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Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
Fluids and electrolyte
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Fluids and electrolyte

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  • The Starling Equation:\n\nJv = Kf [ (Pc-Pi) - (Pic-Pii) ] \n\nWhere:\nJv = fluid movement\nKf = Huraulic conductance\nPc = capillary Hydrostatic Pressure\nPi = interstitial hydrostatic pressure\nPi c = capillary oncotic pressure\nPi i = interstitial oncotic pressure\n
  • Flow = [ (pressure of Cap - Pressure of interstitium) - (oncotic P of Cap - Oncotic P of interstitium) ]\n\n+ Pc: art dilation, venous constriction, venous pressure, Heart failure, EC volume expansion, Dependant limb edema\n- Pi c: - plasma protein, liver disease, protein starving, nephrotic syndrom, \n+ Kf: Burn, Inflammation\n
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  • Perhaps because,\n- Ca outside cell makes cell relatively positive and closer to threshold.\n
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  • You are basically forced to blow off all your CO2.\n
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  • 1 - look at pH\n2 - look at pCO2. (see it as bicarb on chem 7) See if it is metabolic or respiratory. If outside of normal, than it is not \nthe lung’s fault.\n3 - Ex:(Acid)If pCO2 is normal, then it is acute metab. If decreased, then chronic. \n4 - Look at ion gap: Na - (CO2 + Cl) = ion gap. 10-12 = normal. \n Normal, means loss. \n Gap = DKA, LA, ingestion of antifreeze, methanol, aspirin OD, RF, \n If pCO2 elevated, its the lung. Then look at bicarb, see if acute or chronic, see if the kidneys have kicked in.\n*** do the same on the basic side. \n
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    • 1. Fluid and Electrolytes Acid and Base Balance Reference: Pathophysiology by Kathryn McCance Mindy Milton, MPA, PA-C July 1, 2010 1Mosby items and derived items © 2006 by Mosby, Inc.
    • 2. Distribution of Body Fluids Total body water (TBW)  Intracellular fluid Total body water aprox 42L Rest is fat, fat free solids, bones.  Extracellular fluid Mostly intracellular.  Interstitial fluid Adipose tissue has less water, so obese  Intravascular fluid have less total body water, and more risk of dehydration. age also effects, probably due to more fat. 2Mosby items and derived items © 2006 by Mosby, Inc.
    • 3. Fluid Compartment 3Mosby items and derived items © 2006 by Mosby, Inc.
    • 4. Electrolyte Distribution Major Cations:  Extracellular fluid  Plasma: Na  Interstitial Fluid: Na  Intracelluar fluid  K, Mg Major Anions  Extracellular Fluid  Plasma: Cl, HCO3, Protein  Interstitial: Cl, HCO3, HPO4, SO4  Intracellular Fluid  HPO4, Proteins, HCO3, CL,, SO4 4Mosby items and derived items © 2006 by Mosby, Inc.
    • 5. Principles of Fluid and Electrolytes Homeostatic mechanisms respond to changes in the extracellular fluid Cellular receptors respond to changes in volume and osmotic concentration Water is moved by osmotic gradients and not by active transport Water follows sodium 5Mosby items and derived items © 2006 by Mosby, Inc.
    • 6. Water Movement Betweenthe Plasma & Interstitial Fluid Osmolality represent Na consentration Osmotic forces (hydrostatic pressure) due to heart contraction Aquaporins H2O can also diffuse through memb. Starling hypothesis  Net filtration = forces favoring filtration – forces opposing filtration (oncotic) capillary bed 6Mosby items and derived items © 2006 by Mosby, Inc.
    • 7. Net Filtration  Forces favoring filtration  Capillary hydrostatic pressure (blood pressure)  Interstitial oncotic pressure (water-pulling)  Forces favoring reabsorption  Plasma oncotic pressure (water-pulling)  Interstitial hydrostatic pressure 7Mosby items and derived items © 2006 by Mosby, Inc.
    • 8. Water Movement Between Be able to do equation to figure out force. In edema, hypertension,the ICF and ECF obstruction. 8Mosby items and derived items © 2006 by Mosby, Inc.
    • 9. Edema  Factors that increase Capillary Hydrostatic Pressure  Venous obstruction THink Kinking.  Thrombophlebitis, tight clothing, prolonged sitting or standing  Salt and water retention Think osmosis drawing fluid in to make more volume.  CHF  Renal failure  Cirrhosis  Factors that decrease Capillary Oncotic Pressure  Decreased plasma proteins Less fluid in vessels  Cirrhosis  Nephrotic syndrome - centralized edema.  Malnutrition  Burns - lose proteins through skin.  Factors that increase capillary permeability  Inflammation and Immune response as a result of:  Trauma: burns, crush injury, neoplastic disease, allergic Rnx  Proteins escape from plasma  ↓ capillary oncotic pressure & ↑interstitial oncotic pressure  Factors that decrease absorption of interstitial fluids  Lymph obstruction  Infection  Tumor 9  Surgical re-sectionMosby items and derived items © 2006 by Mosby, Inc.
    • 10. Water Balance - two main factors  Thirst perception - stim water drinking behavior.  Osmolality receptors  Hyperosmolality and plasma volume depletion  decrease in actual H2O  ADH secretion  Increase thirst sensation  Increase permeability of Renal distal tubule to water = increased water retention. sensor in atrea, aorta, sensing 10 pressure. Used toMosby items and derived items © 2006 by Mosby, Inc. sense water.
    • 11. Other Regulatory Hormones Aldosterone  Released by the adrenal cortex  Stimulates the retention of NA and excretion of K by the distal tubule of the kidney - therefore water follows.  Aldosterone released in response to:  Increasingserum K (hyperkalemia)  Decreasing serum NA (hyponatremia)  Low renal perfusion Renin, from JGA, sensing  Renin - Angiotensin- Aldosterone System (RAAS) in the kidney. low flow Start RAAS,  Increase volume (Na) and increase BP Angiotensin 2 is a vasoconstrictor. 11Mosby items and derived items © 2006 by Mosby, Inc. Normal is 136 - 145 Na per L
    • 12. Other Regulatory Hormones  Natriuretic peptides  Atrial natriuretic peptide (heart)  Brain natriuretic peptide (heart)  Urodilantin (kidney)  ANP (& BNP) is released by the cardiac muscle fibers in response to abnormal stretching of the atrial walls  Abnormal stretching can be caused by increased blood pressure or increased blood volume  Effects: reduces thirst, decreased release of ADH and Aldosterone  Will cause diuresis – water and sodium 12Mosby items and derived items © 2006 by Mosby, Inc.
    • 13. Alterations in Na+, Cl–, and Water  Total body water change with proportional electrolyte and water change  Isotonic volume depletion -- proportional exchange.  Hemorrhage  Excessive diaphoresis Cl- is the bitch, follows  Decrease fluid intake Na+.  Intestinal losses  Isotonic volume excess  Excessive NS IV - iatrogenically.  Hyperaldosteronism  cortisone - steroid 13Mosby items and derived items © 2006 by Mosby, Inc.
    • 14. Decreased water - Diabetes Insipitus. Loss of ADH: unable toHypertonic Alterations concentrate urine. Fine, as long as they can drink.  Hypernatremia Conn  Serum sodium >147 mEq/L  Related to sodium gain or water loss  Water movement from the ICF to the ECF  Intracellular dehydration (cell shrinks)  Manifestations  Intracellular dehydration, convulsions, pulmonary edema, hypotension, tachycardia 14Mosby items and derived items © 2006 by Mosby, Inc.
    • 15. Hypotonic Alterations  Decreased ECF osmolality  Caused by:  Sodium deficit (Hyponatremia) or  Fee water excess (water intoxication)  Hyponatremia will cause water movement from ECF to ICF  Intracellular overhydration (cell swells)  Cerebral edema – irritability, confusion, HA, depression, systemic edema, weakness, anorexia, nausea, diarrhea  Plasma hypovolemia  Hypotension, tachycardia, decrease urine output  Free water Excess both ICF and ECF volume increase  Intracellular overhydration (cell swells)  Plasma hypervolemia  Cellular and systemic edema as above 15Mosby items and derived items © 2006 by Mosby, Inc.
    • 16. Hyponatremia  Serum sodium level <135 mEq/L  Sodium deficits cause plasma hypoosmolality and cellular swelling  Causes: addisons disease, not  Pure sodium deficits enough cortisol or aldo.  Vomiting, diarrhea, overuse diuretics, burns Innapropriate secretion of ADH - page 104 in  Low sodium intake text.  Rare  Dilutional hyponatremia  Excessive ½ NS IV (.45) - hypotonic saline  Mannitol (shift from ICF to ECF) - not low sodium, just being diluted  Hypoosmolar hyponatremia  ARF (oliguric), severe CHF, Liver Cirrhosis  Hypertonic hyponatremia  Hyperlipidemia, hyperglycemia, hyperproteinemia 16  Displace water volume and decrease Na concentrationMosby items and derived items © 2006 by Mosby, Inc.
    • 17. orthostatic vitals:BPWater Deficit drop, pulse goes up.  Dehydration - common  Isotonic (loss of water and sodium)  Pure water deficits - rare  Hypertonic dehydration  Renal free water clearance - common  Impaired tubular function or inability to concentrate urine  Manifestations  HA, thirst, dry skin/mucous membranes, wt loss, fever, conc urine*  Tachycardia, weak pulses, and postural hypotension  Elevated hematocrit and serum sodium level * Not with diabetes insipidus 17Mosby items and derived items © 2006 by Mosby, Inc.
    • 18. Water Excess Compulsive water drinking  Psychogenic Decreased urine formation  Intrinsic renal disease or decreased renal blood flow Syndrome of inappropriate secretion of ADH (SIADH)  ADH secretion in the absence of hypovolemia or hyperosmolality  Hyponatremia with hypervolemia Manifestations  Rapid loading - cerebral edema, confusion, seizures  Slow loading - weakness, nausea, muscle twitching, headache, and weight gain 18Mosby items and derived items © 2006 by Mosby, Inc.
    • 19. Potassium Major intracellular cation Concentration maintained by the Na+/K+ ATPase pump Regulates intracellular electrical neutrality in relation to Na+ and H+ Essential for transmission and conduction of nerve impulses, normal cardiac rhythms, and skeletal and smooth muscle contraction 19Mosby items and derived items © 2006 by Mosby, Inc.
    • 20. Potassium Levels Changes in pH affect K+ balance  Hydrogen ions accumulate in the ICF during states of acidosis. K+ shifts out to maintain a balance of cations across the membrane. Aldosterone, insulin, and catecholamines influence serum potassium levels ECF acidodic, casue H to be pumped into the cell, exchanging K out. 20Mosby items and derived items © 2006 by Mosby, Inc.
    • 21. Hypokalemia Potassium level <3.5 mEq/L Etiology  Reduced intake  Shifts of potassium from the extracellular to intracellular space (alkalosis)  Loss of potassium from body stores: GI losses with vomiting, diarrhea, fistulas, laxative abuse. Renal losses from overuse of diuretics, increased aldosterone. Manifestations  Membrane hyperpolarization causes a decrease in neuromuscular excitability, skeletal muscle weakness, smooth muscle atony, and cardiac dysrhythmias 21Mosby items and derived items © 2006 by Mosby, Inc.
    • 22. Renal failure is the most common causeHyperkalemia Potassium level >5.5 mEq/L Hyperkalemia is rare due to efficient renal excretion - Caused by increased intake, shift of K+ from ICF, decreased renal excretion, insulin deficiency, or cell trauma K goes into the cells with glucose. 22Mosby items and derived items © 2006 by Mosby, Inc.
    • 23. Hyperkalemia Mild attacks  Hypopolarized membrane, causing neuromuscular irritability  Tall peaked T waves with shortened QT on ECG - rapid repolarization, poor propigation of AP.  Tingling of lips and fingers, restlessness, intestinal cramping, and diarrhea Severe attacks  The cell is not able to repolarize, resulting in muscle weakness, loss or muscle tone, and flaccid paralysis  Depressed ST segment, prolonged PR interval, widened QRS 23Mosby items and derived items © 2006 by Mosby, Inc.
    • 24. Usually inverse relationship.Calcium and Phosphate  Most calcium is stored in bone (99%)  Necessary for structure of bones and teeth, blood clotting, hormone secretion, and cell receptor function  Like calcium, most phosphate (85%) is also located in the bone  Necessary for high-energy bonds located in creatine phosphate and ATP and acts as an anion buffer  Calcium and phosphate concentrations are rigidly controlled  Increase in one will require a decrease in the other 24Mosby items and derived items © 2006 by Mosby, Inc.
    • 25. Calcium and Phosphate Regulated by three hormones - tight control.  Parathyroid hormone (PTH)  Increases plasma calcium levels  Renal activation of Vitamin D  Vitamin D  Fat-soluble steroid; increases calcium absorption from the GI tract - epidemic due to sunscreen.  Calcitonin - parafollicular cells (c cells) in pancreas.  Decreases plasma calcium levels - “tone down”. 25Mosby items and derived items © 2006 by Mosby, Inc.
    • 26. Hypocalcemia and Hypercalcemia Hypocalcemia  Hypercalcemia  < 8.5 mg/dl  > 12 mg/dl  Increased  Decreased neuromuscular neuromuscular excitability excitability (partial depolarization)  Muscle weakness  Muscle cramps  Increased bone  Think of as partial fractures!!!Wierd depolarization  Kidney stones  Constipation - hard to be able to compare/ contrast depolarize 26Mosby items and derived items © 2006 by Mosby, Inc.
    • 27. pH Inverse logarithm of the H+ concentration If the H+ are high in number, the pH is low (acidic). If the H+ are low in number, the pH is high (alkaline). The pH scale ranges from 0 to 14: 0 is very acidic, 14 is very alkaline. Each number represents a factor of 10. If a solution moves from a pH of 6 to a pH of 5, the H+ have increased 10 times. 27Mosby items and derived items © 2006 by Mosby, Inc.
    • 28. pH Acids are formed as end products of protein, carbohydrate, and fat metabolism To maintain the body’s normal pH (7.35-7.45) the H+ must be neutralized or excreted The bones, lungs, and kidneys are the major organs involved in the regulation of acid and base balance 28Mosby items and derived items © 2006 by Mosby, Inc.
    • 29. pH Body acids exist in two forms  Volatile - can blow off.  H2CO3 (can be eliminated as CO2 gas)  Nonvolatile  Sulfuric, phosphoric, and other organic acids  Eliminated by the renal tubules with the regulation of HCO3– 29Mosby items and derived items © 2006 by Mosby, Inc.
    • 30. Buffering Systems A buffer is a chemical that can bind excessive H+ or OH– without a significant change in pH A buffering pair consists of a weak acid and its conjugate base  Ex: H2CO3 ; HCO3- see the kidney work with both of these.  HHb ; Hb- - in plasma. (Hemoglobin system) The most important plasma buffering systems are the carbonic acid–bicarbonate system and hemoglobin The most important intracellular buffering systems are phosphate and protein 30Mosby items and derived items © 2006 by Mosby, Inc.
    • 31. Carbonic Acid–Bicarbonate Pair If the amount of bicarbonate decreases, the pH decreases, causing a state of acidosis The pH can be returned to normal if the amount of carbonic acid also decreases  This type of pH adjustment is referred to as compensation The respiratory system compensates by increasing or decreasing ventilation The renal system compensates by producing acidic or alkaline urine Renal compensatio H2O + CO2 <-->H2CO3 <--> HCO3- + H+ take days. Lungs in minutes to hours. 31Mosby items and derived items © 2006 by Mosby, Inc.
    • 32. Other Buffering Systems Protein buffering  Proteins have negative charges, so they can serve as buffers for H+ Renal buffering  Secretion of H+ in the urine and reabsorption of HCO3– Cellular ion exchange  Exchange of K+ for H+ in acidosis and alkalosis 32Mosby items and derived items © 2006 by Mosby, Inc.
    • 33. Acid-Base Imbalances Normal arterial blood pH  7.35 to 7.45  Obtained by arterial blood gas (ABG) sampling Acidosis  Systemic increase in H+ concentration  < 7.35 Alkalosis  Systemic decrease in H+ concentration  > 7.45 33Mosby items and derived items © 2006 by Mosby, Inc.
    • 34. Acidosis and Alkalosis Four categories of acid-base imbalances:  Respiratory acidosis—elevation of pCO2 due to ventilation depression  Respiratory alkalosis—depression of pCO2 due to alveolar hyperventilation  Metabolic acidosis—depression of HCO3– or an increase in non-carbonic acids  Metabolic alkalosis—elevation of HCO3– usually due to an excessive loss of metabolic acids lactic acidosis - shock, DKA, 34Mosby items and derived items © 2006 by Mosby, Inc. Met Alk - diarrhea/ vomiting.
    • 35. Metabolic Acidosis SLower. 35Mosby items and derived items © 2006 by Mosby, Inc.
    • 36. Metabolic Alkalosis Have alk urine.Depression of breathing. 36 Mosby items and derived items © 2006 by Mosby, Inc.
    • 37. Respiratory Acidosis etiology: depression of respiration. Can be acute and chronic. pCO2 will triggar compensation.head trauma and drug OD,compensation will nothappen.Chronic - will causerespiration to adapt,changing set pint.Kidneys are the one. 37 Mosby items and derived items © 2006 by Mosby, Inc.
    • 38. Respiratory Alkalosis Cause: ICU ventilated patients, anxiety, anemia (less Hb), pulm/cv disorders. Happens rapidly. Kidneys compensate for chronic. 38Mosby items and derived items © 2006 by Mosby, Inc.
    • 39. Acid Base Response Issue is either a production or excretion problem. Buffering systems in the plasma (RBC). bicarb/carbonic acid system and Hb. 39Mosby items and derived items © 2006 by Mosby, Inc.
    • 40. Approach to Acid Base Disturbances 40Mosby items and derived items © 2006 by Mosby, Inc.
    • 41. Questions? 41Mosby items and derived items © 2006 by Mosby, Inc.

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