GROUP

C2
Physiology Laboratory
Small Group Discussion
Output

March 16, 2016

[FLUID & ELECTROLYTE

IMBALANCE/DEHYDRATION]
By: ASUBARIO, Olufunmilola Omonike; BALADAD, Alvin Bryan; DE JESUS, Chrislou; GURUNG, Man
Bahadur; KALANGEG, Kristie; MAHALEE, Naphitcharak; MONTHATHONG, Thanapol; PANLASIGUI,
Rikkimae Maria; SAMSON, Chino Paolo; SOLONIO, Natalie Keith; VALDEZ, Gregorio
 FLUID & ELECTROLYTE IMBALANCE, DEHYDRATION

Electrolytes are the smallest of chemicals that are important for the cells in the
body to function and allow the body to work. Electrolytes such as sodium, potassium,
and others are critical in allowing cells to generate energy, maintain the stability of their
walls, and to function in general. They generate electricity, contract muscles, move
water and fluids within the body, and participate in myriad other activities.

The concentration of electrolytes in the body is controlled by a variety of

hormones, most of which are manufactured in the kidney and the adrenal glands.
Sensors in specialized kidney cells monitor the amount of sodium, potassium, and water
in the bloodstream. The body functions in a very narrow range of normal, and it is
hormones like renin (made in the kidney), angiotensin (from the lung, brain and heart),
aldosterone (from the adrenal gland), and antidiuretic hormone (from the pituitary) that
keep the electrolyte balance within those normal limits.

Keeping electrolyte concentrations in balance also includes stimulating the thirst

mechanism when the body gets dehydrated.

Sodium (Na)

Sodium is most often found outside the cell, in the plasma (the non-cell part) of
the bloodstream. It is a significant part of water regulation in the body, since water goes
where the sodium goes. If there is too much sodium in the body, perhaps due to high
salt intake in the diet (salt is sodium plus chloride), it is excreted by the kidney, and
water follows.

Sodium is an important electrolyte that helps with electrical signals in the body,
allowing muscles to fire and the brain to work. It is half of the electrical pump at the cell
level that keeps sodium in the plasma and potassium inside the cell.

Potassium (K)

Potassium is most concentrated inside the cells of the body. The gradient, or the
difference in concentration from within the cell compared to the plasma, is essential in
the generation of the electricial impulses in the body that allow muscles and the brain to
function.

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Imbalance/Dehydration
Calcium (Ca)

Calcium levels are controlled by calcitonin, which promotes bone growth and
decreases calcium levels in the blood, and parathyroid hormone, which does the
opposite. Calcium is bound to the proteins in the bloodstream, so the level of calcium is
related to the patient's nutrition as well as the calcium intake in the diet. Calcium
metabolism in the body is closely linked to magnesium levels. Often, the body's
magnesium status needs to be optimized before the calcium levels can be treated.

Magnesium (Mg)

Magnesium is an often forgotten electrolyte that is involved with a variety of

metabolic activities in the body, including relaxation of the smooth muscles that
surround the bronchial tubes in the lung, skeletal muscle contraction, and excitation of
neurons in the brain. Magnesium acts as a cofactor in many of the body's enzyme
activities.

Magnesium levels in the body are closely linked with sodium, potassium, and
calcium metabolism; and are regulated by the kidney. Magnesium enters the body
through the diet, and the amount of the chemical that is absorbed depends upon the
concentration of magnesium in the body. Too little magnesium stimulates absorption
from the intestine, while too much decreases the absorption.

Bicarbonate (HCO3)

This electrolyte is an important component of the equation that keeps the acid-
base status of the body in balance. It is formed by the following reaction:

Water + Carbon Dioxide = Bicarbonate + Hydrogen

The lungs regulate the amount of carbon dioxide, and the kidneys regulate
bicarbonate (HCO3). This electrolyte helps buffer the acids that build up in the body as
normal byproducts of metabolism. For example, when muscles are working, they
produce lactic acid as a byproduct of energy formation. HCO3 is required to be
available to bind the hydrogen released from the acid to form carbon dioxide and water.
When the body malfunctions, too much acid may also be produced (for example,
diabetic ketoacidosis, renal tubular acidosis) and HCO3 is needed to try to compensate
for the extra acid production.

Measuring the amount of bicarbonate in the blood stream can help the health
care practitioner decide how severe the acid-base balance of the body has become.

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Imbalance/Dehydration
 DEHYDRATION
There are three types of dehydration: hypotonic or hyponatremic (primarily a loss
of electrolytes, sodium in particular), hypertonic or hypernatremic (primarily a loss of
water), and isotonic or isonatremic (equal loss of water and electrolytes).

In humans, the most common type of dehydration by far is isotonic

(isonatraemic) dehydration which effectively equates with hypovolemia; but the
distinction of isotonic from hypotonic or hypertonic dehydration may be important when
treating people with dehydration. Physiologically, and despite the name, dehydration
does not simply mean loss of water, as both water and solutes (mainly sodium) are
usually lost in roughly equal quantities as to how they exist in blood plasma. In
hypotonic dehydration, intravascular water shifts to the extravascular space,
exaggerating intravascular volume depletion for a given amount of total body water loss.
Neurological complications can occur in hypotonic and hypertonic states. The former
can lead to seizures, while the latter can lead to osmotic cerebral edema upon rapid
rehydration.

In more severe cases, correction of a dehydrated state is accomplished by the

replenishment of necessary water and electrolytes (through oral rehydration therapy or
fluid replacement by intravenous therapy). As oral rehydration is less painful, less
invasive, less expensive, and easier to provide, it is the treatment of choice for mild
dehydration. Solutions used for intravenous rehydration must be isotonic or hypotonic.
Dehydration can be categorized according to osmolarity and severity. Serum
sodium is a good surrogate marker of osmolarity assuming the patient has a normal
serum glucose. Dehydration may be isonatremic (130-150 mEq/L), hyponatremic (< 130
mEq/L), or hypernatremic (>150 mEq/L). Isonatremic dehydration is the most common
(80%). Hypernatremic and hyponatremic dehydration each comprise 5-10% of cases.
Variations in serum sodium reflect the composition of the fluids lost and have different
pathophysiologic effects, as follows:

 Isonatremic (isotonic) dehydration occurs when the lost fluid is similar in sodium
concentration to the blood. Sodium and water losses are of the same relative
magnitude in both the intravascular and extravascular fluid compartments.
 Hyponatremic (hypotonic) dehydration occurs when the lost fluid contains more
sodium than the blood (loss of hypertonic fluid). Relatively more sodium than water is
lost. Because the serum sodium is low, intravascular water shifts to the extravascular
space, exaggerating intravascular volume depletion for a given amount of total body
water loss

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Imbalance/Dehydration
 Hypernatremic (hypertonic) dehydration occurs when the lost fluid contains less
sodium than the blood (loss of hypotonic fluid). Relatively less sodium than water is
lost. Because the serum sodium is high, extravascular water shifts to the intravascular
space, minimizing intravascular volume depletion for a given amount of total body
water loss.

Neurologic complications can occur in hyponatremic and hypernatremic states.

Severe hyponatremia may lead to intractable seizures, whereas rapid correction of
chronic hyponatremia (>2 mEq/L/h) has been associated with central pontine
myelinolysis. During hypernatremic dehydration, water is osmotically pulled from cells
into the extracellular space. To compensate, cells can generate osmotically active
particles (idiogenic osmoles) that pull water back into the cell and maintain cellular fluid
volume. During rapid rehydration of hypernatremia, the increased osmotic activity of
these cells can result in a large influx of water, causing cellular swelling and rupture;
cerebral edema is the most devastating consequence. Slow rehydration over 48 hours
generally minimizes this risk.

Figure 1: General movement of ions in and out of cells

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Imbalance/Dehydration
CAUSES

The following are the causes of electrolyte imbalance:

SIGNS AND SYMPTOMS

 Muscle aches, spasms, twitches and weakness

 Restlessness
 Anxiety
 Frequent headaches
 Feely very thirsty
 Insomnia
 Fever
 Heart palpitations or irregular heartbeats
 Digestive issues like cramps, constipation or diarrhea
 Confusion and trouble concentrating
 Bone disorders
 Joint pain
 Blood pressure changes

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Imbalance/Dehydration
  Changes in appetite or body weight
 Fatigue (including chronic fatigue syndrome)
 Numbness and pain in joints
 Dizziness, especially when standing up suddenly

DIAGNOSIS

Laboratory Tests

Many laboratory studies are conducted to determine the client’s fluid, electrolyte
status.

Serum Electrolytes. Serum electrolyte levels are often routinely ordered for any client
admitted to the hospital as a screening test for electrolyte and acid–base imbalances.
Serum electrolytes also are routinely assessed for clients at risk in the community, for
example, clients who are being treated with a diuretic for hypertension or heart failure.
The most commonly ordered serum tests are for sodium, potassium, chloride,
magnesium, and bicarbonate ions.

Complete Blood Count (Cbc). The complete blood count, another basic screening
test, includes information about the hematocrit (Hct). The hematocrit measures the
volume (percentage) of whole blood that is composed of RBCs. Because the hematocrit
is a measure of the volume of cells in relation to plasma, it is affected by changes in
plasma volume. Thus the hematocrit increases with severe dehydration and decreases
with severe overhydration. Normal hematocrit values are 40% to 54% (men) and 37% to
47% (women).

Physiology Laboratory Small Group Discussion Output | Fluid & Electrolyte 6

Imbalance/Dehydration
Osmolality. Serum osmolality is a measure of the solute concentration of the blood.
The particles included are sodium ions, glucose, and urea (blood urea nitrogen, or
BUN). Serum osmolality can be estimated by doubling the serum sodium, because
sodium and its associated chloride ions are the major determinants of serum osmolality.
Serum osmolality values are used primarily to evaluate fluid balance. Normal values are
280 to 300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit; a
decrease reflects a fluid volume excess. Urine osmolality is a measure of the solute
concentration of urine. The particles included are nitrogenous wastes, such as
creatinine, urea, and uric acid. Normal values are 500 to 800 mOsm/kg. An increased
urine osmolality indicates a fluid volume deficit; a decreased urine osmolality reflects a
fluid volume excess

Vital signs

 Fever, increased heart rate, decreased blood pressure, and faster breathing are
signs of potential dehydration and other illnesses.
 Taking the pulse and blood pressure while the person is lying down and then
after standing up for 1 and 3 minutes can help determine the degree of
dehydration. Normally, when you have been lying down and then stand up, there
is a small drop in blood pressure for a few seconds. The heart rate speeds up,
and blood pressure goes back to normal. However, when there is not enough
fluid in the blood because of dehydration and the heart rate speeds up, not
enough blood is getting to the brain. The brain senses this condition, and
the heart beats faster. If you are dehydrated, you feel dizzy and faint after
standing up.

TREATMENT & MANAGEMENT

 Fluid Replacement Therapy

Aims the restoration of an adequate effective circulating volume.

*Volume needed varies with the clinical situation; continuing reevaluation is required.

Estimating the fluid deficit

Check the weight

-Essential information in fluid replacement therapy. Rapid changes in weight likely
represent changes in TBW. You need the weight to plan where you’re going with your
replacement.

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Imbalance/Dehydration
History
-Ask about losses (diarrhea, vomiting, how much, how often), attempts at replacement
(what fluids used, how much given, how successful), urine output.
Physical exam findings
-Mental status, pulse, BP, body weight, mucous membranes, skin turgor, skin color.

Laboratory evaluation
-Serum chemistries, hematocrit, and urine studies can guide therapy and check for
complications. History and physical exam give a better measure of the volume deficit.

 Oral rehydration therapy

Oral rehydration with electrolyte solutions is safe, efficacious and convenient.

Can be used as first line therapy in nearly all fluid and electrolyte aberrations except
severe circulatory compromise. <30% of clinicians in US use oral rehydration therapies
for dehydrated children.

How to rehydrate with ORS:

Administer ORS with a teaspoon, syringe, or dropper, if needed, to provide 1-2
mL/kg of fluid every 5 minutes (or 5-10 mL every 5-10 min) with a goal of 50-100 mL/kg
over 3 to 4 hours. Parents should be instructed not to give it faster to be successful,
especially for children with nausea and vomiting. Educate even well-hydrated patients
about replacement fluids for home.

 Intravenous therapy

Absolute indications for IV therapy are limited. Clearly indicated in shock; sometimes
in settings of high ongoing losses or in those children who cannot accomplish
rehydration orally. Reestablishing effective circulating volume is the main goal.
Na+ (meq/L) K+ (meq/L) Base (meq/L) Ca++ (mg/dL)
Normal saline 154
(0.9% NaCl)
Ringer’s 147 4 4.5
Ringer’s 130 4 28 (lactate) 3
Lactate

Note that Ringer’s has K+, which may be contraindicated if urine output is poor.
If the patient has volume depletion due to hemorrhage, the best volume expander is
blood.

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Imbalance/Dehydration
Immediate Stabilization.
As previously described, vital signs and physical examination will reveal if a child
is in hypovolemic shock. Once it is determined that a patient is in shock, the general
principles of hypovolemic shock management per pediatric advanced life support
(PALS) should be followed,20 including obtaining rapid vascular access, which may be in
the form of peripheral intravenous (PIV) access or an intraosseous (IO) route if
peripheral access is not successful. Fluid resuscitation should begin immediately after
vascular access is obtained. A 20 mL/kg bolus of an isotonic crystalloid should be given
over 5-10 minutes, followed by clinical evaluation and repeat boluses. Rapid delivery is
key in fluid resuscitation. Most children in hypovolemic shock will require at least 60
mL/kg of fluid in the first hour of care. Patients who have compromised cardiac function
may benefit from 10 mL/kg boluses. Frequent reevaluations of mental status, perfusion,
and vital signs guide the provider to the next step in management.

Management of Severe Dehydration.

As per the CDC, a hemodynamically stable child diagnosed with severe
dehydration (caused by diarrhea) should be treated preferably with 20 mL/kg of lactated
Ringer's (LR) or NS fluid rapid bolus, to be repeated until perfusion and mental status
have improved, followed by twice maintenance therapy of D5 ½ NS or D5 NS.Oral
hydration, breast feeding, or formula should be restarted as soon as tolerated.

Management of Mild-to-Moderate Dehydration.

In mild-to-moderate dehydration, oral rehydration therapy (ORT) is the
management of choice as long as the child is able to tolerate oral liquids either by
mouth or nasogastric tube. It is important to understand the physiology by which ORT
works. Glucose and sodium have coupled transport at the brush border of intestinal
epithelial cells. The glucose:sodium ratio of rehydration fluids should not exceed more
than 2:1 for effective fluid repletion. Pedialyte (or equivalent) is the most effective oral
rehydration solution (ORS). Although commonly used, the majority of fluids given as
oral rehydration to children such as sodas, juice, or sports drinks have a
glucose:sodium ratio that is too high to be effective as ORS. If a child is refusing
Pedialyte, Gatorade (or an equivalent drink) can be diluted 1:1 with water and given with
salt crackers instead.

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References:
1. Guyton, AC; Hall, JE: Textbook of Medical Physiology, 11 th edition. Elsevier Inc.
2006.

2. Koeppen, BM; Stanton, BA: Berne and Levy Physiology, 6 th edition. Elsevier Inc.
2010.

3. en.wikipedia.org

4. http://www.nhlbi.nih.gov/health/health-topics/topics/af

5. www.emedicinehealth.com

Physiology Laboratory Small Group Discussion Output | Fluid & Electrolyte 1

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