Water and electrolytes-

balance and imbalance

FUNCTIONS
Water is the
solvent of life.
Is the major body
constituent.
More imp than any
other single
compound to life.
Participates as a
reactant in several
metabolic rxns.
 Properties of water
• Water is polar inorganic compound.
• Tasteless,odourless nd colorless.
• Solid,liquid nd gas.
• Amphoteric both acid nd base.
• Polar.
• High boiling point.
• Miscible with many liquids.
• Good conductor of electricity.
 DISTRIBUTION OF WATER
( in 70 Kg adult man)
Compartment % body weight Volume (L)

TOTAL 60 42

ICF 40 28

ECF 20 14
ECF 15 10.5
(INTERSTITIAL
FLUID)
ECF 5 3.5
(PLASMA)
WATER BALANCE
WATER TURNOVER & BALANCE

• The body possesses tremendous

capacity to regulate its water
content.
• In a healthy individual, this is
achieved by balancing the daily
water intake & water output.
• WATER INPUT: Exogenous &
endogenous
 EXOGENOUS WATER
• Include ingested water & water
content of food stuffs.
• Intake highly variable.
• Largely depends upon the social habits
& climate.
• In general, people living in hot climate
drink more water.
• Ingestion mainly controlled by a thirst
centre in the hypothalamus.
 ENDOGENOUS WATER
• Metabolic water produced with in
the body (300-350 ml/day).
• Derived from oxidation of
foodstuffs.
• It is estimated that 1g of
carbohydrates, protein & fat
respectively yield 0.6 ml, 0.4 ml &
1.1 ml of water.
 WATER OUTPUT
• Water losses from the body are variable.

• 4 distinct routes for the elimination are- urine,

skin, lungs & feces.

• Through urine- a major route, output is about

1500 ml/day.

• Hormonal regulation of urine production is by

vasopressin also known as ADH of the
posterior pituitary gland. The secretion of
ADH is regulated by the osmotic pressure of
plasma.
 CONTD.

• An increase in osmolality
promotes ADH secretion leading
to increased water reabsorption
causing less urine output.
• Diabetes insipidus is a disorder
caused by deficiency of ADH,
which results in an increased
urine output.
 Contd.
• Skin: about 450 ml/day through the
body surface by perspiration.
• An unregulated process, depends upon
atmospheric temperature & humidity.
• Lungs: about 400 ml/day during
respiration.
• Feces: About 150 ml/day. Loss is higher
in diarrhea.
• Abnormalities of water imbalance are
dehydration & over hydration.
 Regulation of water balance
• Aldosterone-produced by zona glomerulosa of
adrenal cortex. Increases Na+ reabsorption by
renal tubules at the expense of K+ and H+.
• ADH-will increase the water reabsorption by
renal tubules.
• Renin-angiotensin system-
• Fall in ECF volume

↓renal plasma flow

sensed by JG APPARATUS of kidney

secrete RENIN
• Angiotensinogen angiotensin-І
• Angiotensin-І ACE angiotensin-ІІ
• Angiotensin-ІІ angiotensin-ІІІ
• Angiotensin-ІІ and ІІІ degradation
products.
• AT-ІІ stimulates the release of aldosterone.
• ANP-secreted by right atrium of
heart.Increases the urinary Na+excretion by
inhibiting renin and aldosterone.
 DEHYDRATION
 May result from an inadequate
intake or excessive loss of water
or both.
 It can be due to following:
 Deprivation of water alone(pure
water depletion)
 Pathological loss of water &
electrolytes(salts)
 Loss of electrolytes alone(salts)
 Causes

 DIARRHEA
 VOMITING
 EXCESSIVE SWEATING
 FLUID LOSS IN BURNS
 KIDNEY DISEASES
 DEFICIENCY OF ADH.
 MANAGEMENT

 Replacement of the fluid deficient.

 Water is given orally or via

nasogastric tube in unconscious
patients.

 5% dextrose or hypotonic saline is

given intravenously.
 Water intoxication
• Water intoxication is caused by excessive
retention of water in the body.
• This may occur due to:
-Excessive intake of large volumes of salt free fluid.
-renal failure
-overproduction of ADH.
-major trauma
-surgical operations.
• causes dilution of ECF and ICF with a decrease in
osmolality.
S/S:
-Headache
-lethargy
-Convulsions
• Treatment
-Stoppage of water intake
-Administration of hypertonic saline.
 ELECTROLYTES
 Are small, inorganic substances that
can dissociate or break apart in
solution & carry an electric charge.

 These charged particles are called

ions.

 In a chemical solution, the separate

particles are constantly in balance
b/w cations & anions.
 CONTD.

 Cations: ions carrying +ve charge.

 E.g. sodium(Na+), potassium(K+),
calcium(Ca2+)

 Anions: ions carrying –ve charge.

 E.g. chloride(Cl-), carbonate(HCO3-),
phosphates(HPO42-)

 A balance b/w Cation & Anion conc.

Maintains a state of chemical
neutrality that is necessary for life.
 SODIUM
• Principal cation of the extracellular fluid.
• Total body content is about 70 gm.
• 50% occurs in bones,40% in ECF, remaining
10% in soft organs.
 Dietary sources
• Common salt(NaCl).
• Whole grains.
• Nuts.
• Eggs.
• Leafy vegetables.
• Milk
• Bread.
 Daily requirement
• RDA of sodium is about 5-10 gm/day.
• Low in persons with family H/O
hypertension(5gm/day).
• Intake of 1 gm/day is recommended for
patients of hypertension.
• Sodium in ECF:The normal concentration of
sodium in plasma is 135-145mEq/L.
• Sodium metabolism is monitored by
aldosterone.
• Kidney is the major route of sodium excretion
from the body.
• About 800 gm of sodium is filtered by the
glomeruli everyday and 99% of this is
reabsorbed by the renal tubules by an active
process controlled by aldosterone.
 Biochemical functions
1) Sodium regulates the body’s acid-base balance
along with chloride and bicarbonate.It is involved in
forming a bicarbonate buffer system and phosphate
buffer system.
2) Sodium plays a role in maintaining osmotic
pressure and fluid balance.
3) Sodium is important in muscle excitability and is
necessary for initiating and maintaining the
heartbeat.
4) Sodium plays a role in cell permeability.
5) Sodium plays a role in the absorption of glucose,
galactose and amino acids in the intestine.
 Contd….
6) Na+ is the major inorganic component in many
secretions like saliva, gastric, pancreatic and
intestinal juices.
7) In neurons, the Na+ -K+ pump maintains electric
neutrality.
8) Sodium is involved in the formation of bile salts.
 Hypernatremia
• Plasma Na+ > 145 mEq / L
– Due to ↑ Na + or ↓ water
– Water moves from ICF → ECF
– Cells dehydrate

Due to:
– Excess Na intake (hypertonic IV solution)
– Excess Na retention (oversecretion of aldosterone)
– Loss of pure water
• Long term sweating with chronic fever
• Respiratory infection → water vapor loss
• Diabetes (mellitus or insipidus) – polyuria
– Insufficient intake of water (hypodipsia)
29
 Clinical manifestations
of Hypernatremia
• Thirst
• Lethargy
• Irritability
• Seizures
• Fever
• Oliguria

30
 Hypernatremia
Evaluation
• Volume
• Serum sodium, osmolality, BUN/Creatinine
• Urine sodium, osmolality
 Treatment of Hypernatremia

• Calculate the free water deficit:

– 0.6 x wt (kg) x (patient’s sodium/140  - 1)
• Correct the free water deficit at a rate of
1mEq/L/hr
• Check serum Na q4hr
• Use isotonic salt-free IV fluid

32
 Hyponatremia(s/s)
• Anorexia • Bradycardia
• Headache • Hypertension or
• Nausea hypotension
• Emesis • Altered temperature
• Impaired response to verbal regulation
stimuli • Dilated pupils
• Impaired response to • Seizure activity
painful stimuli • Respiratory arrest
• Bizarre behavior • Coma
• Hallucinations • Hypotension
• Incontinence • Renal failure as
• Respiratory insufficiency consequence of
• Weakness,muscular hypotension
cramps
 Hyponatremia
Evaluation

• Volume.
• Serum sodium, osmolality,
BUN/Creatinine.
• Urine sodium, osmolality.
 Hyponatremia-types
• Hypovolemic hyponatremia
– Renal losses caused by diuretic excess,
osmotic diuresis, salt-wasting
nephropathy, adrenal insufficiency,
proximal renal tubular acidosis, metabolic
alkalosis, and pseudohypoaldosteronism
result in a urine sodium concentration
greater than 20 mEq/L
– Extrarenal losses caused by vomiting,
diarrhea, sweat.
• Rx: Volume resuscitation with NS
 Hyponatremia

• Normovolemic hyponatremia
– When hyponatremia is caused by SIADH,
glucocorticoid deficiency, hypothyroidism,
or water intoxication, urine sodium
concentration is greater than 20 mEq/L
• Rx:
– Fluid restriction
– Correct endocrine abnormality
 Hyponatremia
• Hypervolemic hyponatremia
– If hyponatremia is caused by an
edema-forming state (eg, congestive
heart failure, cirrhosis, nephrotic
syndrome).
– If hyponatremia is caused by acute or
chronic renal failure, urine sodium
concentration is greater than 40 mEq/L
• Rx: Correct underlying state
 Treatment of Hyponatremia

• Correct serum Na by 1mEq/L/hr

• Check serum Na q4hr
• Use 3% saline in severe hyponatremia
• Goal is serum Na 130
• Avoid too rapid correction:
– Central pontine myelinolysis
– Flash pulmonary edema

38
 POTASSIUM
• Major intracellular cation.
• Total body potassium is about 3500mEq(150gm).
• Out of which 75% is in skeletal muscle and
remaining 25% is distributed all over the body.
 Dietary sources and RDA
DIETARY SOURCES:
-Banana.
-Orange.
-Pineapple.
-Potato.
-Beans.
-Chicken.
-Organ meat(liver).
-COCONUT WATER.
RDA:3-4gm/day
 Potassium in ECF and ICF
• The plasma concentration of potassium is 3.5-
5.0mEq/L.
• Whole blood contains much higher levels of K+
since it is predominantly an intracellular
cation.
• Potassium concentration in the ICF is almost
the same as that of the sodium in the ECF.
 BIOCHEMICAL FUNCTIONS
1) Potassium maintains intracellular osmotic
pressure. Movement of water across the biological
membranes is dependent on the osmotic pressure
differences between ICF and ECF.
2) It plays a role in the regulation of acid-base and
water balances in the cells.
3) The enzyme, pyruvate kinase is dependent on K+
for its optimal activity.
4) Potassium is required for the transmission of nerve
impulses.
5) Adequate levels of K+ within the cell is necessary for
protein biosynthesis.
 Contd….
6) Extracellular K+ influences the activity of the
cardiac cycle.
7) H+-K+ ATPase plays a role in the transport of ions
across the cell membrane.
 Hypokalemia
• Serum K+ < 3.5 mEq /L
• Beware if diabetic
– Insulin pushes K+ into cells
– Ketoacidosis – H+ replaces K+, which is lost
in urine
• β – adrenergic drugs or epinephrine

44
 Causes of Hypokalemia
• Decreased intake of K+
• Increased K+ loss
– Chronic diuretics
– Severe vomiting/diarrhea
– Acid/base imbalance
– Trauma and stress
– Increased aldosterone
– Redistribution between ICF and ECF
45
Clinical manifestations of Hypokalemia
• Neuromuscular disorders:
–Weakness, flaccid paralysis,
respiratory arrest, constipation
• Dysrhythmias, appearance of U wave
• Postural hypotension.
• Cardiac arrest.
• Rx- Increase K+ intake, but slowly,
preferably by foods.
46
 Hyperkalemia
• Serum K+ > 5.5 mEq / L
• Check for renal disease
• Massive cellular trauma
• Insulin deficiency
• Addison’s disease
• Potassium sparing diuretics
• Decreased blood pH
• Exercise pushes K+ out of cells
47
 Hyperkalemia
Management
• 10% Calcium Gluconate or Calcium
Chloride
• Insulin (0.1U/kg/hr) and IV Glucose
• loop diuretics
• β-adrenergic drugs
• Hemodialysis.
 CHLORIDE
• Mostly occurs as a constituent of
sodium chloride. Hence, the
homeostasis of Na+, K+ and
chloride are interrelated.
 Dietary sources
•Common salt used in cooking.
•Whole grains
•Leafy vegetables.
•Eggs.
•Milk.
RDA:5-10gm.
 Very important
• The normal concentration of chloride is 95-
105mEq/L.
• CSF contains higher levels of Cl- (125mEq/L)
than any other body fluid.
• Since the protein content of CSF is low, Cl- is
high to maintain Gibbs Donnan membrane
equilibrium.
 BIOCHEMICAL FUNCTIONS
1) Chloride is important in the formation of HCl
in the gastric juice, which is isotonic with
plasma.
2) Chloride plays a role in the regulation of acid-
base balance.
3) Ptyalin (amylase)of saliva converts starch into
dextrins and maltose in presence of chloride
ions.
4) Chloride ions are also involved in chloride
shift which is important in transport of gases.
 Hypochloremia
• Most commonly from gastric losses
–Emesis, gastric suctioning, EC
fistula
• Often presents as a metabolic
alkalosis with paradoxical aciduria
(Na+ retained and H+ wasted in the
kidney)
• Rx: resuscitation with normal saline
 Hyperchloremia
• Most commonly from over-
resuscitation with normal saline
• Rx: stop normal saline and replace
with hypotonic crystalloid.