Fluid and Electrolyte Imbalances

Calcium Imbalances
Calcium is essential to many functions including;
- forming the bony matrix as salts along with phosphates
- muscle contraction- calcium allows crossbridge formation between actin and myosin
- in neuron function Ca++ closes the sodium channels right after depolarization to
prevent continuous impulse transmission
- in neuron function it stimulates the movement of vesicles to the axon end membrane
leading to the release of neurotransmitters in a synapse
- in blood clotting mechanism it must be present to allow for the conversion of
prothrombin to thrombin and fibrinogen to fibrin

Hypocalcemia ; Some possible causes include;

- inadequate calcium in the diet - ie. from dairy, some green veg and some fish and
meat
- inadequate vit. D in diet or vit. D activation d/t insufficient sunlight exposure which
leads to decreased calcium absorption
- deficiency of PTH hormone ( hypoparathyroidism)

Manifestations of hypocalcemia include

- muscle weakness - especially for cardiac muscles which have no intracellular
storage of calcium and so depend on extracellular calcium to contract
- tetanic contractions or cramping of skeletal muscles d/t continuous stimulation of
muscles by nerves because sodium channels are not closed enough
- bleeding disorders d/t reduced clotting cascade activation
- decreased bone density - osteoporosis

Hypercalcemia ; Some possible causes of hypercalcemia include

- immobility leading to increased bone reabsorption ( in response to reduced
stress on them)
- excess intake of calcium in the diet especially if in combination with increased
vit.D intake
- hyperparathyroidism leading of increased calcium absorption from the gut and
increased breakdown of the bones
- Some cancer tumours will break down bones releasiong calcium and others will
produce PTH hormone ie; paraneoplastic syndrome.

Manifestations of hypercalcemia include

- cardiac dysrrhythmias and in increase in the strength of cardiac muscle
contractions
- decreased neural activity d/t decreased ability to depolarize leading to lethargy or
a stuporous state
- decreased neural stimulation of muscles leading to decreased muscle tone and
muscle weakness
- in some cases you may see calcification of soft tissues
Potassium Imbalances
Hypokalemia ; Some possible causes include
- deficiency of potassium intake ( eg. bananas tomatoes citrus and many legumes
as well as meats. This is most common with malnutrition associated with excess
dieting , alcohol abuse etc.
- excess losses with longterm diarrhea
- effects of some diuretic drugs which may be taken to treat hypertension
- excess aldosterone ( or glucocorticoids) secretion which leads to increased
sodium reabsorption and increased potassium loss in exchange
- alkalosis - because the renal response to compensate for alkalosis will be to
secrete K+ rather than H+ in cation exchange for Na+
- excess insulin intake because insulin increases transport of K+ into cells and out
of hte blood.

Manifestations of hypokalemia may include;

- cardiac dysrrhythmias that involve prolonged repolarization phases in the ECG
including a depressed s-t interval and a flattened T-wave and it can lead to cardiac
arrest
- decreases muscle activity so that the muscles become fatigued easily and
weaker in their contractions and less responsive to stimuli.
- decreased sensory sensitivity ie. paresthesia
- shallow or weak respirations d/t decreased respiratory muscle muscle contraction
- in severe cases it can lead to respiratory arrest.
- decreased motility of the gut.
- postural hypotension d/t decreased skeletal muscle pump in venous return
Hyperkalemia ; Some possible causes include
- Acidosis which leads to a shift of potassium out of cells in exchange for H+
movement into cells along with decreased renal loss of K+ in cation exchange as the
tubules preferentially secrete H=
- crushing or burn injury of tissues d/t the high level of K+ release from damaged
cells
- aldostero e deficiency leading to decreased cation exchange and so less
opportunity to remove excess k+ by the kidneys
- kidney failure
- potassium sparing antihypertensive drugs which may block K+ secretion

Manifestations of hyperkalemia can include;

- cardiac dysrrhythmias involving a wider QRS wave , depressed S and an
elevated and wider T-wave with a very high risk of cardiac arrest
- general muscle weakness for skeletal as well as smooth muscles leading to
fatigue, weakness and eventually paralysis
- loss of sensory function - paresthesia
Sodium Imbalances
Hyponatremia ; Some causes include
- a relative decrease d/t excess water intake
- excess losses d/t excess sweating , diarrhea or vomiting
- some diuretics especially in combination with low salt diets
- a deficiency of aldosterone or excess ADH

Manifestations can include ;

- decreased neural function leading to lethargy and weakness, confgusion and
seizures
- decreased blood osmotic pressure which can lead to widespread edema and a
decrease in blood volume. In particular it can lead to a swelling of brain tissue leading
to elevated intracranial pressure leading to confusion, seizures and possible death.

Hypernatremia ; Some causes can include

- inadequate water intake such as when it is unavailable or if the thirst centre is
impaired or if the individual is unconscious
- excess water loss in excess sweating, vomiting or diarrhea or prolonged rapid
breathing
- insufficient ADH leading to high levels of water loss from the kidneys

Manifestations can include;

- fluid shift out of cells into the ISF and blood leading to decreased function of most
tissues leading to weakness , irritability
- signs of attempted accommodation including increased thirst a decreased urine
output

Fluid Balance

Water makes up about 60% of the total body mass in an adult male. In females it accounts for
about 50% of body mass but in infants it may make up as much as 75 – 80 % of body mass. The
water is found in several compartments. 40% of body mass is water in the intracellular
compartment while the other 20 % is in the extracellular fluid compartments which include the
ISF ( 14%) , plasma (5%) and small transcellular compartments such the cerebral spinal fluid
( 1%). Fluid can readily shift from one compartment into another. One kind of shift that can be
harmful is edema.

Edema. This is an excess of fluid in the Interstitial fluid compartment. It can be harmful
because it can lead to compression of tissues but it also increases the distance between tissue
cells and their blood supply leading to a decrease in the level of metabolic activity. Edema can
occur in four main ways;
A. Increased Capillary Permeability ; which may be the result of an increase in pore size d/t
the effects of inflammatory mediators and in allergic reactions. This allows albumin proteins in
the blood to leak out leading to an increase in OP of the interstitial fluid and a decrease in the OP
of the blood.

B. Decrease in Blood Osmotic Pressure (OP) ; which could be a result of

- decrease blood protein (mainly albumin) production possibly d/t
i) Liver disease such as viral hepatitis or alcohol toxicity to the liver
ii) Protein malnutrition which means that there won’t be enough amino acids
available for the liver to make albumins. A good example of this would be
with Kwashiorkor – protein malnutrition especially to children during
famines of in refugee situations.
- excess blood protein loss such as with some forms of kidney pathologies
( glomerulonephritis) or in the case of severe burns

C. Increased Capillary Hydrostatic Pressure (HP); which could result from;

i) severe hypertension
ii) increased vascular volume as can occur with pregnancy, PMS, a
compensatory response to heart failure and in some kidney disease
iii) venous obstruction so that the blood backs up into the capillaries. This can
occur with varicose veins, liver disease (cirrhosis), some pulmonary
disorders and venous thrombosis.

D. Obstruction of Lymph Flow. Recall that about 10 % if fluid that leaves blood at the arterial
end of the capillary doesn’t normally return to the blood at the venous end of the capillary. This
excess enters terminal lymph capillaries and then flows along the lymph vessels, through lymph
nodes and progressively larger lymph vessels until it reenters the blood via the thoracic ducts
into the subclavian veins. Obstruction of this flow will back up lymph and so fluid will
accumulate in the ISF. This may occur as a result of ;
- obstruction of lymph nodes by malignant tumours
- surgical removal of lymph noders ( eg. removal of axillary lymph nodes in
treatment of breast cancer.
- clogging of lymph nodes by nematodes called filarial worms leading to
Filariasis/Elephantiasis

When we consider fluid balance we have to take into account all the gains and losses. Typically
Gains and losses should be about equal and that can be in the range of 2.5 L gained and lost each
day. We gain fluids by drinking fluids ( about 1L/day), eating foods ( about 1.3 L/day and
metabolically from the process of cellular respiration ( about .2 L/day) ( recall C6H12O6 + O2
 CO2 + H2O + ATP and Heat).
We lose water by urinating ( about 1.5 L/day) , through insensible losses both through the skin
and by breathing (about .8 L/day) and via the feces (about .2L/day)
Fluid imbalances occur when gains and losses are not equal.

Dehydration or Fluid Volume Deficit;

This can occur in one of two main ways. It could be d/t
Inadequate Water Intake which could be the result of
- unavailability of water ( maybe you are stuck on a desert island or lost in the
wilderness or in a life raft out at sea)
- unconsciousness. In this case you are unable to drink and if you are not being given IV
fluids then you will dehydrate because you are still continuing to lose fluids insensibly
and in your urine.
- Damage to the nerves of the swallow reflex or perhaps to the muscles for swallowing
- Loss of the thirst response
Excess Water Loss which could be d/t a wide variety of causes including;
- vomiting
- diarrhea ( eg. With cholera or some other gastroenteritis)
- inadequate ADH secretion ( such as with ADH suppression by alcohol toxicity
- polyuria ( eg. with diabetes) or diuretic therapy improperly applied
- kidney diseases in which tubular reabsorption is inadequate
- endocrine disorders such as a deficiency of aldosterone secretion by the adrenal cortex
(Addisons disease)
- Third space losses such as in the case of ascites in Kwashiorkor or alcoholic liver
disease

Manifestations of Fluid Volume Deficit:

There are many possible manifestations and the ones that are observed may depend on the cause
of the deficit. Manifestations can include;
- weight loss ( remember that 50-60 % of your normal body mass is water)
- higher body temperature ( remember that you lose heat through evaporative cooling
all the time but now you won’t have the water available to lose)
- decreased skin turgor pressure ( appears loose)
- dry skin and mucous membranes ( esp. dry mouth)
- eyes sunken in and the eyeballs are softer
- for infants the fontanels will be sunken or depressed
- S/S o f decreased vascular volume such as
a. decreased blood pressure ( hypotension)
b. a rapid but weak or thready sounding pulse
c. flattened or collapsed-appearing veins
d. postural hypotension
- signs of attempted compensation such as;
a. if the cause is not a kidney dysfunction then there will be
oliguria and the urine will be dark coloured and high
Specific Gravity ( high [solute])
b. increased thirst ( an hypothalamic response)

Fluid Volume Excess or Overhydration:

In a similar way we can classify causes as;
Excess fluid gains such as;
- excess intake of fluids ( not usually a problem but could be in situations where
output is impaired)
- excess IV infusion or excess rate of blood transfusion
- excess sodium intake which is then compensated by increased water intake

Decreased fluid losses such as;

- kidney failure
- excess aldosterone secretion ( or corticosteroid use or Cushings disease)
- hypersecretion of ADH
- an inappropriate compensatory response to heart failure including increased
aldosterone and ADH

Manifestations of Fluid Volume Excess include;

- weight gain
- edema d/t the increase in interstitial volume
- S/S of increased vascular volume including;
a. decreased HR and a full and bounding pulse
b. hypertension
c. venous distension – full and bulging veins
d. pulmonary edema – excess fluid entering the lungs from the
pulmonary capillaries leading to SOB, coughing, dyspnea and
crackles
- depending on the cause there may be increased urine output with colourless
urine of low S.G.