28 L

Interstitial
fluid
x body
weight
10,5 L

Plasma
of ECF
3,5 L
Capillary wall

Volume of Fluid Needed

There are several methods of calculating the volume of water needed to treat water loss. However, one should
remember that, regardless of the method of calculating water loss, additional water must be given to supply the
daily water needs. For example, suppose that you calculate that a water loss of 4000 ml is present. The
patient needs not only the 4000 ml but an additional 1500 ml or more water daily to cover the daily water
losses due to insensible perspiration, urinary output, and other causes.

Method 1. A simple way to calculate the water deficit is the following :

If thirst is present, but other clinical signs are minimal,
----- one can assume that the water deficit is about 2% of the
body weight.
Thus, in a 70 kg ( 154-b) patient, the water deficit would be
approximately 1400 ml.
If the patient has gone 3 to 4 days without water, and if there is marked
thirst, a dry mouth and oliguria,
the water
deficit is approximately 6% of the body weight. In a 70 kg patient, the
water deficit would be approximately 4200 ml.
The above signs are present. In addition, if there are marked physical
weakness and severe mental changes, such as confusion or delirium,
the water deficit is 7 to 14% of the body weight. In a 70 kg
patient, this would be approximately 5 to 10 liters.
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Method 2. If the patient has been weighed daily, and it is known, for
example, that he has lost 4 kg weight during an acute period of
desiccation, the water deficit is approximately 4000 ml, or 4 liters.

Method 3. This method is based on the fact that the plasma sodium concentration
varies inversely with the volume of extracellular water. It assumes, however, that only
water has been lost and the sodium content of the body has remained unchanged.
The following formula is used :
Na2 X BW2 = Na1 X BW1
Na2 presents the present serum sodium concentration. BW2 represents the present
body water volume. Na1 represents the original, or normal, serum sodium concentration
of 142 mEq/L. BW1 represents the original volume of body water. This is 60% of the
body weight of a man (50 % in a woman).
The loss of body water therefore equals BW1 BW2.
Example :
Man, weighing approximately 70 kg. Present serum sodium concentration, 162 mEq/L
Na2 X BW2
= Na1 X BW1
162 x X = 142 X 42
X
=
142 X 42 = 37 liters.
162
Adapted from Goldberger, Water, Electrolyte, Acid base balance.
The water loss is therefore 42 37 = 5 liters.

Osmosis

Moving a liquid through the membrane from lesser to

greater solute concentration

Rate depends on concentration

Temperature
Electrical charges
Differences between osmotic pressures ----Works at equalizing
concentration

Osmotic Pressure (Osmolarity)

Pulling power for water

Depends on number of molecules in solution
Higher the concentration, greater pulling power--(higher osmotic pressure)
Rate is quicker ----Continues until equilibrium is reached

Osmolality = concentration of a solution

# mOsm/kg fluid

Tonicity

Hypertonic

Higher osmotic pressure as RBCs

Pulls fluid from cells -----Shrinks cell

Osmotic

Isotonic

Same osmotic pressure as RBCs

No fluid shift

Hypotonic

Lower osmotic pressure than RBCs

Fluid moves into cells ------Enlarges cell

Pressure
(Osmolarity
)

Affected by plasma proteins

Albumin
Keeps fluid in intravascular compartment
using osmotic pressure
Hydrostatic pressure draws fluid back into
capillaries
Force of fluid pressure outward against surface

ICF 300 mOsm

Normal cell
volume

Hypertonic Solution
-----Shrinks cell

Isotonic Solution
No change in cell volume

Hypotonic Solution
Enlarges cell

Diffusion
Moving a solid across the semi permeable membrane
From higher concentration to lower
To reach equilibrium
Difference between the two is concentration gradient

Filtration
Both

water and solids move together

in response to fluid pressure

Seen in capillary beds

ACTIVE Transport

Requires energy
Moves against gradient

Sodium and potassium pump

Uses carrier molecule

Glucose entering cell

Fluid moves
between
intracellular &
extracellular

Fluid moves
compartments
between
intravascular &
interstitial
compartments
Arteriole

via
.osmos

is
via ..filtration
and osmotic
pressure
Venule
Hydrostatic P

Hydrostatic P

Oncotic P

Fluid Movements
Plasma
Starling
Forces

(b) Starling
Hypothesis
(1896): solutes
are exchanged
between blood
and ECF due to
effects of pHy
and pOs

Interstitial
Fluid

Osmosis

Osmosis

Intracellular
Fluid

Fluid Filtration
Filtration
Coefficient
(K)

Fluid Absorption
Interstitial Fluid

Hydrostatic
Pressure

Capillary Blood

Net Hydrostatic Pressure = Pc - Pif

Net Colloid Osmotic Pressure = p - if
Fluid Filtration Rate = K {(Pc Pif) (p - if)}

Protein
Colloid Osmotic Pressure

Claude Bernard
(1813-1878)

m
o
H

t
s
o
e

s
i
s
a

Walter Cannon
(1929)
La fixit du milieu intrieur est
la condition de la vie libre.

The fixity of the internal

environment is the condition
for free life.

Regulation of the internal

environment in order to maintain
life processes
. This fluid environment surrounding each cell is called
the Internal environment .
The bodys internal environment is the extracellular
fluid ( literally, fluid outside the cells), which bathes
each cell.

Importance of Homeostasis
Fluid

and electrolyte and Acidbase balance are critical to

health and well-being

Maintained by intake
and output
Regulation by :
..renal and pulmonary
systems

Fluid Balance
A result of the relationship between body
water/fluids, fluid compartments, movement of
fluids, movement of solutes, effect of regulatory
mechanisms

 Values

< 3.0 or > 6.0 are

potentially dangerous

ECF

Clinical

Problems are
common

K+
K

ICF

Many

are iatrogenic and avoidable

140

Major
cation in
intracellula
Normal
r level
(3.5 - 5.0
compartments
mEq/L)

Basal requirement of Potassium

K+ intake ranges from 40-150 mEq daily

Homeostasis (minimum req) 20-30
mEq/day

Increased requirement in
heart failure and
hypertension

Ionic Composition of Body Fluids

Concentration Units are in mEq/L
(How many grams of electrolyte (solute) in a liter of plasma

Cations

(solution)

140

Extracellular
Fluid

Na

Anions

110

Cl

24
HCO3

Ca2+
Mg2+

Intracellular
Fluid

More protein
And more cations
in plasma than
Interstitial fluid

Protein--

K+

140
Phosphate and Organic Anions

KESEIMBANGAN

ASAM BASA

PENGATURAN ION H DI DLM CAIRAN SEL

PERUBAHAN ION H KEC REAKSI KIMIA SEL-SEL
pH YG RENDAH DG KONSENTRASI ION H TINGGI
ASIDOSIS
pH tinggi DG KONS. ION HIDROGEN RENDAH
ALKALOSIS
pH NORMAL DRH ARTERI 7.4 VENA & CAIRAN
INTERSTITIAL MEMBTK AS.KARBONAT DI DLM
CAIRAN

KESEIMBANGAN

ASAM BASA

pH NORMAL DARAH ATERI 7.4

BILA < ASIDOSIS
BILA > ALKALOSIS

BATAS SESEORG BISA HIDUP BATAS BAWAH BBRP

JAM 7.O, BATAS ATASNYA : 8.0
UTK MENCEGAH ASIDOSIS ATAU ALKALOSIS
BBRP SISTEM PENGATURAN :
1. SEMUA CAIRAN TBH MEMP SISTEM BUFER
ASAM-BASA MENCEGAH PERUBAHAN ION H
BERLBH

KESEIMBANGAN

ASAM BASA

2. KOSN.ION H JELAS BERUBAH PUSAT

PERNAFASN SEGERA TERSG UYK MENGUBAH KEC
VENTILASI PARU PARU
3. ION KONS H BERUBAH DARI NORMAL GINJAL
MENGEKSKRESI URIN YG ASAM-BASA
JUGA MEMBANTU MENYESUAIKAN KONS CAIRAN
TUBUH KEMBALI KE NORMAL
SISTEM BUFER MENJAGA PERUBAHAN KONS H
BERLBH
RESPIRASI MEMRLUKAN WAKTU 3 12 MENIT
MENYESUAIKAN KEMBALI KONS. ION HIDROGEN
SETELAH TERHADI PERUBAHAN MENDADAK

KESEIMBANGAN

ASAM BASA

AKHIRNYA GINJAL SISTEM PENGATURAN ASAMBASA PALING KUAT

FUNGSI SISTEM ASAM-BASA
AD. SUATU SISTEM BUFER MENJAGA PERUBAHAN
KONS H BERLBH
SISTEM BUFER BIKARBONAY
SUATU BUFER YG KHAS TDD CAMPURAN
BIKARBONAT DAN Na BIKARBONAT

KESEIMBANGAN

ASAM BASA

CAMP AS.KARBONAT SBG BUFER MENCEGAH

PENINGKATAN pH UTK MENCEGAH
PENINGKATAN ATU PENURUNAN pH
SISTEM BUFER FOSFAT= BIKARBONAT
SISTEM INI PENTING DLM CAIRAN TUBULUS
GINJAL FOSFAT SGT TERKONSENTRASI
SISTEM BUFER PROTEIN
BUFER PALING BANYAK PROT SEL DAN PLASMA
SDKT DIFUSI ION H MEL MEMBRAN SEL
CO2 JUGA MUDAH BERDIFUSI DAN BIKARBONAT DLM
BATAS TERTENTU (BBRP JAM MENCAPAI KESIMBANGAN)

KESEIMBANGAN

ASAM BASA

PENGATURAN KESEIMBANGAN AS-BASA OLEH

PERNAFASAN
CO2 BERKOMBINASI DG AIR MEMBTK AS KARBONAT
PENINGAKATAN KONS.CO2 DI DLM CAIORAN TBH
MEMPERKECIL pH KE SISI ASAM
PENURUNAN CO2 PENINGKATAN pH KE SISI ALKALI
BERDSRKAN EFEK INILAH SISTEM PERNAFASN DPT
MENGUBAH pH BAIK MENINGKAT ATAU MENURUN