Fluid Balance

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65-75% TBW

Infants - 10 years of age

~40% TBW

Elderly

40-50% less water in fat vs muscle

Obesity Related

60-40-20 Rule

60% is body weight, 40% is intercellular fluid, 20% is extracellular fluid

Water moves freely by diffusion through the lipid bilayer cell membrane through aquaporins, a water channel protein. Ions balance is mediated by ion channels or transporters. Under normal condition, Na+ is responsible for the osmotic balance of the ECF space; K+ for osmotic balance of the ICF space.

Water movement between ICF and ECF

Na+ is responsible for the osmotic balance of the

ECF space

K+ is responsible for osmotic balance of the

ICF space

Milimoles of solute per liter of solvent (mmol/L)

Osmolarity

Millimoles of solute particles per kg of solvent (mmol/kg)

Osmolality

275-295 mOsm/L

Normal plasma level

(Na+) x (2+10)

Serum Osmolality Normal Conditions

Facilities the outward movement of water from the space. Capillary hydrostatic pressure (BP) and Interstitial hydrostatic pressure.

Hydrostatic Pressure

Osmotically attracts water into the space (proteins, like albumin, globulins and fibrinogens). Capillary (plasma) oncotic pressure. Intersitital oncotic pressure.

Oncotic Pressure

How the presence of solutes (ions, nutrients, small proteins) changes fluid movement.

Osmotic Pressure

Forces favoring filtration - Forces opposing filtration

Net Filtration

Capillary hydrostatic pressure (Pc) + Interstitial oncotic pressure (Pi)

Forces favoring filtration

Capillary oncotic pressure (pc) + Interstitial hydrostatic pressure (pi)

Forces opposing filtration

Substances can cross the capillaries in 3 ways

Simple diffusion, vesicular transport, and osmosis

90% of extracellular cations, maintains balance extracellular fluid. Balance of this cation is main goal of osmosis. Normal: 135-145.

Sodium

Cation maintains intracellular balance. Balance maintained by active transport. Responds to: acid/base imbalance, hyperglycemia, adrenergic antagonists/agonists, cell lysis. Normal: 3.5-5.5.

Potassium

Drink too much water. Inadequate Na+ intake. Caused medications. Heart, kidney, liver problems. SIADH. Pure Na+ deficits: chronic, severe vomiting or diarrhea, burns, other causes of dehydration. Hormonal changes: Addisons.

Causes of Hyponatremia

SALT LOSS: Seizure, stupor, abdominal cramping, lethargic, diminished tendon reflexes, difficulty concentrating, loss of appetite and urine. Orthostatic hypotension, overactive bowel sounds. Shallow respirations (late). Spasms of muscles.

Clinical manifestations of Hyponatremia

Severe vomiting, diarrhea, diabetic ketoacidosis, medications, CKD, dietary deficiency, overheating.

Causes of Hypokalemia

Weakness, fatigue, muscle cramps and twitching, hypotension, arrhythmia, polyuria, polydipsia.

Clinical Manifestations of Hypokalemia

CKD, uncontrolled DM, dehydration, severe bleeding, excessive K+ intake, medications.

Causes of Hyperkalemia

Abdominal pain and diarrhea, heart symptoms, muscles symptoms, N/V.

Clinical Manifestations of Hyperkalemia

Decreased perfusion, altered cell to cell interactions

Fluid Volume Deficit

Impaired O2 and metabolic diffusion, obstructed capillary flow and lymphatic drainage, altered cell to cell interactions, cerebral, myocardial, pulmonary, kidney interstitial edema, hepatic congestion, gut and tissue edema.

Fluid Volume Excess (Overload)

Excessive accumulation of fluid within interstitial spaces. Often problem in fluid distribution not fluid excess.

Edema

Produced in the hypothalamus and released from posterior pituitary. Increases water permeability in the distal tubule, collecting tubule, and collecting duct = water reabsorption (or decreased UOP). Without it leads to decreased water reabsorption and intravascular dehydration. Secreted in response to low intravascular volume. Osmoreceptors cause thirst sensation.

ADH/Vasopressin

Secreted by adrenal cortex. Primary sites of action in the principle cells of the late distal tubules and cortical collecting tubules. Stimulates Na-K ATPase pump (regulates sodium reabsorption and K secretion). Secretion regulated by ATCH, Angiotensin II, and increased serum K levels. Major hormone responsible for K homeostasis.

Aldosterone

Secreted in response to decreased blood volume. Constricts efferent arterioles to increase filtration rates and net tubular reabsorption. Directly stimulates Na reabsorption in the proximal tubules, loop of Henle, and distal tubules (stimulates Na/H+ exchange). Stimulates aldosterone release. Most powerful Na retaining hormone.

Angiotensin II

Produced by cells in the cardiac atria (ANP) and myoendocrine ventricular cells (BNP) when distended by increased intravascular volume. Inhibits Na and water reabsorption by the renal tubules, particularly the collecting ducts. Increases Na and water excretion in the urine. May contribute to cerebral salt wasting - produced by neurons in brain injury.

Natriuretic Peptide (ANP & BNP)

Cushing’s, increased Cortisol release, Conn’s Syndrome, increased Aldosterone, hypertonic solutions, corticosteroids, drinking too much water or loosing too much (Diabetes Insipidis, burns, etc)

Causes of Hypernatremia

FRIED: Fatigue, Restless and agitated, Increased reflexes (seizures/coma), Extreme thirst (BIG), Decreased urine, dry mucous membranes and skin.

Clinical Manifestations of Hypernatremia

Intravascular fluid compartment has ___ TBW (AKA blood plasma) and attributes to ___ and ____.

8%; blood pressure and vascular resistance

Interstital fluid compartment is ____ TBW (AKA fluid between cells, lymph, GI, spinal, eyes/synovial fluid) cause fluid shifts between ___ and ____ using the 4 Starking Forces.

25%; plasma and interstitial

Intracellular fluid compartment accounts for ___TBW (fluid inside the cell) and ___ shifts freely across PM through ____.

67%; water; aquaporins

Increased capillary hydrostatic pressure

Caused by venous obstruction, Na/H2O retention

Decreased capillary oncotic pressure

Caused by plasma albumin (liver disease or malnutrition)

Increased capillary permeability

Caused by inflammation and immune response

Lymphatic obstruction

Caused by Lymphatic channel blockage due to tumor or infection

Common reasons someone’s TBW would not be 60%

Obesity, women, elderly

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