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Hashmi
60 40 20 4 16
100 67 33 8 25
Intracellular Fluid
largest proportion in the skeletal muscle potassium and magnesium are the principal cations phosphates and proteins the principal anions
Extracellular Fluid
interstitial fluid: two types
functional component (90%) - rapidly equilibrating nonfunctioning components (10%) - slowly equilibrating
connective tissue water and transcellular water called a third space or distributional change
sodium is the principal cation chloride and bicarb the principal anions
Osmotic Pressure
physiologic and chemical activity of electrolytes depend on three factors: the number of particles present per unit volume (moles or millimoles [mmol] per liter) the number of electric charges per unit volume (equivalents or milliequivalents per liter) the number of osmotically active particles or ions per unit volume (osmoles or milliosmoles [mOsm] per liter)
Terminology
mole: molecular weight of that substance in grams mole eg: sodium chloride is 58 g (Na23, Cl35) equivalent: chemical combining activity; atomic weight expressed in grams divided by the valence divalent ions (calcium or magnesium) 1 mmol equals 2 mEq osmole: used when the actual number of osmotically active particles present in solution is considered millimole of sodium chloride, which dissociates nearly completely into sodium and chloride, contributes 2 mOsm
Water Exchange
daily water gains normal individual consumes 2000 to 2500 mL water per day approximately 1500 mL taken by mouth rest is extracted from solid food, either from the contents of the food or as the product of oxidation
Water Exchange
daily water losses
250 mL in stools, 800 - 1500 mL in urine, and 600 mL as insensible loss total losses ~ 2.2 liters Insensible loss: skin (75%) and lungs (25%) increased by hypermetabolism, hyperventilation, and fever 250 mL/day per degree of fever unhumidified tracheostomy with hyperventilation = insensible loss up to 1.5 L/day
Water Exchange
Minimum of 500 to 800 mL urine per day required to excrete the products of catabolism
Volume Changes
If isotonic salt solution is added to or lost from the body fluids, only the volume of the ECF is changed, ICF is relatively unaffected
If water is added to or lost from the ECF, the conc. of osmotically active particles changes Water will pass into the intracellular space until osmolarity is again equal in the two compartments
Volume Changes
BUN level rises with an ECF deficit of sufficient magnitude to reduce GFR creatinine level may not incr. proportionally in young people with healthy kidneys hematocrit increases with an ECF deficit and decreases with ECF excess sodium is not reliably related to the volume status of ECF a severe volume deficit may exist with a normal, low, or high serum level
Volume Deficit
ECF volume deficit is most common fluid loss in surgical patients most common causes of ECF volume deficit are: GI losses from vomiting, nasogastric suction,diarrhea, and fistular drainage other common causes: soft-tissue injuries and infections, peritonitis, obstruction, and burns
Volume Deficit
signs and symptoms of volume deficit: CNS: sleepy, apathy stupor, coma GI: dec food consumption N/V CVS: orthostatic, tachy, collapsed veins - hypotension Tissue: dec skin turgor, small tongue sunken eyes, atonia
Volume Excess
Iatrogenic or Secondary to renal insufficiency, cirrhosis, or CHF signs & symptoms of volume excess: CNS: none GI: edema of bowel CVS: elevated CVP, venous distension pulmonary edema Tissue: pitting edema anasarca
Concentration Changes
Na+ primarily responsible for ECF osmolarity Hyponatremia and hypernatremia s&s often occur if changes are severe or occur rapidly The concentration of most ions within the ECF can be altered without significant osmolality change, thus producing only a compositional change Example: rise of potassium from 4 to 8 mEq/L would significantly effect the myocardium, but not the effective osmotic pressure of the ECF
Composition Changes
Acid/Base Balance Potassium Abnormalities Calcium Abnormalities Magnesium Abnormalities
Acid-Base Balance
large load of acid produced endogenously as a by-product of body metabolism acids are neutralized efficiently by several buffer systems and subsequently excreted by the lungs and kidneys Buffers: proteins and phosphates: primary role in maintaining intracellular pH bicarbonatecarbonic acid system: operates principally in ECF
Acid-Base Balance
buffer systems consists of a weak acid or base and the salt of that acid or base Henderson-Hasselbalch equation, which defines the pH in terms of the ratio of the salt and acid: pH = pK + log BHCO3 / H2CO3 = 27 mEq/L / 1.33 mEq/L = 20 / 1 = 7.4 As long as the 20:1 ratio is maintained, regardless of the absolute values, the pH will remain at 7.4
Acid-Base Balance
Four types of acid-base disturbances combinations of respiratory and metabolic changes may represent: compensation for the initial acid-base disturbance or, two or more coexisting primary disorders 10-mmHg PaCO2 change yields a 0.08 pH change
Respiratory Acidosis
retention of CO2 secondary to decreased alveolar ventilation management involves prompt correction of the pulmonary defect, when feasible, and measures to ensure adequate ventilation prevention: tracheobronchial hygiene during the postoperative , humidified air, and avoiding oversedation
Respiratory Alkalosis
PaCO2 should not be below 30 mmHg dangers of a severe respiratory alkalosis are those related to potassium depletion
hypokalemia is related to entry of potassium ions into the cells in exchange for hydrogen and an excessive urinary potassium loss in exchange for sodium
shift of the oxyhemoglobin dissociation curve to the left, which limits the ability of hemoglobin to unload oxygen at tissues
Metabolic Acidosis
Anion gap is a useful aid: normal value is 10 to 15 mEq/L unmeasured anions that account for the gap are sulfate and phosphate plus lactate and other organic anions measured ions are sodium, bicarb, and chloride
Metabolic Acidosis
treatment of metabolic acidosis should be directed toward correction of the underlying disorder sodium bicarbonate is discouraged, attempt to treat underlying cause shifts the oxyhemoglobin dissociation curve left interference with O2 unloading at the tissue level
Metabolic Alkalosis
common surgical patient has hypochloremic, hypokalemic metabolic alkalosis resulting from persistent vomiting or gastric suction in the patient with pyloric obstruction
unlike vomiting with an open pylorus, which involves a combined loss of gastric, pancreatic, biliary, and intestinal secretions
Potassium Abnormalities
normal daily dietary intake of K+ is approx. 50 to 100 mEq majority of K+ is excreted in the urine 98% of the potassium in the body is located in ICF @ 150 mEq/L and it is the major cation of intracellular water intracellular K+ is released into the extracellular space in response to severe injury or surgical stress, acidosis, and the catabolic state
Hyperkalemia
signs & symptoms: CVS: peaked T waves, widened QRS complex, and depressed ST segments Disappearance of T waves, heart block, and diastolic cardiac arrest GI: nausea, vomiting, diarrhea (hyperfunctional bowel)
Hypokalemia
K+ has an important role in the regulation of acid-base balance
alkalosis causes increased renal K+/H+ excretion
Calcium Abnormalities
majority of the 1000 to 1200g of calcium in the average-sized adult is found in the bone Normal daily intake of calcium is 1 to 3 gm Most is excreted via the GI tract half is non-ionized and bound to proteins ionized portion is responsible for neuromuscular stability
Hypocalcemia
signs & symptoms (serum level < 8):
numbness and tingling of the circumoral region and the tips of the fingers and toes hyperactive tendon reflexes, positive Chvostek's sign, muscle and abdominal cramps, tetany with carpopedal spasm, convulsions (with severe deficit), and prolongation of the Q-T interval on the ECG
Hypocalcemia
causes: acute pancreatitis, massive soft-tissue infections (necrotizing fasciitis), acute and chronic renal failure, pancreatic and small-bowel fistulas, and hypoparathyroidism
Hypercalcemia
signs & symptoms: CNS: easy fatigue, weakness, stupor, and coma GI: anorexia, nausea, vomiting, and weight loss, thirst, polydipsia, and polyuria
Hypercalcemia
two major causes:
hyperparathyroidism and cancer
bone mets PTH-like peptide in malignancies
Magnesium Abnormalities
total body content of magnesium 2000 mEq about half of which is incorporated in bone distribution of Mg similar to K+, the major portion being intracellular normal daily dietary intake of magnesium is approximately 240 mg most is excreted in the feces and the remainder in the urine
Magnesium Deficiency
causes: starvation, malabsorption syndromes, GI losses, prolonged IV or TPN with magnesium-free solutions signs & symptoms: similar to those of calcium deficiency
Magnesium Excess
Symptomatic hypermagnesemia, although rare, is most commonly seen with severe renal insufficiency signs & symptoms:
CNS: lethargy and weakness with progressive loss of DTRs somnolence, coma, death CVS: increased P-R interval, widened QRS complex, and elevated T waves (resemble hyperkalemia) cardiac arrest
Secretions
Correction of Concentration Changes: If severe symptomatic hypo or hypernatremia complicates the volume loss, prompt correction of the concentration abnormality to the extent that symptoms are relieved is necessary
Fluid Composition
Laboratory Studies
Urinalysis: blood or myoglobin is a positive diagnostic test - can test via Hemoccult card Urinary lytes: urine sodium, creatinine, urea, osmolality, and specific gravity help classify type of renal failure using Renal failure indices
Renal Indices
Indices U Osm U/P osm U/P urea U/P cr Urine Na FENa Prerenal > 500 >1.25 >8 > 40 < 20 < 1% Renal < 350 <1.1 <3 < 20 > 40 > 3% Postrenal Varies Varies Varies < 20 > 40 > 3%