Fluids & Electrolytes Acid/Bas Balance

Dr wael sadaqah

2013
Lecture Objectives


Identify Acids and Bases .
Identify major electrolyte disorders
Regulation of acid-base
Interpretation of blood gases
Basics of Body Fluids
Water - primary body fluid. 40%-60% of
weight in adult. Affected by age, sex, &
body fat.
Distribution - ICF & ECF.
ICF: in cells. 2/3 of body fluid in adults.
ECF: outside cells. 1/3 of body fluid. 4
compartments-intravascular, interstitial,
lymph, & transcellular
Electrolyte Basics
Usually measured in mEq/L

Lab tests are usually done on plasma, an ECF.

ECF: Na+*, Cl-, HCO3-(bicarbonate)

ICF: K+*, Mg+, P-(phosphate),

Other electrolytes: Ca+ & H+
Solute Concentration
Osmolality: determined by total solute
concentration within a fluid compartment. Parts of
solute per Kg of H2O.

Reported as milliosmols per Kg (mOsm/kg).

Na+ biggest determinant of serum osmolality.

K+, glucose, & urea determine osmolality of ICF.
Tonicity
Refers to osmolality of a solution

Isotonic: same osmolality of body fluids. NS,
0.9%NaCl, RL

Hypertonic: higher osmolality than body fluids.
D5NS, 3%NaCl, D5RL

Hypotonic: lower osmolality than body fluids.
H2O, 1/2NS (0.45%NaCl)
Movement of Fluids
Active transport is important in maintaining
differences in Na+ & K+ concentrations of ECF &
ICF.

Usually Na+ concentrations are higher in ECF and
K+ higher in ICF.

To maintain this, the Na-K pump is activated,
moving Na+ from cells and K+ into cells.
Body Fluid Regulation
Intake should equal output.

Averages around 2500ml for an adult.

Average Adult Intake:
Fluids- 1500ml
Water in Food- 750 ml
Water formed from food metabolism- 200ml
Body Fluid Regulation
Average Adult Output
Urine- 1500ml
Feces- 200ml
Sweat- 100ml
Insensible losses-
Lungs- 400ml
Skin- 400ml
Maintaining Homeostasis
Regulation of homeostasis of body fluids-
kidneys, endocrine system, CV, lungs, GI
system.

Hormones - antidiuretic hormone (ADH),
renin-angiontensin-aldosterone system,
atrial natriuretic factor.
Maintaining Homeostasis
Kidneys: primary regulator of fluids and
electrolytes. Regulate volume and osmolality of
ECF by regulating H2O and lyte excretion.

Water: adjust reabsorption of water from plasma
filtrate and amount excreted as urine.

Electrolytes: selective retention and excretion by
kidneys. Big role in acid-base balance by excreting
H+ and retaining HCO3-.
Maintaining Homeostasis
ADH : regulates H2O excretion from kidneys.

Increased serum osmolality, ADH is produced,
causes collecting ducts to become more
permeable to H2O.

Allows more H2O to be reabsorbed into blood.

Then, urine output falls, serum osmolality
decreases due to H2O dilution of body fluids.


Maintaining Homeostasis
Renin-Angiotensin-Aldosterone System: special
cells in nephrons react to changes in renal
perfusion.

If blood flow or pressure to kidneys decreases,
renin is released.

Causes conversion of AT to AT1 which converts
to AT II.

AT II acts directly on nephrons to promote Na+
& H2O retention.
Maintaining Homeostasis
Atrial Natriuretic Factor: ANF: released from cells
in atria in response to excess blood volume and
stretching of atrial walls.

Acts on nephrons by promoting Na+ wasting and
acts as a potential diuretic which reduces vascular
volume.

Also inhibits thirst, therefore reducing fluid intake.
Electrolyte Regulation
Most lytes come from dietary intake and excreted
by urine.

Na+ & Cl- not stored-must be consumed daily.

K+ & Ca+ are stored in cells and bones.

When serum levels drop, ions can go from storage
into blood to maintain adequate serum levels.
Sodium: Na+: 135-145mEq/L
Major ECF cation
Major functions:
Water balance
Transmission of nerve impulses
Regulation controlled at cellular level by
sodium-potassium pump.
Na+ retention/secretion controlled by
aldosterone
Aldosterone controlled by renin-
angiotensin pump
Potassium: K+: 3.5-5.5mEq/L
Major cation of ICF

Major function: Electrical conduction of nerve impulses-
cardiac conduction

Regulation at cellular level by Na-K pump

Serum K+ maintained by kidneys ability to retain
extra K+ if needed

Kidneys can excrete K+ in exchange for Na+ - controlled
by aldosterone

Body more sensitive to small changes in serum K+ than
other electrolytes
Calcium: Ca++: 8.5-10.5 mg/dl
Major functions: 1% in ECF
Normal skeletal muscle, smooth muscle, & cardiac
muscle contraction; blood clotting

In through diet. Needs Vit. D. to be absorbed

Regulation:
Parathyroid hormone: triggers Ca release from bone
and/or inhibits renal excretion: raises serum levels

Calcitonin: thyroid gland; causes ECF levels to
decrease by inhibition of bone resorption (release);
inhibits Vit. D absorption, & increases renal excretion
Chloride: Cl
Major anion of ECF

Functions with Na to regulate serum osmolality
and blood volume

Major component of gastric juice (HCl)

Helps regulate acid-base balance

Acts as buffer in exchange of O2 & CO2 in RBCs
Bicarbonate: HCO3

Acid-Base balance: essential part of
carbonic acid-bicarbonate buffering system.

ECF regulated by kidneys.

Kidneys regenerate and reabsorb if needed.
Acid-Base Balance
pH: measure of number of H+ ions present

Acid: releases H+

Base: accept H+

Higher H+ concentration-more acidic

Lower H+ concentration-more alkaline

Water is neutral-pH=7.

<7: acidic >7: alkaline
Acid-Base Balance
Body very sensitive to small changes in Ph

Normal pH: 7.35-7.45

Regulation:
Buffers
Respiratory
Renal

Acid-Base Balance
Buffers: remove or release H+ ions.
Immediate action but limited.

Major ECF: bicarbonate and carbonic acid.

Plasma proteins, Hgb, phosphates act as
buffers
35
Blood Buffer Systems
Four Major Buffer Systems
Protein Buffer systems
Amino acids
Hemoglobin Buffer system
Phosphate Buffer system
Bicarbonate-carbonic acid Buffer system
Blood Buffer Systems
Protein Buffer System
Originates from amino acids
ALBUMIN- primary protein due to high concentration
in plasma
Buffer both hydrogen ions and carbon dioxide

Blood Buffering Systems
Hemoglobin Buffer System
Roles
Binds CO
2

Binds and transports hydrogen and oxygen
Participates in the chloride shift
Maintains blood pH as hemoglobin changes
from oxyhemoglobin to deoxyhemoglobin
Blood Buffer Systems
Phosphate Buffer System
Has a major role in the elimination of H
+
via the
kidney
Assists in the exchange of sodium for
hydrogen
It participates in the following reaction
HPO
-2
4
+ H
+
H
2
PO

4

Essential within the erythrocytes

Blood Buffer Systems
Bicarbonate/carbonic acid buffer
system
Function almost instantaneously
Cells that are utilizing O
2
, produce CO
2
, which builds up.
Thus, more CO
2
is found in the tissue cells than in
nearby blood cells. This results in a pressure (pCO
2
).
Diffusion occurs, the CO
2
leaves the tissue through the
interstitial fluid into the capillary blood
Bicarbonate/Carbonic Acid Buffer
Carbonic
acid
Bicarbonate
Conjugate
base
Excreted in
urine
Excreted
by lungs
Bicarbonate/carbonic acid buffer system

How is CO
2
transported?
5-8% transported in dissolved form
A small amount of the CO
2
combines directly with
the hemoglobin to form carbaminohemoglobin
92-95% of CO
2
will enter the RBC, and under the
following reaction
CO
2
+ H
2
0 H
+
+ HCO
3
-
Once bicarbonate formed, exchanged for chloride

Acid-Base Balance
Respiratory: retain or eliminate CO2.

Works with bicarb-carbonic acid system. Alter rate
and depth of respiration.

CO2 powerful stimulator.

When blood levels of carbonic acid and CO2 rise,
respiratory center increase rate & depth. CO2
exhaled, carbonic acid falls.
Acid-Base Balance
Renal: ultimate long-term regulator.

Slower to respond but more permanent and
selective.

Excrete or conserve bicarb. and H+ ions.

Excess H+ and pH falls, kidneys reabsorb and
regenerate bicarb. and excrete H+.

Alkalosis and high pH, bicarb. Excreted and H+
retained.
Factors affecting fluids/lytes
Age: elderly: thirst response blunted. Nephrons
less able to conserve water in response to ADH.


Increased risk of dehydration, heart diseases,
impaired RF, multiple meds.

Gender/Body Size: fat cells have no H2O.

Women have more fat-less body water.
Factors
Environmental Temp: illness and strenuous
activity with high env. temp-increased risk of
imbalances. Salt and water lost with sweating. If
only water replaced, salt depletion risk-- Heat
exhaustion or heat stroke.


Diet: anorexia, bulimia, malnourishment-low
albumin, edema, acidosis


Stress: increased cellular metabolism, glucose,
ADH production-decreased urine output. Overall
effect: increases blood volume
Fluid Imbalances
Dehydration: water loss without lyte loss.

Overhydration: water intoxication. More
water than lytes. Low serum osmolality and
low Na levels.
Electrolyte Imbalances
Hyponatremia: <135 mEq/L. Low osmolality.
Water out of vascular into interstitial tissues and
cells.

Hypernatremia: >145. Fluid out of cells into ECF.
Cells dehydrated.

Hypokalemia: <3.5. GI losses from vomiting,
suction, diuretics.

Hyperkalemia: >5.0. Can lead to cardiac arrest.
Electrolyte Imbalances
Hypocalcemia: <8.5. Tetany, muscle
spasms, paresthesias, convulsions.
Greatest risk: parathyroid removed.

Hypercalcemia: >10.5. Malignancy,
prolonged immobilization.
Electrolyte Imbalances

Hyperchloremia: Na retention. Excessive
replacement of NaCl or KCl. Acidosis, weakness,
lethargy, dysrhythmias, coma.

Hypochloremia: excess loss of Cl through GI,
kidneys, sweating. Muscle tremors, twitching,
tetany. Risk of alkalosis.



Acid-Base Imbalances
Respiratory Acidosis: anything which prevents
body from getting rid of excess CO2, increases
acid which decreases pH

Respiratory Alkalosis: anything which makes
body lose CO2, decreases acid, which increases
pH

Metabolic Acidosis: anything which decreases
HCO3 decreases base which decreases pH

Metabolic Alkalosis: anything which increases
HCO3 increases base which increases pH
Respiratory Acidosis
Low pH caused by high CO2; high HCO3 will
develop later to help balance pH

Caused by processes which decrease
exchange of CO2 for O2 in lungs
COPD, CHF, Head injury with resp. depression,
Lung CA, Pneumonia, Asthma

Associated with high serum K+

Respiratory Alkalosis
High pH caused by low CO2; low HCO3
develops later to balance pH

Caused by anything which increases resp.
Fever, Severe pain, Anxiety, ASA OD,
Thyrotoxicosis, Overventilation with vent

Associated Imbalances: low K+ and Ca
Metabolic Acidosis
Low pH caused by low HCO3; CO2 will
rapidly decrease to help balance pH

Caused by anything which increases
accumulation of acids or decreases the
amount of bicarb. in body
DKA, RF, diuretic therapy (HCO3 loss), loss of
bases from pancreatic fistulas or diarrhea

Associated with increased K+
Metabolic Alkalosis
High pH caused by high HCO3: high CO2
develops quickly to help balance pH

Caused by anything which decreases H+
ions in body or increases bicarb.
Prolonged vomiting, NG suctioning, excessive
intake of HCO3 antacids, prolonged diuretic
therapy thats K+ wasting

Associated Imbalances: decreased K+ and
Ca
The Anion Gap
The anion gap is the difference
between the measured anions and
cations.
Anion gap = Na - (Cl + HCO3)
Normal = 12+ 2
>14 consistent with met acidosis
>30 severe organic acidosis
The pH is calculated by
taking the negative
logarithm of the
hydrogen ion
concentration.
pH = -log10[H+]:
where [H+] is the
hydrogen ion
concentration.

pH and Hydrogen ion
concentration
pH [H+] nanomol/l
6.0 1000
7.0 100
8.0 10
9.0 1
Simplified Henderson - Hasselbach
equation


(H+) = 24 x PaCO
2

HCO
3

Shows relationship between 3 major factors:
H+
CO
2

HCO
3

ABG Interpretation
Look at pH and see if high or low: Acidosis or
Alkalosis

If pH low: look at CO2, then HCO3
If CO2 high-respiratory acidosis
If HCO3 low-metabolic acidosis

If pH high: look at CO2, then HCO3
If CO2 low-respiratory alkalosis
If HCO3 high-metabolic alkalosis

Anytime CO2 and HCO3 going in same direction,
compensated process
ABG Interpretation
PH pH
CO2 Metabolic
alkalosis
respiratory
acidosis
CO2 respiratory
alkalosis
Metabolic
acidosis


Golden Rules for ABGs

pH increases 0.10 for every 10mm/hg
decrease in PaCO2
HCO3 decreases 2meq/l for every 10mm/hg
decrease in PaCO2
Golden Rules for ABGs
Over time, pH will nearly normalize if
hypocarbia is sustained
Bicarbonate will decrease 5-6 meq/L for
each chronic 10mm/hg decrease in PaCO2
Clinical

History: Chronic conditions, meds,
functional, developmental, socioeconomic
status, food/fluid intake/output.

Physical: skin, mucous membranes, eyes,
CV, respiratory, neuro, muscular systems
Clinical
Clinical Measurements:
Daily Weight: same time, scale, condition

2.2kg=1L fluid

Best assessment data if done right

Must document!!

Clinical
Vital Signs: Tachycardia-early sign of
hypovolemia.

Pulse volume (intensity)

Irregular pulse with lyte imbalances

BP-sensitive to blood volume.
Clinical
Intake/Output: very important. Document
correctly on I/O form. Measure urine output

Intake: Oral fluids, ice chips, foods that
tend to become liquid at room temp., tube
feedings, IVs, tube irrigants
Clinical
Output: urinary, vomitus, liquid feces, tube
drainage, wound drainage

Totaled at end of shift (8-12 hours). Then
added and totaled at 24 hours.

Labs: electrolytes, CBC, osmolality, urine
pH, urine specific gravity, ABGs
Clinical
Diagnosis

Enteral fluid/lyte replacement

Intake modification, dietary changes, oral lyte
supplements

Parenteral Replacement

IVs : Monitor IV infusion, determining IV flow
rates, infusion pumps