Fluid, Electrolyte And Acid-

base Imbalance
Prepared by
Md. Shamim Ahasan, PhD
Associate Professor
Department of Medicine, Surgery and Obstetrics,
HSTU, Dinajpur-5200

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 1

Fluid, electrolyte and acid-base imbalance
• Electrolyte imbalance, or water-electrolyte imbalance, is an
abnormality in the concentration of electrolytes in the body.
• Fluid, electrolyte and acid base balance within the body are
necessary to maintain the health and function in all the body
systems.
• These balance are maintain by the intake and output of the water
and electrolyte and regulation by the renal and pulmonary
systems.

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 2

Fluid, electrolyte and acid-base imbalance
• Electrolytes are elements or minerals found in bodily fluids that
become electrically charged particles (cations or anions)
• There are responsible for many activities of the body including
heart automaticity, nerve impulses, movement of water and
fluids, and chemical reactions
• allow cells to generate energy and maintain cell wall stability
• hormones produced by the kidneys and adrenal glands control
most electrolyte levels

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 3

 Scientific Knowledge Base : Location and Movement of
Water and Electrolytes

Intracellular Fluid (ICF) Extracellular Fluid (ECF) = Fluid outside of

= Fluids within cells cells
 ~2/3 (~60-65%) of total  ~1/3 of total body water

body water  Three divisions:

➢ 25 % interstitial fluid (ISF)

➢ 5- 8 % in plasma (IVF intravascular fluid)

➢ 1- 2 % in Tran cellular fluids(TSF) -CSF,

intraocular fluids, serous membranes, and in GI,

respiratory, urinary tracts and synovial fluid

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 4

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 5
Composition of body fluid
• Electrolytes Two types of electrolytes are
• Cations e.g. Na+, K+, Ca+, H+
• Anions e.g. Cl-, HCO3 -,SO4 -, P-
• The unit of these ions are expressed in terms of Milliequivalent
(mEq/l)

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 6

Fluid and Electrolyte Transport

• PASSIVE TRANSPORT • ACTIVE TRANSPORT SYSTEM

SYSTEMS • Pumping
• Diffusion • Requires energy expenditure
• Filtration
• Osmosis

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 7

Diffusion
• Molecules move across a biological membrane from an area of
higher to an area of lower concentration
• Membrane types
• Permeable
• Semi-permeable
• Impermeable

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 8

 Filtration
• Movement of solute and solvent across a membrane caused by
hydrostatic (water pushing) pressure
• Occurs at the capillary level
• If normal pressure gradient changes (as occurs with right-sided
heart failure) edema results from “third spacing”

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 9

Osmosis
• Movement of solvent from an area of lower solute concentration
to one of higher concentration
• Occurs through a semipermeable membrane using osmotic
(water pulling) pressure

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 10

Active Transport System
• Solutes can be moved against a concentration gradient
• Also called “pumping”
• Dependent on the presence of ATP

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 11

Fluid Types
Isotonic:
• No fluid shift because solutions are equally concentrated.
• Example: Normal saline solution (0.9% NaCl)
Hypotonic
• Lower solute concentration
• Fluid shifts from hypotonic solution into the more concentrated solution to create a balance (cells swell)
• Half-normal saline solution (0.45% NaCl)
Hypertonic
• Higher solute concentration
• Fluid is drawn into the hypertonic solution to create a balance (cells shrink)
• 5% dextrose in normal saline (D5/0.9% NaCl)
Regulatory Mechanisms

• Baroreceptor reflex
• Volume receptors
• Renin-angiotensin-aldosterone mechanism
• Antidiuretic hormone

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 13

Baroreceptor Reflex

• Respond to a fall in arterial blood pressure

• Located in the atrial walls, vena cava, aortic arch and
carotid sinus
• Constricts afferent arterioles of the kidney resulting
in retention of fluid

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 14

Volume Receptors

• Respond to fluid excess in the atria and great vessels

• Stimulation of these receptors creates a strong renal
response that increases urine output

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 15

 Renin-Angiotensin-Aldosterone
• Renin
• Enzyme secreted by kidneys when arterial pressure or volume drops
• Interacts with angiotensinogen to form angiotensin I (vasoconstrictor)

• Angiotensin
• Angiotensin I is converted in lungs to angiotensin II using ACE (angiotensin
converting enzyme)
• Produces vasoconstriction to elevate blood pressure
• Stimulates adrenal cortex to secrete aldosterone
• Aldosterone
• Mineralocorticoid that controls Na+ and K+ blood levels
• Increases Cl- and HCO3- concentrations and fluid volume
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 16
 Aldosterone Negative Feedback Mechanism

• ECF & Na+ levels drop → secretion of ACTH by the

anterior pituitary → release of aldosterone by the
adrenal cortex → fluid and Na+ retention

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 17

Antidiuretic Hormone (ADH)
• Also called vasopressin
• Released by posterior pituitary when there is a need to
restore intravascular fluid volume
• Release is triggered by osmoreceptors in the thirst center of
the hypothalamus
• Fluid volume excess  decreased ADH
• Fluid volume deficit  increased ADH

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 18

Fluid Imbalances
• Dehydration
• Hypovolemia
• Hypervolemia

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 19

Dehydration

• Loss of body fluids  increased concentration of

solutes in the blood and a rise in serum Na+ levels
• Fluid shifts out of cells into the blood to restore
balance
• Cells shrink from fluid loss and can no longer
function properly

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 20

Hypovolemia

• Isotonic fluid loss from • Caused by:

the extracellular space • Excessive fluid loss
• Can progress to (hemorrhage)
hypovolemic shock • Decreased fluid intake
• Third space fluid shifting

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 21

Hypervolemia

• Excess fluid in the extracellular compartment as a result of

fluid or sodium retention, excessive intake, or renal failure
• Occurs when compensatory mechanisms fail to restore fluid
balance
• Leads to Congestive heart failure (CHF) and pulmonary edema

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 22

Electrolyte and Electrolyte Imbalances
Cations e.g. Na+, K+, Ca+, H+
Anions e.g. Cl-, HCO3 -,SO4 -, P-

• Hyponatremia/ hypernatremia • Hypochloremia/ Hyperchloremia

• Hypokalemia/ Hyperkalemia • Hypophosphatemia/

• Hypocalcemia/ Hypercalcemia Hyperphosphatemia

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 23

Reasons for Electrolyte Imbalances
Abnormalities occur when electrolyte concentrations are imbalanced
between intercellular and extracellular fluids

Reasons:
• Kidney Dysfunction
• Lack of Water: Dehydration or Diarrhea
• Medication Side Effects

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 24

Sodium (Na+)
• Most abundant cation in ECF
• Most often found in the plasma outside the cell
• Contributes to serum osmolality
• Regulating ECF volume and distribution
• Transmit electrical impulses in heart and nervous system
• Regulates water distribution and fluid balance through entire body
• Help regulate acid/base balance

Normal Levels
• Extracellular level: 135-145 mEq/L
• Intracellular level: 10-12 mEq/L

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 25

Types and causes of Hyponatremia
• Dilutional - results from Na+ loss, water gain
• Depletional - insufficient Na+ intake
• Hypovolemic - Na+ loss is greater than water loss; can be renal (diuretic use) or
non-renal (vomiting)
• Hypervolemic - water gain is greater than Na+ gain; edema occurs
• Isovolumic - normal Na+ level, too much fluid
Hypernatremia
• Occurs less often than hyponatremia
• When hypernatremia occurs, fluid shifts outside the cells
• May be caused by water deficit or over-ingestion of Na+
• Also may result from diabetes insipidus
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 26
Potassium (K+)
• Major cation in ICF and maintains ICF osmolality
• Transmits nerve and other electrical impulses
• Regulates acid–base balance
• Regulates muscle tissue contractility, including heart muscle
• Helps control cellular metabolism: converts glucose to glucagon for muscle
fuel
• Must be ingested daily
• Regulated by kidneys; excess levels removed by feces and sweat
• Serum potassium levels controlled by Sodium-Potassium Pump (pumps
sodium out of cells and allows potassium back into cells)
Normal Levels
• Serum level: 3.5-5.0 mEq/L
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 27
Chloride (Cl–)
• Normal serum level: 95–105 mEq/L
• Major anion of ECF
• Regulates serum osmolality
• Regulates ECF balance
• Regulates acid–base balance
• Secreted in the stomach as hydrochloric acid
• Major component of stomach fluids
• Sodium and chloride maintain water balance
• Aids carbon dioxide transport in blood

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 28

Chloride (Cl–)
Hypochloremia
caused by decreased intake or decreased absorption, metabolic alkalosis,
and loop, osmotic or thiazide diuretics
Hyperchloremia
Caused by dehydration, renal failure, respiratory alkalosis, salicylate
toxicity, hyperpara-thyroidism, hyperaldosteronism, hypernatremia

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 29

Calcium (Ca2+)
• Normal serum level: 9–11 mg/dL
• Most is found in skeletal system
• Cation
• Skeletal maintenance
• Regulates muscle contractions (cardiac)
• Neuromuscular function
• Cardiac function
• Blood clotting
• Activates enzymes

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 30

Magnesium (Mg2+)
• Normal serum level: 1.5–2.5 mEq/L
• Second most abundant ICF cation
• Found in skeletal system, ICF
• Intracellular metabolism
• Protein, DNA synthesis
• Operates sodium-potassium pump
• Regulates cardiac, neuromuscular function
• Relaxes muscle contractions

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 31

Phosphate (PO4–)
• Normal serum level: 2.4–4.5 mg/dL in adults
• Major anion of ICF
• Much higher in children
• Forms bones and teeth
• Metabolism of protein, fat, carbohydrates
• Cellular metabolism
• Muscle, nerve, RBC function
• Regulates acid–base balance
• Regulates calcium levels

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 32

Bicarbonate (HCO3)
• Major body buffer
• Found in both ICF, ECF
• Regulates acid–base balance
• Produced through metabolic processes

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 33

Acid-Base Imbalances
• Acid base imbalances occur when the carbonic acid or bicarbonate levels become
disproportionate.
• Normal blood pH (hydrogen ion concentration) is maintained within the
normal range of 7.35 to 7.50 by the bicarbonate carbonic acid (buffer) systems.
• Within this system the addition of a strong acid results in the formation of
carbonic acid (H+ + HCO3- → H2CO3), while addition of a base results in the
formation of bicarbonate and water (OH- + H2CO3→H2O + HCO3- ), minimizing
the effects of changes in pH.
• Metabolic acidosis and alkalosis decrease and increase standard bicarbonate
( i.e. HCO3-) respectively, while respiratory acidosis and alkalosis are
accompanied by an increase or a decrease respectively
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 34
Acidosis
The term acidosis is derived from Latin word `acidus' means sour and Greek
word 'osis' means condition, that is, depletion of the body's alkali (HCO3-)
reserve with resulting disturbance of the acid-base balance is called acidosis.

Etiology:
The general causes of acidosis can be divided into three categories on on basis
of pathogenesis. These are:
1. Excessive loss of base (bicarbonate)
2. Accumulation of endogenous or exogenous acid and
3. Combination of both of the above processes.

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 35

Acidosis
Excessive loss of HCO3 ion in acute enteritis.
Absorption of large quantities of fixed acids as in carbohydrate engorgement
in ruminants, grain engorgement in horses, ketosis in ruminants.
Retention of CO2 in blood due to interference with respiratory exchange in
pneumonia, severe pulmonary emphysema, respiratory centre depression,
prolonged parturition causing asphyxia in newborn.
Shock and peripheral circulatory failure leading to anaerobic oxidation.
Retention of acid metabolites due to renal disease – renal insufficiency and renal
failure.
Overdosing with acidifying solutions for the treatment of alkalosis.

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 36

Acidosis
Diagnosis
❖ Tentative diagnosis of acidosis can be made on the history of diet and clinical
signs.
❖ Laboratory examination of blood samples include:
❖ Reduced venous blood pH, pCO2, and bicarbonate ion concentration.
❖ The body can tolerate a pH range of 7.0 - 7.8.
❖ Elevated blood urea nitrogen, increased an ion gap and a neutrophilic
leukocytosis with a left shift.

Treat ment
• Isotonic sodium bicarbonate (1.3%) solution @ 2.5 to 4.5 litre IV depending
on the size and severity of the condition.
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 37
Alkalosis
Increased plasma carbonate (CO3) concentration and a fall in blood acid (H+)
concentration is known as alkalosis.
Etiology
• It is caused by an increased absorption of alkali,
• Excessive loss of acid or a deficit of CO2 or
• Combination of two.

Clinical findings
• Although the clinical signs of alkalosis are not characteristic but it results in
slow, shallow respirations because of lack of CO2 stimulation.
• Depression of ionized fraction of serum calcium may lead to muscular tremors
and tetany with tonic and clonic convulsions.
•8/30/2020
Hyperopnea and dysnea may also occur in the terminal stages.
Prepared by Md. Shamim Ahasan, PhD 38
Alkalosis
Diagnosis
• History of treatment with alkali or abnormal disorders along with clinical
findings would help to diagnose alkalosis.
• Laboratory analysis of blood samples which include: (a) increased
venous blood pH and bicarbonate ion concentration.

Treatment
• The cause of alkalosis should be removed and where possible a high
urinary output encouraged.
• Correction of increased alkali by oral administration of vinegar in
ruminants.
• If the cause is due to abomasal disorders, it should be corrected.
8/30/2020 Prepared by Md. Shamim Ahasan, PhD 39
Types of Acid-Base Imbalances

• Respiratory Acidosis

• Respiratory Alkalosis

• Metabolic Acidosis

• Metabolic Alkalosis

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 40

Respiratory Acidosis
• Any compromise in breathing can result in respiratory
acidosis
• Hypoventilation carbon dioxide buildup and drop in pH
• Can result from neuromuscular trouble, depression of the
brain’s respiratory center, lung disease or airway
obstruction

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 41

Clinical findings
• Apprehension, restlessness
• Confusion, tremors
• Diaphoresis/sweating
• Dyspnea, tachycardia
• warm flushed skin

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 42

Treatment
• Correct underlying cause
• Bronchodilators
• Supplemental oxygen
• Treat hyperkalemia
• Antibiotics for infection
• Remove foreign body obstruction

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 43

Respiratory Alkalosis
• Most commonly results from hyperventilation caused by pain,
salicylate poisoning, use of nicotine or aminophylline, hypermetabolic
states or acute hypoxia (overstimulates the respiratory center)

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 44

Clinical findings
• Anxiety, restlessness
• Diaphoresis/sweating
• Dyspnea ( rate and depth)
• Tachycardia
• Tetany

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 45

Treatment
• Correct underlying disorder
• Oxygen therapy for hypoxemia
• Sedatives or antianxiety agents
• Paper bag breathing for hyperventilation

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 46

Metabolic Acidosis
• Characterized by gain of acid or loss of bicarb
• Associated with ketone bodies
• Diabetes mellitus, starvation, hyperthyroidism
• Other causes
• Lactic acidosis secondary to shock, heart failure, pulmonary disease, hepatic
disease, seizures, strenuous exercise

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 47

Clinical findings
• Confusion, dull headache
• hyperkalemia (abdominal cramps, diarrhea, muscle weakness)
• Hypotension
• Lethargy, warm & dry skin

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 48

Treatment
• IV bicarb to correct acidosis
• Fluid replacement
• Dialysis for drug toxicity
• Antidiarrheals

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 49

Metabolic Alkalosis
• Commonly associated with hypokalemia from diuretic use,
hypochloremia and hypocalcemia
• Also caused by excessive vomiting, NG suction, Cushing’s disease,
kidney disease or drugs containing baking soda

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 50

Clinical findings
• Anorexia • Muscle twitching
• Apathy • Nausea
• Confusion • Paresthesia
• Cyanosis • Polyuria
• Hypotension • Vomiting
• Loss of reflexes • Weakness

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 51

Treatment
• IV ammonium chloride
• Antiemetics

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 52

 Thank you

8/30/2020 Prepared by Md. Shamim Ahasan, PhD 53