19/05/2014

Dr Mario Zerafa MD, FRCA, DESA

Consultant Anaesthetist
Mater Dei Hospital
MALTA

 Topics Fluid compartment volumes

Total body water (TBW)
Intracellular fluid (ICF)
 Fluid compartment volumes
Extracellular fluid (ECF)
 Composition of body fluids
Plasma
 Composition of commonly used I.V. fluids
Transcellular fluids
 Electrolyte physiology (Na, K, Ca, Mg)
 Common electrolyte disturbances

• Total body water (TBW) P T

l
• 60% of body weight of young adult male 40% x 70 kg = 28 L water a
r The 60-40-20 Rule:
60 % of body weight is water
ISF, 10 L
• But varies with age, sex and build s
a
40% of body weight is intracellular

• Range can be 45% – 75% depending on amount of

n fluids
m
s 20% of body weight is extracellular
adipose tissue a
,
, fluid

1
4

• Female: for same age F < M

L L
Intracellular Water =40% Extracellular=20%

• Difference starts at puberty and ↓ in old age Total Body Water = 60% of weight

• In young adult female, TBW=50% of body weight

• In neonate, TBW ≤ 80% body weight

1
 19/05/2014

Fluid % body weight Volume (litres)

Age TBW ECF
(% body weight) (% body weight) Interstitial fluid 15 10.5
Neonate 80 45
Plasma 5 3.5
6 months 70 35
Transcellular fluid 1 0.7
1 year 60 28
Total ECF 21 14.7
5 years 65 25

Young adult 60 22

Elderly 50 20

Comparison of the constituents of different crystalloids

 Fluids that have been secreted but are separated
from the plasma by an epithelial surface Na+ K+ Ca2+ Cl- HCO3- Osmolarity pH
0.9%
sodium
154 0 0 154 0 300 5
CSF
chloride
•
5%
• Intraocular fluid glucose 0 0 0 0 0 280 4
• Gastrointestinal fluid 4% glucose,
• Bile 0.18%
sodium
• Pleural, peritoneal, pericardial fluid chloride 30 0 0 30 0 255 4
• Sweat Hartmann’
s 131 5 2 111 29 278 6

Comparison of the constituents of different crystalloids Comparison of the constituents of different crystalloids

Na+ K+ Ca2+ Cl- HCO3- Osmolarity pH Na+ K+ Ca2+ Cl- HCO3- Osmolarity pH
0.9% 0.9%
sodium sodium
chloride 154 0 0 154 0 300 5 chloride 154 0 0 154 0 300 5
5% 5%
glucose 0 0 0 0 0 280 4 glucose 0 0 0 0 0 280 4
4% glucose, 4% glucose,
0.18% 0.18%
sodium sodium
chloride 30 0 0 30 0 255 4 chloride 30 0 0 30 0 255 4
Hartmann’ Hartmann’
s 131 5 2 111 29 278 6 s 131 5 2 111 29 278 6

2
 19/05/2014

Comparison of different colloids Comparison of different colloids

Na+ K+ Ca2+ Cl- HCO3- Osmolarity pH Na+ K+ Ca2+ Cl- HCO3- Osmolarity pH

Gelofusine 154 0.4 0.4 125 0.4 279 7.4 Gelofusine 154 0.4 0.4 125 0.4 279 7.4

Haemaccel 145 5.1 6.25 145 0 301 7.3 Haemaccel 145 5.1 6.25 145 0 301 7.3

Dextran Dextran
70 0 0 0 0 0 287 3.5-7.0 70 0 0 0 0 0 287 3.5-7.0
4.5% 4.5%
Human Human
albumin albumin
solution 100-160 <2 0 0 100-160 0 270-300 6.4-7.4 solution 100-160 <2 0 0 100-160 0 270-300 6.4-7.4

 The Osmole: 1 osmole = the amount of solute that exerts an
osmotic pressure of 1 atm when placed in 22.4 litres of
solution at 0◦C
 For a substance that does not associate or dissociate in
solution e.g. glucose,
• 1 osmole = 1 mole
 Osmolarity is the concentration of a solution expressed in osmoles
of solute per litre of solution (solute plus water).
 The units of osmolarity are thus osmoles per litre (Osm l -1) or
milliosmoles per litre (mOsm l -1).
 Osmolality is the concentration of a solution expressed as osmoles
of solute per kg solvent (water alone).

 For a substance that dissociates into 3 osmotically active
particles (e.g. CaCl2→Ca2++ 2 Cl-), then
• 1 osmole = 1 mole/3
 The units of osmolality are thus osmoles per kg water
(Osm kg-1H2O) or milliosmoles per kg water (mOsm kg-1H2O).
 OSMOLALITY is the preferred term in most physiological
applications.

 Plasma osmolality = 280 – 295 mOsm kg-1 H2O

• Constant c. 290 mOsm kg-1 H2O throughout the body
↑ Osmolality -

Estimation of osmolality from solute

 +
concentration
• Plasma osmolality
↓ TBW -
-
-
+ ↑ Thirst
= [Na+]+[Cl-]+[glucose]+[urea] Hypothalamic osmoreceptors
= 2 x [Na+]+[glucose]+[urea] +
= 2 x 140 +5.0 + 5.0
↑ ADH release
= 290 mOsm kg-1 H2O ↑ Water retention

3
 19/05/2014

Substance Plasma Interstitial fluid Intracellular fluid

 Describes the relative osmolality between two fluid Cations
compartments
Na+ 153 145 10
K+ 4.3 4.1 159
 ISOTONICITY – cells can be suspended without a change in
cell volume
Ca2+ 2.7 2.4 <1
Mg2+ 1.1 1 40

Cells placed in a HYPERTONIC solution will shrink

Total 161.1 152.5 209


Cells placed in a HYPOTONIC solution will swell

Anions

Cl - 112 117 3

 A 0.9% solution of NaCl is approx. isotonic HCO3 - 25.8 27.1 7

(308 mOsm kg-1 H2O )

Proteins 15.1 <0.1 45
Others 8.2 8.4 154
Total 161.1 152.5 209

 ICF  Interstitial Fluid

 K+ is predominant cation
 organic phosphates and proteins are main anions
 Composition maintained by the cell plasma membrane
 Involves both passive (diffusion, osmosis) and active
modes of transport
 Na+ is predominant cation
 Cl - and HCO3 - are main anions
 Composition depends on filtration of plasma through
capillary wall
 Mostly a PASSIVE process, the balance of
HYDROSTATIC and COLLOID OSMOTIC pressures

 Plasma
 Na+ is predominant cation
 Cl - and HCO3 - are main anions
 PLASMA PROTEINS are the main distinguishing
component
 Total protein content in plasma = c. 7g / 100ml
 ALBUMIN
• 60% of plasma protein
• Main transport protein
• Binds free fatty acids, bilirubin
• Principally responsible for colloid osmotic pressure
• Intravascular half-life is 19 days
• 5% circulates through interstitial fluid each hour
• 60% of total albumin is actually extravascular

4
 19/05/2014

 Immunoglobulins Substance Saliva Gastric Bile Sweat

(mmol l -1) juice
• Approx. 20% of plasma proteins
Na+ 33 60 149 45
• IgG, IgD, IgE are monomers
K+ 20 9 5 5
• IgA is a dimer
Cl - 34 84 101 58
• IgM is a pentamer completely confined to the HCO3 - 0 0 45 0
intravascular space. pH 6.6 3 8 5.2

 Cerebrospinal fluid (CSF) • Circulation of CSF

• Approx. 150ml of CSF surrounds brain and spinal • CSF flows from lateral ventricles → brain stem via the
cord third & fourth ventricles

• Continuously produced at c. 600ml / 24h
• 70% of CSF is produced by choroid plexuses within
the cerebral ventricles and
• 30% in the endothelium of cerebral capillaries
• CSF exits to Subarachnoid space via lateral foramina of
Luschka and median foramen of Magendie
• Reabsorbed by subarachnoid villi in the venous sinuses
of the skull
• Rate of reabsorption α CSF outflow pressure
• (N = 11 cmH2O; No reabsorption if <7 cmH 2O)

• Composition of CSF • Blood Brain Barrier (BBB)

CSF formed by • Located in the cerebral capillaries and choroid
• ULTRAFILTRATION and modified by plexuses
• ACTIVE SECRETION
• Functions of BBB
• Functions of CSF • Providing precise ionic concentration control in CNS
• Providing bouyancy and protection • Protects brain from plasma glucose fluctuations
• Ionic homeostasis • Protects brain from toxins
• Respiratory control • Prevents the release of central neurotransmitters into
the systemic circulation

5

• Blood Brain Barrier
• Freely permeable to CO2
• Relatively impermeable to H+ and HCO3-
• CSF ↓[protein] → ↓ Buffering capacity
• Respiratory Control
• ↑plasma [CO2] → H+ + HCO3- (carbonic anhydrase)
• Buffering by ↑ HCO3- BUT CSF ↓[protein]
• HCO3- [plasma] > [CSF]
• ↑ H+ → ↑ Respiratory Rate
 Intraocular fluid
• Aqueous and Vitreous humour are formed from plasma
• Aqueous is continuously formed in ANTERIOR chamber,
circulated and drained.
• Normal Intraocular pressure 15-18mmHg
• Vitreous humour
• In Posterior chamber
• Vitrein is a gelatine-like protein
 Lymphatic functions
 Augment fluid removal from peripheral tissues
 Protect against infection
 Absorb and transport nutrients
 Lipoproteins
 Chylomicrons
19/05/2014
 Pleural fluid
• Thin layer needed as lubrication
• Formed by ultrafiltration and reabsorption
• Starling Forces here favour reabsorption
 Plasma colloid pressure > hydrostatic pressure in
pulmonary capillaries
• System of blind-ending tubules with endothelium
• Lymph nodes have phagocytic cells to kill bacteria
• Every 24h , 2-4 litres of lymph is produced
• Lymph is pumped by arteriolar pulsations, muscle
activity, presence of one-way valves and positive
intra-thoracic pressure
• The Thoracic duct and the Right Lymphatic duct
 2 main vessels that drain lymph into subclavian veins
• Lymph composition
• Protein content < Plasma (depends on drained organ)
• Contains all coagulation factors
• Antibodies are found in high concentrations
• Electrolyte composition is similar to plasma
• Lymphocytes are common, RBC’s and platelets are rare
6
 19/05/2014

Condition Definition Cause

 ECF volume depends on total body Na+
Dehydration A decrease in TBW ↓ intake e.g. NBM, Dysphagia
with or without a
loss of Na+
↑ insensible loss e.g. pyrexia,
hyperhidrosis, hyperventilation
 Plasma vol. depends on ECF vol.

Water Deficiency A decrease in TBW ↑ urinary loss, e.g. Diabetes

without a insipidus, diabetes mellitus  Plasma vol. is vitally important for perfusion
comparable decrease ↑ GIT losses, e.g. vomiting,
in body Na+
diarrhoea

Water An increase in TBW Renal failure, SIADH, hepatic

intoxication without a failure, IV infusion of dextrose
comparable increase
in body Na+

 Kidney controls Na+ balance  Hormones increasing sodium reabsorption

 Through Na+ balance, Kidney controls blood ◦ Renin
pressure ◦ Angiotensin II
 99.5% of Na+ filtered thru’ kidney is ◦ Aldosterone
reabsorbed in Prox. Tub. and Loop of Henle ◦ ADH / AVP
(fixed)
 0.5% of filtered Na+ is potentially reabsorbed  Hormones increasing sodium excretion
in Distal Tub. and collecting ducts (variable)
◦ Atrial Natriuretic Peptide (ANP)
 This potential reabsorption is controlled by
◦ Brain natriuretic peptides (BNP), may have similar
various hormones and is how the body
roles
maintains Na+ balance

 Plasma sodium concentration greater than 145 mmol l-1. Cause ECFV Total body Total body
free water sodium
 Hypernatremia always implies hypertonicity of all body
Diuresis, vomiting, Low ↓↓ ↓
fluids. pyrexia
 Coma ensues at plasma osmolality >350 mOsm kg-1 H2O Over-transfusion with High ↑ ↑↑
 May occur with ↑ or ↓ ECF volume (ECFV) depending on hypertonic sodium
solutions
cause
 Clinical features may reflect both hypo or hypervolaemia

7
 19/05/2014

a. Free water may be administrated orally, which is the preferred route,

or intravenously as a 5% dextrose solution. Infusion of a fluid with a
tonicity less than 150 mmol l-1 is dangerous and may lead to acute
haemolysis.
• NB replacement must be gradual to avoid risk of cerebral oedema
b. Vasopressin
c. Thiazide diuretics and other drugs, such as clofibrate,
chlorpropramide enhance the renal tubular effects of ADH and also
contribute to the stimulation of ADH release.
 Plasma sodium concentration less than 135 mmol l-1
 May occur with ↑ or ↓ ECF volume (ECFV) depending on
cause
 Clinical features may reflect both hypo or hypervolaemia
 Central signs: mild lethargy → seizures, respiratory arrest
 Rapid correction can lead to central pontine myelinolysis

Cause ECFV Total Total Urinary 1. Fluid restriction to about 700ml/day

body body sodium
free sodium 2. Inhibition of water reabsorption (furosemide)
water
Cardiac /
renal / hepatic
High
↑↑↑ ↑ < 20 mmol l-1
3. Infusion of 3% (hypertonic) sodium chloride
failure, TUR rapidly raises the tonicity of ECF
syndrome
Inappropriate
vasopressin
Normal ECFV,
plasma ↑ → < 20 mmol l-1,
urine osmolality 4. The amount of Na+ needed to raise the serum
secretion osmolality >100mOsm kg -1 H2O
(SIADH) <290mOsm kg-1 H2O
sodium =
[normal serum Na+ ] – [current serum Na+ ] x total body water
Adrenal failure Low
↓ ↓↓↓ > 20 mmol l-1

 Hyperkalemia is defined as serum potassium

Factors enhancing potassium transport into cells
concentration greater than 5,5 mmol l-1


◦ Insulin
◦ Epinephrine / Adrenaline
◦ Aldosterone
 Pseudohyperkalemia may be caused by
◦ Serum pH release of potassium from red cells

 Factors influencing renal potassium handling

◦ Aldosterone
 True hyperkalemia may result from extrarenal
◦ Glucocorticoids and renal causes.
◦ Increased tubular flow rate (seen with volume expansion)
◦ Extracellular pH
◦ Diuretics

8
 19/05/2014

Condition Cause Symptoms and signs

1. Calcium chloride, i.v. administration antagonizes the cardiac effects of
hyperkalemia

Hyperkalaemia Renal failure, Addison’s Cardiac arrhythmias, heart block, 2. Glucose and insulin, i.v. infusion lowers potassium level within 10
disease, iatrogenic cardiac arrest in diastole minutes.
(spironolactone,
administration of Weakness, numbness, 3. Salbuatmol (β 2 agonist) by nebulizer.
potassium supplements) paraesthesiae, confusion
4. Hypocapnia by hyperventilation.
Hypokalaemia Acute: admin of insulin Tachycardia, extrasystoles, cardiac
and glucose, vomiting, dilatation
5. Diuretics (furosemide), increase potassium excretion
diarrhoea, familial
periodic paralysis
6. Cation exchange resins, administration of polystyrene sulfonate binds
potassium in the gastrointestinal tract.
Chronic: dietary Weakness, hypotonia and paralysis
insufficiency, of muscle, metabolic alkalosis
malabsorption, diuretics,
7. Dialysis.
hyperaldosteronism,
Cushing’s syndrome 8. (Sodium bicarbonate, i.v. infusion stimulates cellular uptake of
potassium – no longer recommended)

1. Potassium chloride, orally is the safest  Total body content ≈ 1200g (most common mineral)
2. KCl by i.v. administration – with CAUTION  >99% of Ca is in bone
• Slow i.v. injection, the rate should not exceed 20mmol.h-1  Remainder in body fluids
• Dilute ++ especially if i.v. central venous access not  Partially ionised
available
 Partially protein bound
• Perivascular injection causes tissue necrosis – check for
extravasation
• If rapid correction needed, monitor ECG

Condition Cause Symptoms and signs

 Coagulation cascade
 Excitability of Hypocalcaemia Hypoparathyroidism, Tetany, convulsions, cataracts,
post-thyroidectomy, ectopic calcification in CNS
• Myocrdium Vit D deficiency, renal
failure,
• Skeletal muscle hyperventilation Weakness, hypotonia and paralysis
of muscle, metabolic alkalosis
• Smooth muscle
• Nerves Hypercalcaemia Hyperparathyroidism, Nephrolithiasis, personality
malignancy, changes, muscle weakness and
sarcoidosis, multiple atrophy, abdominal discomfort,
 Regulation of membrane permeability myeloma, Vit D corneal calcification
toxicity, milk-alkali
 Cofactor in various other metabolic processes syndrome

9
 19/05/2014

Important Roles  Total body content ≈ 25g

 About 50% of Mg is in bone and teeth
 Cofactor in various metabolic processes
• Essential for activity of all kinases  Normal plasma level ≈ 1.1 mmol l-1
• Enzymes that catalyze reactions of ATP

 I.V. Mg2+ useful in management of

 Muscle contraction
• Hypertension,
• Eclampsia,
 Glycolysis
• certain Arrhythmias

Condition Cause Symptoms and signs

Hypomagnesaemia Diarrhoea, ‘Calcium-resistant’ tetany,

malabsorption, muscular weakness, depression,
hyperaldosteronism irritability, convulsions

Hypermagnesaemia Renal failure,

iatrogenic
administration
Prolonged AV and
intraventricular conduction
rates; Decreased or absent deep
Any Questions?
tendon reflexes; impaired
breathing

1. Fundamentals of Anaesthesia (Cambridge Medicine), Tim Smith

(Editor), Colin Pinnock (Editor), Ted Lin (Editor), Robert Jones
(Editor). Chapter 2

2. Body Fluid Compartments, Sodium and Potassium, Bruce

McCormick, Update in Anaesthesia; WFSA Education Resources;
http://update.anaesthesiologists.org/

3. Color Atlas of Physiology (Thieme Flexibook), Agamemnon

Despopoulos (Author), Stefan Silbernagl (Author)

4. http://physiology.lf2.cuni.cz/teaching/lecturenotes/elektrolytes
/index.htm

10