PHYSIOLOGY of

Fluids and Electrolyte

Elisa Salakay. MD

Jayapura, 23 Oktober 2019

Pendahuluan

We are
approximately
two-thirds
water

Jayapura, 23 Oktober 2019

Pendahuluan
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.
Jayapura, 23 Oktober 2019
 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

Jayapura, 23 Oktober 2019

Exchange Between Compartments

Jayapura, 23 Oktober 2019

Functions of body fluid:

- medium for transport/exchange nutrients

- medium for metabolic needs
- regulation body temperature
- form for body structure
- insulation
- lubrication

Jayapura, 23 Oktober 2019

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 and around
blood vessels) the cells )

Intravascular volume is the most critical for survival: determinant of blood pressure,
cardiac output, organ perfusion, oxygenation etc.

Jayapura, 23 Oktober 2019

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.

Jayapura, 23 Oktober 2019

Kompartemen Cairan Tubuh Utama

Jayapura, 23 Oktober 2019

Water is the “universal solvent”

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Composition of Body Fluids

Jayapura, 23 Oktober 2019

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

Jayapura, 23 Oktober 2019
 • ADH
– Stored in posterior pituitary gland
Regulation • Released in response to changes in
blood osmolarity
• Makes tubules and collecting ducts
of more permeable to water
– Water returns the systemic circulation
Body » Dilutes the blood
– Decreases urinary output
Fluids
Aldosterone
– Released by adrenal cortex
In response to increased plasma
Hormonal 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

Renin
– Secreted by kidneys
ADH Responds to decreased renal perfusion
Acts to produce angiotensin I
– Causes vasoconstriction
Converts to Angiotensin II
Aldosterone – Massive selective vasoconstriction
» Relocates and increases the blood flow
to kidney, improving renal perfusion
– Stimulates release of aldosterone with low
Renin sodium

Jayapura, 23 Oktober 2019

 • Kidneys
– Major regulatory organ
Regulation • Receive about 180 liters of blood/day to filter
of • Produce 1200-1500 cc of urine
• Skin
Body
– Regulated by sympathetic nervous
Fluids system
• Activates sweat glands
– Sensible or insensible-500-600 cc/day
» Directly related to stimulation of
Fluid Output Regulation sweat glands
• Respiration
– Insensible
• Increases with rate and depth of respirations,
oxygen delivery
Kidneys – About 400 cc/day
Skin • Gastrointestinal tract
Respiration
Gastrointestinal tract – In stool
– Average about 100-200
» GI disorders may increase or decrease
it.

Jayapura, 23 Oktober 2019

 Regulation and
Movement – Major contributor to
maintaining water balance
of Sodium (Na) • By effect on serum osmolality,
nerve impulse transmission,
regulation of acid-base balance
Most abundant cation in ECF and participation in chemical
reactions
– Regulated by dietary intake
and aldosterone
Normal level :
135-145

Jayapura, 23 Oktober 2019

 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

Jayapura, 23 Oktober 2019

 Caused by excess water loss or overall
Hypernatremia
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

Jayapura, 23 Oktober 2019

 Functions
Regulation – osmotic P within cell
– neuromuscular activity
and Movement – related to movement of
glucose
of – acid-base balance

K+Potassium
Serum levels maintained by:
– dietary ingestion
– renal regulation
the influence of aldosterone

Basal requirement of Potassium

Major cation in
intracellular K+ intake ranges from 40-150 mEq daily
Homeostasis (minimum req) 20-30 mEq/day
compartments Increased requirement in heart failure and
Normal level hypertension
(3.5 - 5.0 mEq/L)

Jayapura, 23 Oktober 2019

 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

Jayapura, 23 Oktober 2019

• 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

Jayapura, 23 Oktober 2019

 _ 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.

Jayapura, 23 Oktober 2019

 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.

Jayapura, 23 Oktober 2019

 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

Jayapura, 23 Oktober 2019

 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.

Jayapura, 23 Oktober 2019

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

Jayapura, 23 Oktober 2019

 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)

Jayapura, 23 Oktober 2019

 Hyperkalemia
• Pseudohyperkalemia Impaired potassium
– hemolysis secretion
– thrombocytosis – Aldosterone deficiency
>1,000,000 adrenal failure
– WBC > 200,000 Syndrome of hyporeninemic
hypoaldosteronism (SHH)
• Redistribution tubular unresponsiveness
– acidosis – Renal failure
– digitalis overdose GFR < 10 -20% of normal
– AD hyperkalemic periodic
paralysis

Jayapura, 23 Oktober 2019

 – 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
*NaHCO3
Therapy directed at actual removal of potassium from the body
*sodium polystyrene sulfonate (Kayexalate)
*dialysis
Determine and correct the underlying cause

Jayapura, 23 Oktober 2019

Imbalances
Result
• Illness
From:
• Altered fluid intake

• Prolonged vomiting or diarrhea

Imbalances Affect:

Respiration
Metabolism

Function of Central Nervous

System
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It’s time for quiz

Jayapura, 23 Oktober 2019

 Terima kasih

Strive for better medical education

Jayapura, 26 Agustus 2019

Kurang cerdas dapat
diperbaiki dengan
belajar, kurang cakap
dapat dihilangkan
dengan pengalaman.
Namun tidak jujur sulit
diperbaiki.

Jayapura, 26 Agustus 2019