Composition of Body Fluids

 Water – the most

abundant constituent in
the body.
 - 60% of body weight
 - 50% of body weight
Water percentage of BW

Age Male Female

Newborn 80% 75%
1 to 5 years 65% 65%
10 to 16 years 60% 60%
17 to 39 years 60% 50%
40 to 59 years 55% 47%
60+ 50% 45%
Body Compartment
 2/3 reside inside the
cell (ICF)
 1/3 reside outside
the cell (ECF)
 plasma
 interstitial fluid
Distribution of Body Fluids
Compartment Amount Volume in 70 kg
Total body fluid 60 % of BW 42 L
Intracellular 40% of BW 28 L
Extracellular 20% of BW 14 L
Interstitial 2/3 of ECF 9.4L
Plasma fluid 1/3 of ECF 4.6L
Venous fluid 85% of plasma 3.9 L
Arterial fluid 15% of plasma 0.7 L
 EXTRACELLULAR FLUID INTRACELLULAR
FLUID

BLOOD PLASMA HCO3

INTERSTITIAL
FLUID
HCO3
HCO3
K+ HPO4=
Na+
Cl Na+
Cl SO4=

SO4 Mg ++
K+ K+
Org. acid Protein
Ca++ Ca++
Mg++ protein Mg++ AG Na+
Hyponatremia

Serum Na+ < 135 mmol/L

 Sodium is the primary determinant of blood

osmolality in the body
 Involved in the regulation of extracellular fluid
volume

“ A sodium problem is a water problem”

Hyponatremia - Etiology
Euvolemia Hypovolemia Hypervolemia
SIADH Diuretic use CHF

Psychogenic Aldosterone Cirrhosis

polydipsia deficiency
Hypothyroidism Renal tubular Nephrotic syndrome
dysfunction
Vomiting

Diarrhea

Third-space losses
Hyponatremia - Treatment

 Treat the underlying disease

 Remove offending drugs

 Improve circulating sodium levels

Na deficit = (Desired Na – Actual Na) x 0.6

x wt (Kg)
Hyponatremia - Treatment
 Hypovolemic hyponatremia – give normal
saline, rule out adrenal insufficiency
 Hypervolemic hyponatremia – increase free
water losses
 Euvolemic hyponatremia
- Restrict free water intake
- Increase free water loss
- Normal or hypertonic saline
Hypernatremia

Serum Na+ > 145 mmol/L

 Indicates intracellular volume depletion with a

loss of free water
 which exceeds sodium loss
Hypernatremia - Etiology

Water Loss Reduced Water Excessive

Intake Sodium Intake
Diarrhea Altered thirst Salt tablets

Vomiting Impaired access Hypertonic saline

Excessive sweating Sodium bicarbonate

Diuresis

Diabetes insipidus
Hypernatremia - Treatment
 Provide intravascular volume replacement
 Consider giving one-half of free water deficit
initially
 Reduce Na cautiously: 0.5 – 1.0 mmol/L/hr

Rapid correction of serum sodium can result in

cerebral edema and neurologic injury!
Potassium
 most abundant intracellular cation in the body
 Regulates intracellular enzyme function,
neuromuscular, and cardiovascular
tissue excitability
 Normal value : 3.5 – 5.0 mmol/L
 90 % of excretion via renal loss;
very small quantities in stool or sweat.
 98-99 % intracellular – mostly in muscle
Renal handling of K+
 K+ is freely filtered
 90% is reabsorbed from proximal tubule
 Secretion from the DCT and CT is the
primary modulator of K excretion
Potassium
 98 % of K+ is intracellular
 Serum K+ concentration generally reflects total body
K+
 Serum K+ is affected by the serum pH

 Acidosis K+ is high

 Alkalosis K+ is low
Assessment
 History
 Physical examination
Symptoms seldom unless K < 3 meq/L
Fatique, myalgia, muscular weakness of lower
extremeties
Progressive weakness, paralysis, hypoventilation
Paralytic ileus
Assessment
 Laboratories
 Serum K+

 EKG

 H+
Causes of Hypokalemia
Transcellular Renal Losses Extrarenal Losses Decreased Intake
Shifts
Alkalosis Diuresis Diarrhea Malnutrition
Hyperventilation Metabolic Profuse sweating Alcoholism
Alkalosis
Insulin Renal tubular Nasogastric Anorexia nervosa
defects suction
ß-Adrenergic DKA
agonists
Drugs (diuretics,
aminoglycosides)
Hypomagnesemia
Vomiting
Hyperaldosteronism

Cushing’s disease
Hypokalemia
Clinical Manifestations
 Cardiac
- ECG abnormalities
- arrythmias
 Neuromuscular
- paralysis
- paresthesias
 Gastrointestinal
- ileus
- abdominal cramps
Correction of Hypokalemia
 Oral therapy is desirable
 For intravenous correction:
- If K+ > 2.5 mEq/L and no EKG changes
rate < 10 mEq/HR & conc. not > than 30
mEq/L of IVF
- If K+ < 2 mEq/L w/ EKG changes
40 mEq/HR & conc. up to 60 mEq/L
Hyperkalemia
 Defined as serum K of > 5 mEq/L

 Rarely seen in patient with normal renal function

 Seen in severe injury or surgical stress, acidosis and the

catabolic state.

 Other causes:
- Metabolic Acidosis
- Hypoaldosteronism
- Drugs
- Cell Death
- Excessive intake
Hyperkalemia - Treatment
 If with significant ECG abnormalities:
- Administer Calcium gluconate (10%) 1 vial IV over 5 to 10
minutes ( cardiac monitoring)
 For redistribution of potassium:
- D50 + Regular Insulin IV
- Inhaled ß2-agonists
- NaHCO3 IV
 For removal of potassium
- Loop diuretic
- Cation exchange resin
- Dialysis
Calcium
 Effective levels best assessed by using ionized
calcium measurements
 If using total calcium, the albumin
concentration should be considered

For each decrease or increase in serum albumin

of 1 g/dL, the serum calcium increases or
decreases by 0.8 mg/dL.
Hypocalcemia

Total calcium < 8.5 mg/dL, Ionized calcium < 1.0 mmol/L

 Clinical manifestations are mainly cardiovascular and

neuromuscular

 Treatment:
- Mild hypocalcemia is usually well-tolerated
- Severe symptomatic hypocalcemia give
calcium IV bolus followed by infusion
Hypercalcemia
Total Calcium > 11 mg/dL, Ionized Calcium > 1.3 mmol/L

 Clinical manifestations are primarily cardiac and

neuromuscular
 Treatment:
- Restore intravascular volume with normal saline
- Loop diuretics
- Dialysis
Hypophosphatemia
Phosphate < 2.5 mg/dL
 Phosphate depletion primarily affects
neuromuscular and central nervous systems
 Serious adverse effects: respiratory failure and
rhabdomyolysis
 Replace IV for levels < 1 mg/dL

Milk is a good source of dietary phosphate!

Hypomagnesemia

 Clinical manifestations
overlap those of
hypokalemia and
hypocalcemia

 For emergency treatment:

administer
1 to 2 g MgSO4
intravenously over 5 to 10 Torsade de Pointes
minutes
Magnesium < 1.8 mg/dL
 ELECTROLYTE CONCENTRATIONS
IN DIFFERENT BODY FLUIDS IN Meq/L

NA K H CL HCO3
SWEAT 50 5 55
GASTRIC 40 10 90 140
SECRETIONS
PANCREATIC 135 5 50 90
FLUID
BILE 135 5 105 35
SMALL INT. 130 10 115 25
FLUID
DIARRHEAL 50 35 40 45
FLUID
Composition of Parenteral Fluids
Sol’n Na K Ca Mg Cl HCO3 mOsm

ECF 142 4 5 3 103 27 280-

310
LR 130 4 3 - 109 28 273
0.9% 154 - - - 154 - 308
NSS
D5 77 - - - 77 - 407
45%
NaCl
General Management of Fluids
A. Minimum Water Requirements
 It is not uncommon to administer 2 to 3 L water/
day
 Produce a urine volume greater than 1000 to 1500
ml/day
 BECAUSE THERE IS NO ADVANTAGE TO
MINIMIZING URINE OUTPUT
General Management of Fluids
A. Minimum Water Requirements
• WEIGHING THE PATIENT ON A DAILY BASIS
• the best means of assessing net gain or loss
of total body fluids,
• since GI, renal and insensible fluid losses of
patients are unpredictable.
General Management of Fluids
B. Electrolytes
 The kidneys are normally capable of compensating
for wide fluctuations in dietary Na+ intake
 Renal Na+ can fall to less than 5 mmol/day in the
absence of Na+ intake
 It is customary to provide 50 to 150 mmol /day Na+
General Management of Fluids
B. Electrolytes
 K+ supplementation of 20-60 mmol/day is
included if renal function is adequate.
 CHO in the form of dextrose 100-150 g/day
 Minimize the protein catabolism and prevent
ketoacidosis
General Management of Fluids
C. Maintenance Fluid IV Regiments
 Calcium, magnesium, phosphorus, vitamins and
protein replacement are necessary after 1 week of
parenteral therapy.
Replacement of Abnormal Water &
Electrolyte Losses
A. INSENSIBLE WATER LOSSES from
 Skin : 0.3 to 0.4 L/d
 Respiration : 0.3 to 0.4 L/d
 Sweating : 0.1 L/d
 B. GASTROINTESTINAL LOSSES
 vary in composition and volume depending on their
source:
Feces accounts for ~ 0.1 to 0.2 L/d
Urine accounts for ~ 0.5 to 1.5 L/d
Factors Modifying Fluid Requirements

Condition Adjustment Needed

Extra Needed
● Fever - 12% for each °C > 37.5°C, 24% for each °C >38.5°C
● Sustained hyperventilation or excessive muscular activity as in seizures,
chills - 25 to 50%
● Hypermetabolic states:
- severe thermal injury, salicylate intoxication, thyrotoxicosis - 25 to 75%
- burns on the 1st day (4% increase per 1% area burnt), subsequent days
● Abnormal water and electrolyte losses as in diarrhea and vomiting - 2% increase per 1% area burnt
● Sweating
● Room temperature - volume per volume
● Newborn under radiant warmer or phototherapy
● Full activity and oral feeds - 10 to 25%
- 30% per °C rise
- 25%
- 50%

Less required
● Hyperthermia - 12% per each °C below 37.5°C
● Very high humidity - 30%
● Humidified inspired air - 25%
● Oliguria or anuria - case to case basis due to reduced energy expenditure
● edematous and anti-diuretic states - 30%
Types of IVF
1) Hypotonic
- D5W - D5 0.3% NaCl
- D5NM - D5Maintresol
- D5IMB - Isolyte
2) Isotonic
- D5LR - D5NSS
- D5NR - PNSS
3) Hypertonic
- D50W - D10W
Commonly Used IV Fluids for Infants
and Children
Fluid Dextrose g/L Na mEq/L Cl mEq/L K mEq/L
PLRS - 130 109 4
NSS - 154 154 -
D5 0.15% NaCl 50 25 25 -
D5 0.3% NaCl 50 51 51 -
D5 0.45% NaCl 50 77 77 -
D5 0.9% NaCl 50 154 154 -
D5 IMB 50 25 22 20
D5 LRS 50 130 109 4
D5 NR 50 140 98 5
D5 NM 50 40 40 13