Keseimbangan Cairan, Elektrolit dan Asam-Basa

Departemen Fisiologi Fakultas Kedokteran Universitas Sumatera Utara

Specific Learning Objectives:

1. Menjelaskan fungsi cairan tubuh. 2. Menjelaskan input dan output cairan. 3. Menjelaskan kompartemen cairan intrasel dan ekstrasel. 4. Menjelaskan komposisi elektrolit dan zat terlarut lain dalam kompartemen. 5. Menjelaskan osmolaritas & tekanan osmotik cairan tubuh. 6. Menjelaskan peran elektrolit dalam mempertahankan homeostasis pH cairan tubuh.

Body Water Content

Infants have low body fat, low bone mass, and are 73% or more water Total water content declines throughout life Healthy males are about 60% water; healthy females are around 50% This difference reflects females: Higher body fat Smaller amount of skeletal muscle In old age, only about 45% of body weight is water

Functions of Body Water

Regulating body temperature As protective cushion & lubricant As reactant As solvent As transporter

Water Homeostasis
The body maintains a balance of water intake and output by a series of negative feedback loop involving the endocrine system and autonomic nervous system

Water Balance and ECF Osmolality

To remain properly hydrated, water intake must equal water output Water intake sources Ingested fluid (60%) and solid food (30%) Metabolic water or water of oxidation (10%)

Water Balance and ECF Osmolality

Water output
Urine (60%) and feces (4%)

Insensible losses (28%), sweat (8%)

Increases in plasma osmolality trigger thirst and release of antidiuretic hormone (ADH)

Water Intake and Output

Daily WATER BALANCE

Water intake
DRINK 1500 ml/Day

Water excretion
Vaporization from lungs 400 ml/day Insensible perspiration 600 ml/day

In solid food 800 ml/day

BODY

In feces 100 ml/day

METABOLISM 294 ml/day

URINE 1500 ml/day

( Total 2600 ml ) approx

( Total 2600 ml )
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

We are
approximately

two-thirds water

 Water occupies two main fluid compartments Intracellular fluid (ICF) about two thirds by volume, contained in cells Extracellular fluid (ECF) consists of two major subdivisions Plasma the fluid portion of the blood Interstitial fluid (IF) fluid in spaces between cells

Fluid Compartments

Distribution/Compartment of Body Fluids

Total Body Water ( TBW) = 60% wt ( 70 kg -> 42 L 0 varies due to ?

Kidneys

Guts

Lungs

Skin

Fluid shifts / intakes

40% TBW
20% TBW

ECF (Internal environment)

Volume= 14 L, 1/3 TBW

Intracellular fluid Volume = 28 L, 2/3 TBW

Interstitial fluid
volume = 11 L 80% of ECF

IV (Plasma
Volume )= 3L 20% of ECF

TBW

Composition of Body Fluids

Water is the universal solvent Solutes are broadly classified into: Electrolytes inorganic salts, all acids and bases, and some proteins Nonelectrolytes examples include glucose, lipids, creatinine, and urea

Electrolyte Composition of Body Fluids

Figure 26.2

Ionic Composition of Body Fluids

Concentration Units are in mEq/L
(How many grams of electrolyte (solute) in a liter of plasma (solution)

Cations
140
110

Anions
More protein And more cations in plasma than Interstitial fluid

Extracellular Fluid

Na+
Ca2+ Mg2+

Cl

24 HCO3

Protein--

Intracellular Fluid

K+

140

Phosphate and Organic Anions

OSMOTIC PRESSURE
The tendency for movement of solvent molecules to a region of greater solute concentration can be prevented by applying pressure to the more concentrated solution. The pressure necessary to prevent solvent migration is the osmotic pressure of the solution.

 The osmolarity is the number of osmoles per liter of solutioneg, plasmawhereas the osmolality is the number of osmoles per kilogram of solvent. Therefore, osmolarity is affected by the volume of the various solutes in the solution and the temperature, while the osmolality is not.

TONICITY
Tonicity: a measure of the ability of a solution to cause a change in cell shape by promoting osmotic flow. The term tonicity is used to describe the osmolality of a solution relative to plasma. Solutions that have the same osmolality as plasma are said to be isotonic; those with greater osmolality are hypertonic; and those with lesser osmolality are hypotonic.

ICF 300 mOsm

Normal cell volume

Hypertonic Solution -----Shrinks cell

Isotonic Solution No change in cell volume

Hypotonic Solution Enlarges cell

Osmosis & IV fluids

Hypotonic IV solutions if too much water enters the cells eventually it could undergo hemolysis or break open Hypertonic IV solutions there is a net flow of water out of the cell and that cause the cell to shrink

Acid-Base Balance
Normal pH of body fluids Arterial blood is 7.4 Venous blood and interstitial fluid is 7.35 Intracellular fluid is 7.0 Alkalosis or alkalemia arterial blood pH rises above 7.45 Acidosis or acidemia arterial pH drops below 7.35 (physiological acidosis)

Sources of Hydrogen Ions

Most hydrogen ions originate from cellular metabolism Breakdown of phosphorus-containing proteins releases phosphoric acid into the ECF Anaerobic respiration of glucose produces lactic acid Fat metabolism yields organic acids and ketone bodies Transporting carbon dioxide as bicarbonate releases hydrogen ions

Hydrogen Ion Regulation

Concentration of hydrogen ions is regulated sequentially by: Chemical buffer systems act within seconds The respiratory center in the brain stem acts within 1-3 minutes Renal mechanisms require hours to days to effect pH changes

Chemical Buffer Systems

One or two molecules that act to resist pH changes when strong acid or base is added Three major chemical buffer systems Bicarbonate buffer system Phosphate buffer system Protein buffer system Any drifts in pH are resisted by the entire chemical buffering system

Physiological Buffer Systems

The respiratory system regulation of acid-base balance is a physiological buffering system There is a reversible equilibrium between: Dissolved carbon dioxide and water Carbonic acid and the hydrogen and bicarbonate ions CO2 + H2O H2CO3 H+ + HCO3

Renal Mechanisms of Acid-Base Balance

Chemical buffers can tie up excess acids or bases, but they cannot eliminate them from the body The lungs can eliminate carbonic acid by eliminating carbon dioxide Only the kidneys can rid the body of metabolic acids (phosphoric, uric, and lactic acids and ketones) and prevent metabolic acidosis The ultimate acid-base regulatory organs are the kidneys

Imbalances Result
From:
Illness Altered fluid intake Prolonged vomiting or diarrhea
Imbalances Affect:
Respiration Metabolism Function of Central Nervous System

Dehydration
Dehydration is loss of water and important blood salts like potassium (K+) and sodium (Na+).

CAUSES OF DEHYDRATION
GI losses Vomiting Diarrhea Malabsorption disorders

Internal loss - loss of fluids into various body

compartments, especially from intravascular into interstitial. Illness - peritonitis, pacreatitis, bowel obstruction Poor nutritional states

Increased insensible loss

Fever Hyperventilation High environmental temperatures

Plasma losses
Burns Surgical drains Fistulas (Abnormal tubelike passage from a normal cavity to another cavity or free standing surface). Open wounds

Increased sweating
Medical conditions High environmental temperatures

Types of dehydration
Dehydration is classified as mild, moderate, or severe based on the percentage of body weight lost during the acute illness:
Depending on age,

Mild dehydration -- a loss of 3-5% of body weight Moderate dehydration -- a loss of 6-10% of body weight

Severe dehydration -- a loss of more than 9-15% of body

weight

. This is a life-threatening emergency ! ! !

Signs of Dehydration.
Mild
Thirst Dry lips Slightly dry mouth membranes

Moderate
Very dry mouth membranes Sunken eyes Sunken fontanelle (soft spot) on infants head. Skin doesnt bounce back quickly when lightly pinched and released (poor skin turgor)

Severe
All signs of moderate dehydration Rapid, weak pulse (> 100 at rest). Cold hands and feet Rapid breathing Blue lips Confusion, lethargy, difficult to arouse hypotension

Treatment
Treat the cause of the dehydration.!!!
Mild dehydration.

Drinking fluids is often sufficient

Moderate to Severe dehydration.

Intravenous fluids and hospitalization may be necessary

 30 ml / kg B.W.

Daily of water

70 kg adult 2000ml/day

and electrolyte
requirements
Fever water needs 15% for each 1C rise in the patient's temperature

 Na, 100 mEq( 5,9 g NaCl) K, 60 mEq daily ( 4,5 g KCl)

Daily of water

and electrolyte
requirements

Fever or sweating
water needed 500 to 2000 ml (if the patient's temperature is > 38.3C or room temperature is > 32C( 101F) More 4 mEq K , will be needed
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

a water loss of 4000 ml is

Volume of Fluid Needed

present.How much the patient needs

?
The patient needs not only the 4000 ml

but

There are several methods of calculating the volume of water water losses due to insensible needed to treat water loss. perspiration, urinary output,

an additional 1500 ml or more water daily to cover the daily

and other causes.

Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Volume of Fluid Needed

If thirst is present, but other clinical signs are minimal, assume that the water deficit is about 2% of the body weight. In a 70 kg patient, the water deficit 1400 ml. If the patient has gone 3 to 4 days without water, and if there is marked thirst, a dry mouth and oliguria, the water deficit is approximately 6% of the b. w. In a 70 kg patient, the water deficit 4200 ml. The above signs are present. In addition, if there are marked physical weakness and severe mental changes, such as confusion or delirium, the water deficit is 7 to 14% of the body weight. In a 70 kg patient, the water deficit 5 to 10 liters.

Method 1.
A simple way to calculate the water deficit is the following :

Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Method 2.
If the patient has been weighed daily, and it is known, for example, that he has lost 4 kg weight during an acute period of

desiccation, the water deficit

is

approximately 4000 ml, or 4 liters.

Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Method 3. based on the fact that the plasma sodium concentration varies inversely with the volume of extracellular water. It assumes, however, that only water has been lost and the sodium content of the body has remained unchanged.

The formula is : Na2 X BW2 = Na1 X BW1

Na2 presents the present serum sodium concentration. BW2 represents the present body water volume. Na1 represents the original, or normal, serum sodium concentration of 142 mEq/L. BW1 represents the original volume of body water. This is 60% of the body weight of a man (50 % in a woman). The loss of body water therefore equals BW1 BW2.
Adapted from Goldberger, Water, Electrolyte, Acid base balance.

Method 3.
based on the fact that the plasma sodium concentration varies inversely with the volume of extracellular water. It assumes, however, that only water has been lost and the sodium content of the body has remained unchanged.

Example : Man, weighing approximately 70 kg. Present serum sodium concentration, 162 mEq/L Na2 X BW2 = Na1 X BW1 162 x X = 142 X 42 X = 142 X 42 = 37 liters. 162

The water loss is therefore 42 37 = 5 liters.

Adapted from Goldberger, Water, Electrolyte, Acid base balance.

How Does a Clinician Determine ECF and ICF Volumes in a Patient?

ECF volume : CLINICAL EXAM
Plasma volume: jugular venous pressure central venous pressure (with a catheter) examine chest for pulmonary edema (or Xray) postural hypotension - not specific Interstitial volume edema

How Does a Clinician Determine ECF and ICF Volumes in a Patient?

Intracellular Volume Serum sodium concentration and serum osmolality
Hyponatremia and hyposmolality = ICFV Hypernatremia = ICFV

What are the expected losses ?

Measurable:
urine ( measure hourly if necessary ) GI ( stool, stoma, drains, tubes )

Insensible:
sweat exhaled

ICF 300 mOsm

Normal cell volume

Hypertonic Solution -----Shrinks cell

Isotonic Solution No change in cell volume

Hypotonic Solution Enlarges cell