PHYSIOLOGY of Fluid &

ELECTROLYTE

Dr. Dedi Ardinata, M.Kes (Biomedik)

Department of Physiology, Faculty of Medicine
University of Sumatera Utara, Medan
Indonesia
 We are
approximately
two-thirds
water
 Claude Bernard
(1813-1878)
“La fixité du milieu intérieur est
la condition de la vie libre.”
“The fixity of the internal
environment is the condition
for free life.”
Walter Cannon
(1929)
“Regulation of the internal environment in order to maintain
life processes”
. This fluid environment surrounding each cell is called
the Internal environment .
The body’s internal environment is the extracellular
fluid ( literally, fluid outside the cells), which bathes
each cell.
 Importance of Homeostasis
• Fluid and electrolyte and Acid-base
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
Water is the largest single component of the body

60% of adult’s weight is

………………water
• Water is main solvent in living cells

Distribution/Compartment of Body Fluids

Body Water

Intracellular fluid Extracellular fluid

(inside cells) (outside cells)

Plasma Interstitial Fluid

(inside (outside blood vessels, Between
blood vessels) and around the cells )

Intravascular volume is the most critical for survival: determinant of blood pressure, cardiac output, organ perfusion, oxygenation
etc.
 Body Fluid Compartments:
Total Body Water ( TBW) = 60% wt ( 70 kg -> 42 L 0 …… varies due to ?

TBW
Extracellular fluid (ECF)
(Internal environment)
Volume= 14 L, 1/3 TBW

Interstitial fluid Plasma

Intracellular fluid volume = 11 L Volume =
3L
80% of ECF
Volume = 28 L, 2/3 TBW 20% of
ECF
Transcellular Fluid ~1% body weight
 includes cerebrospinal, intraocular,
pleural, peritoneal, synovial fluids, and
digestive secretions.
 are surrounded by specialized epithelial
cells, and have specialized compositions.
 Intracellular fluid differs from
Arteriole Extracellular
ECF
P

ISF

ICF

Venule

Fig. Diffusion of fluid through the capillary walls and through the
interstitial spaces
 To maintain
homeostasis, fluids
Regulation are regulated by:
of
Body
– Fluid intake
Fluids
– Hormonal controls
– Fluid output
 Daily WATER BALANCE

Water intake Water excretion

Vaporization from lungs 400
DRINK
ml/day
1500 ml/Day Insensible perspiration
600 ml/day

In solid food
In feces
800 ml/day BODY 100 ml/day

METABOLISM URINE
294 ml/day 1500 ml/day

( Total 2600 ml ) approx ( Total 2600 ml )

Adapted from Goldberger, Water, Electrolyte, Acid base balance.
 Ionic Composition of Body Fluids
Concentration Units are in mEq/L
(How many grams of electrolyte (solute) in a liter of plasma (solution)

Cations Anions
140
110
More protein
Extracellular 24 And more cations
Fluid Na+ in plasma than
Cl HCO3
Interstitial fluid
Ca2+
Mg2+
Protein--

Intracellular K+
Fluid

140

Phosphate and Organic Anions

 • ADH
Regulation – Stored in posterior pituitary gland
• Released in response to changes in blood
of •
osmolarity
Makes tubules and collecting ducts more
permeable to water
Body – Water returns the systemic circulation
» Dilutes the blood
– Decreases urinary output
Fluids
• Aldosterone
– Released by adrenal cortex
Hormonal • In response to increased plasma potassium
• Or as part of renin-angiotensin-aldosterone
regulation mechanism
– Acts on distal tubules to increase reabsorption
of sodium and water
– Excretion of potassium and hydrogen

ADH • Renin
– Secreted by kidneys
• Responds to decreased renal perfusion
• Acts to produce angiotensin I
–
Aldosterone •
Causes vasoconstriction
Converts to Angiotensin II
– Massive selective vasoconstriction
» Relocates and increases the blood flow to
kidney, improving renal perfusion
Renin – Stimulates release of aldosterone with low sodium
 • Kidneys
Regulation – Major regulatory organ
• Receive about 180 liters of blood/day to filter
of • Produce 1200-1500 cc of urine
Body • Skin
Fluids – Regulated by sympathetic nervous
system
• Activates sweat glands
– Sensible or insensible-500-600 cc/day
» Directly related to stimulation of sweat
Fluid Output Regulation glands
• Respiration
– Insensible
• Increases with rate and depth of respirations,
oxygen delivery
Kidneys – About 400 cc/day
Skin • Gastrointestinal tract
Respiration – In stool
Gastrointestinal – Average about 100-200
tract » GI disorders may increase or
decrease it.
Regulation and
– Major contributor to
Movement maintaining water balance
of Sodium (Na) • By effect on serum
osmolality, nerve impulse
transmission, regulation of
acid-base balance and
Most abundant participation in chemical
cation in ECF reactions
– Regulated by dietary intake
Normal level and aldosterone
: 135-145
 Diagnosing Hyponatraemia
Extravascular Volume
Hypovolaemic Oedema Euvolaemic
CCF Cirrhosis
Nephrosis Pl Osmo
Normal Low High
Pseudo- Water Hypertonic
hypoNa Overload hypoNa

Urine Sodium Urine Sodium

>20 <20 >20 <20

Diuretics Vomiting SIADH Stress
Addisons’s Diarrhoea Drugs Post Surgery
Na losing Nephritis Skin loss CRF Endocrine:
Hypothyroid
 Caused by excess water loss or
Hypernatremia
overall sodium excess
Excess salt intake, hypertonic
(Na > 145, solutions, excess
sp gravity < aldosterone,diabetes insipidus,
increased water loss, water
1.010) deprivation
S&S: thirst, dry, flushed skin,
dry, stick tongue and mucous
membranes

Occurs with net loss of sodium or net

Hyponatremia water excess
Kidney disease with salt wasting,
adrenal insufficiency, GI losses,
(Na < 135, increased sweating, diuretics, SIADH
S&S: personality change, postural
sp gravity > hypotension, postural dizziness,
1.030 abd cramping, diarrhea,
tachycardia, convulsions and
coma
 • Functions
Regulation – osmotic P within cell
– neuromuscular activity
and Movement – related to movement of
of glucose

K+
– acid-base balance

• Serum levels maintained by:

– dietary ingestion
Potassium – renal regulation
• the influence of aldosterone

•Major cation Basal requirement of Potassium

in • K+ intake ranges from 40-150 mEq daily
intracellular • Homeostasis (minimum req) 20-30 mEq/day
Normal level • Increased requirement in heart failure and
compartments hypertension
(3.5 - 5.0
mEq/L)
 Disorders of Potassium
• 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
• 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  •EKG changes (flat T)
flaccid paralysis
•hypoactive bowel sounds
•decreased reflexes
•polyuria
•rapid, irregular pulse
•decreased BP
 _ Normal serum K+ 3.5-
5.0 — normal ECG; T
wave is much higher than
the U wave.

Hypokalemia
&
ECG 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).
Hypokalemia —
• Appearance of U waves. (U
prominent U waves; wave also seen with digitalis,
may have camel hump quinidine, epinephrine,
hypercalcemia, exercise,
effect. It is never
hyperthyroid.)
normal for the U wave • T wave may be flat, inverted and
to be larger than the T ST may be depressed.
wave.
 Serum K+ 2.7-3.0
• 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
Hypokalemia the amplitude of the T wave
frequently exceeds 1.0 in V2
or V3.

&
Serum K+ <2.6
ECG
ST segment depression
Hypokalemia —
associated with tall U waves and
prominent U waves;
low amplitude TR waves.
may have camel hump
• May produce PVCs,
effect. It is never
tachycardia, ventricular fibrillation
normal for the U wave
because necessary for polarized
to be larger than the T
state
wave.
 Hypokalemia, initial approach
Hypokalemia
Life threatening?
ECG, PaCO2, hepatic
encephalopathy?

No Yes
___
Excessive K Immediate treatment
excretion?

No Yes
___ ___
Previous excretion high? Why is K excretion so high?

No Yes High urine [K] High CCD flow rate

___ ___ ___ ___
Chronic low K intake Remote vomiting High mineralocorticoid and Diuretics
GI K loss K shift into cells Remote diuretics see next algorithm Osmotic diuresis
Hypokalemia replace potassium !!!
Management
• 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
 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 • Impaired potassium
– hemolysis secretion
– thrombocytosis – Aldosterone deficiency
>1,000,000 • adrenal failure
– WBC > 200,000 • Syndrome of
• Redistribution hyporeninemic
hypoaldosteronism (SHH)
– acidosis
• tubular unresponsiveness
– digitalis overdose
– Renal failure
– AD hyperkalemic
periodic paralysis • GFR < 10 -20% of normal
 – Stop potassium!
Hyperkalemia – Get and ECG
Treatment – 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*NaHCO3
actual removal of potassium from the body
*sodium polystyrene sulfonate (Kayexalate)
*dialysis
Determine and correct the underlying cause
Imbalances
• Result
• Illness
From:
• Altered fluid intake

• Prolonged vomiting or diarrhea

Imbalances Affect:
Respiration
Metabolism

Function of Central Nervous

System