• Water • Osmolality • Electrolytes (ionts) •Disorders of electrolytes and water balance • Fluids • Total body water volume: 60 % body weight, 40 L • Body fluids/weight of adult 4Male 55-60 % 4Female 50-55 % 4Newborn 75-80 % 4Elderly - decreases to 45-50% of body weight 4Water content varies greatly from fat to muscle • Loss of 20 % BF - fatal •Compartments • Intracellular (ICF) 42/3 of body fluid Located primarily in skeletal muscle mass • Extracellular (ECF) 41/3 of body fluid 4Comprised of 3 major components Intravascular (plasma X serum) Interstitial (fluid in and around tissues) Transcellular •Transcellular component • < 1 % of BF • Physiologically located in 4Body cavities (CSF, synovial fluid), gastrointestinal tract, bones, .. • Potential to increase significantly in abnormal conditions 4Hydrothorax, ascites, haematoma (massive bleeding into joint or cavity), ileus (bowel obstruction) • Assessment of transcellular-spacing • Signs/Symptoms 4Decreased urine output with adequate intake 4Tachycardia 4Decreased BP, CVP 4Increased weight (in case od water intake) • Reabsorption phase 4Increased BP, CVP 4Hyperhydration, risk of heart failure ??Drains, .. 100Stool 100Sweating 2,0 - 2,5 L2,0 - 2,5 L 400Respiratory300Metabolic water 400 Insensible perspiration 700Food 1000-1500Urine1000-1500Beverages Losses (mL)Intake (mL) •Water bilance (water exchanges) • Diuresis < 50 mL/24 hodAnuria 50 - 500 mL/24 hodOliguria 500 - 2500 mL/24 hodNormal amount of urine > 2500 mL/24 hodPolyuria •Serum osmolality: 275-295 mosm/kg < 240 or > 320 is critically abnormal • The ratio of the amount of solute (particles) dissolved in a given weight of water • The principal contribution to osmolality 4Na+ (Cl-, HCO3 - ), urea, glucose • Effective osmolality 4Osmolality by solutes, generating gradient in the cell (semipermeabile) membrane • Calculation (= osmolality) 4(2 x Na) + K + glucose + urea) •Osmolal gap • Osmolar gap 4Difference between the measured osmolality and the calculated osmolality Measured osmolality is higher than calculated o. 4Difference > 10 mmol/kg •Absolute value x change of osmolality • Osmotic difference between ICF and ECF 4Osmosis (transfer of water, not ions) • Rapid changes of effective osmolality Rapid transfer of the water to (from) the cells • Optimal osmolality changes during treatment of hyper (hypo) osmolality 41 - 3 mosm/hr. • Causes 4Water deficit Vomiting, diarrhea, fever, burns, uncontrolled DM 4Excess of solutes, retention/supply Na+ Acute catabolism, DM decomp, alkohol • Sings, symptoms (volume deficit) 4Acute weight loss, decreased skin turgor, oliguria, concentrated urine, rapid pulse, decreased BP, sensations of thirst • Labs 4Increased HCT, TP, osmolality (serum, urine), decreased urine volume •Hyperosmolality • Intervention = hydration 41. Isotonic solution 42. Hypotonic solution ? • Osmolality changes during treatment should be gradual 41 - 3 mosm/hod. • Risk of rapid changes (rapid treatment of hyperosmolality) 4Brain oedema ! •Hyperosmolality • Causes 4Excess of water (water retention) Hypersecretion ADH (brain injury) 4Loss of Na+, chronic catabolism, protein malnutrition • Sings, symptoms 4Oedema, dyspnoea, mental status changes, cramps, cephalea,.. • Labs 4Decreased HCT, TP, osmolality (serum, urine) •Hypoosmolality • Intervention 41. Isotonic solution 42. Hypertonic solution ? • Osmolality changes during treatment 41 - 3 mosm/hod. •Hypoosmolality •Urine osmolality • 50 - 1400 mosm/kg H2O 4In elderly: max. 800 mosm/kg H20 • Depends on secretion of ADH 651,0P 151,0Mg 0,0012,2Ca 1554,0K 8102Cl 10140Na ICF (cells) mmol/LECF (blood) mmol/L •Ions in ECF and ICF •Cations and anions in blood (el.charge)mmol/l Na: 140 Cl: 102 HCO3: 24 Prot: 17 K Mg Ca 4 1 2,5 RA: 8 mmol/L anionskations •K+ - potassium • Physiological concentration 43,5 - 5,1 mmol/L 4Major cation in ICF • Why examinate K+ ? 4ABB 4Neuromuscular excitation Cardiac and neuromuscular function Influences nerve impulse conduction • Evaluation of the kalemia 4Connection to pH ! •Relationship between K a pH 1 2 3 4 5 6 7 8 9 6,9 7 7,1 7,2 7,3 7,4 7,5 7,6 7,7 pH K(mmol/l)Kmmol/L •Hyperkalaemia - causes • Shift K+ (from ICF to ECF) 4Acidosis, hypoxemia, haemolysis, catabolism • Excessive K intake 4In renal failure • Insufficient excretion by kidney 4Renal failure, lack of of adrenal corticoids, drugs (spironolacton) • Critical values 4> 6,5 mmol/L • MAC is accompanied by hyperkalaemia • Hyperkalaemia - signs, symptoms • Signs, symptoms 4Cardiac arrhythmias (bradycardia) 4ECG Tall T, low P, a-v block, wide QRS complex 4Muscle weakness, paralysis, paraesthaesia of tongue, face, hands, and feet, cramping • Therapy 4Acidosis - causal treatment 410 - 20% G + insulin 4Diuretics, Ion exchanger (resonium) 4Hemodialysis • Hypokalaemia - causes • Shift K+ (from ECF to ICF) 4Alcalosis, anabolism • Excessive K loss 4Renal - diuretics 4Gastrointestinal - diarrhea 4Drugs - large doses of adrenal corticoids • MAL is accompanied by hypokalemia • Signs, symptoms 4Muscle weakness, paralytic ileus 4Cardiovascular: ↓ BP, possible cardiac arrest 4EKG changes: decrease T wave, U wave 4Mental depression and confusion • Therapy: 4Therapy of alkalosis 4Replacement of K Oral, Parenteral (KCl 7,5 % = hypertonic solution !) • Hypokalaemia - signs, symptoms •Na+ (sodium): 135-145 mmol/L • Significance 4Major cation in ECF 4One of main factors in determining ECF volume 4Helps maintain acid-base balance 4Regulates voltage of action potential • Normal concentration of Na 4Physiological conditon 4Loss of isotonic fluid 4Excess of isotonic fluid •Hypernatraemia • Causes 4Excess of Na gain or loss of water 4Use of large doses of adrenal corticoids • Critical value: > 155 mmol/l • Risk 4If hypovolemia present - prerenal failure 4If hyperhydration - heart failure •Hypernatraemia - symptoms • Early 4Generalized muscle weakness • Moderate 4Confusion, thirst • Late 4oedema, restlessness, thirst, hyperreflexia, muscle twitching, irritability, possible coma • Severe 4Brain damage, hypertension, tachycardia •Hypernatraemia - therapy • Therapy should be gradual 4Changes osmolality 4Fast therapy = risk of brain oedema !! • When Na > 155 mmol/l - start with isotonic saline • Gradual lowering with hypotonic solution of NaCl • Decrease of natraemia: no more than 2 mmol/L/hr ! •Hyponatraemia - causes, risks • Excess Na loss or water gain • Hepatic cirrhosis, congestive heart failure, deficit of suprarenal corticoids • The major risks 4Oedema (lungs) 4Hyponatraemic encephalopathy ! Intracerebral osmotic fluid shifts Intracerebral vasoconstriction •Hyponatraemia - therapy • Therapy 40.9% solution NaCl (3% solution NaCl ?) • Hyponatraemia must be corrected slowly (risk of the development of central pontine myelinolysis). • Rapid correction of hypoNa is the most common cause of that potentially devastating disorder. • Serum sodium should not be allowed to rise by more than 8 mmol/l over 24 hours (i.e. 0.33 mmol/l/h • Chronic hyponatraemia • Chronic ill 4Hypoproteinaemia, katabolism 4Shift sensitivity of osmoreceptors 4Na+ levels drop gradually over months 4Chronic hypoNa is often called „asymptomatic hypoNa“ • Therapy? 4Try to increase albumin level 4Try to induce anabolism •Chloride: 98 - 107 mmol/L • Major anion in ECF • Why examinate Cl- ? 4ABB Acidosis, alkalosis 4Balance of fluid (hydration) mmol/l Na: 140 Cl: 102 HCO3: 24 RA, Prot. 26 K Mg Ca 4 1 2,5 + ↑ ↓ anionscations mmol/L • The law of electroneutrality: the sum of positive and negative charges must be equal HCO3 is anion, which can adapt its concentration rapidly to the changing conditions •Hyperchloraemia • Causes 4Diarrhea, kidney diseases (CRF) 4Excessive intake Cl • Hyperchloraemia is accompanied by acidosis • Therapy 4Correcting the underlying diseases 4Loop diuretics • Causes 4Heavy vomiting, (sweating) 4Adrenal gland insufficiency 4Loop diuretics • Hypochloraemia is accompanied by alkalosis • Therapy 4NaCl, KCl, Arginin-Cl, NH4Cl •Hypochloraemia • Saline („0,9 % solution NaCl, 300 mOsm/l) • Saline acidify body fluids ! •Phosphorus - P: 0,9 – 1,5 mmol/L • Intracellular mineral • Inverse relationship to Ca • Significance 4Tissue oxygenation, normal CNS function 4Movement of glucose into cells 4Maintenance of acid-base balance 4Enzymes, storage of energy (ATP - ADP),…. 4Bone mass • Supply P in bone: > 20 000 mmol •Hypophosphataemia • Causes 4Malnutrition 4Hyperparathyroidism 4Disorders causing hypercalcemia • Signs/Symptoms 4Muscle fatigue, weakness, paresis 4Disorientation, seizures, coma 4Haemolysis • Therapy 4Supplementation of P •Hyperphosphataemia • Causes 4Chronic renal failure (most common) 4Hypoparathyroidism 4Severe catabolic states 4Conditions causing hypocalcemia • Signs/Symptoms 4Muscle cramping and weakness 4↑ HR, diarrhea, nausea 4Calcifications •Hyperphosphataemia • Treatment 4Treat cause (if possible) 4Restrict phosphate-containing foods 4Administer phosphate-binding agents CRF - CaCO3 4Diuretics •Calcium: 2,1-2,5 mmol/l • Extracellular compartment 4Blood coagulation, neuromuscular contraction, enzymatic activity • Distribution 4Bone (99 %), ECF (1 %) 4ECF Protein-bound Complexes with anions Ionized - neuromuscular activity Ionized Ca Bounded Ca albumin Total Ca organic complexes 48 % 46 % 6 % • Decrease of ionized Ca • ↑ pH • ↑ Albumin • ↑ P • Increase of ionized Ca • ↓ pH • ↓ Albumin • ↓ P •Calcium homeostasis • Parathyrin (PTH, parathyroid hormone) • Calcitonin (thyreocalcitonin) • Calcitriol •Hypercalcaemia • Causes 4Mobilization of Ca from bone Malignancy, hyperparathyroidism, immobilization 4Thiazide diuretics, hyperfunction of thyroid gland 4Excessive ingestion of Ca and vit. D •Hypercalcaemia • Signs/Symptoms 4Anorexia, constipation 4Generalized muscle weakness, lethargy, ataxia 4Depression, fatigue, confusion, coma 4Rhythm disorders and heart block 4Polyuria & predisposes to renal calculi •Hypercalcaemia • Treatment 4Infusion of saline (0,9% NaCl) Loop diuretics (furosemid) 4Corticosteroids 4Bifosfonates and/or calcitonin 4Treatment of underlying diseases •Hypocalcaemia • Causes 4Depressed function of parathyroid gland Surgical removal of parathyroid gland 4Hypomagnesemia 4Hyperphosphatemia 4Administration of large quantities of stored blood (preserved with citrate) 4Renal insufficiency 4Lack of vitamin D •Hypocalcaemia • Signs/Symptoms 4Abdominal and/or extremity cramping 4Tetany; hyperactive reflexes 4Irritability, reduced cognitive ability, seizures 4Prolonged QT on ECG, hypotension, decreased myocardial contractility 4Abnormal clotting •Hypocalcaemia • Treatment 4Treatment of underlying diseases 4High calcium diet or oral calcium salts 4i.v. 10% calcium gluconate 4Vitamin D therapy •Magnesium: 0,7-1,1 mmol/l • Intracellular compartment 4Ensures K/Na transport across cell membrane 4Carbohydrate and protein metabolism 4Nerve cell conduction, neuromuscular activity 4Blood clotting, parathormone secretion 4Urine - defend concrements formation 4...... • Distribution 4Bone (60 %), ICF (38 %), ECF (2 %) ECF - protein-bound, ionized Mg2+ •Hypermagnesaemia • Causes 4RF, muscle necrosis • Signs and symptoms 4Hypotension, weakness, respiratory depression 4ECG - bradycardia, tall T waves, a-v block 4> 6 mmol/l - cardiac arrest, apnoea • Therapy 4Calcium chloride or gluconate i.v. for acute symptoms 4Diuretics, G + inzulin 4HD •Hypomagnesaemia • Causes 4Malabsorption, starvation, acute pancreatitis, alcoholism, diarrhea, diuretics therapy • Signs and symptoms 4Tremor, tetany, paraesthaesia of feet and legs, convulsions, personality changes with agitation 4ECG: ventricular tachycardia, fibrillation • Th 4MgSO4 i.m., slowly i.v.