Fluids, Electrolytes & Acid-base

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Balance
‫فـكرّية فـريح‬
‫ حـسين الحيـص‬.‫د‬
2-11-2008
8-11-2008
 General Medicine
2-11-008
Fluids, Electrolytes and Acid-base Balance
Fikria Freih

The fluids in the body or in the abdominal cavity are

distributed into intra cellular and extra cellular compartments,
The dominant electrolyte in the intra cellular
compartment is potassium (K+), while in the extra
cellular is sodium (Na+), usually we divide the fluids in the
abdominal cavity into the following sectors: gastric juice, bile,
and the fluids in the intestine.

List the normal range of the main electrolytes in serum:

* mol/L=mEq/L.

◘Sodium Na+: normal is about 135-145 mEq/L.

If 135 =hyponatremia. If 145= hypernatremia.

◘Potassium K+: The normal serum level of potassium is 3.5

to 4 mEq/L.
If 3.5 =hypokalemia. If 4.5= hyperkalemia.

◘Bicarbonate HCO3-: 22-31 mEq/L.

◘Chloride Cl -: 100-108 mmol/L.

Indicate how the electrolytes range in perspiration, gastric

juice, bile & intestine content:
Perspiration (sweating): is a mechanism to dissipate fluids
from the body. It participates in the control of
temperature .The center of temperature is in the
hypothalamus, this thermostat is set normally at 37
‫ء‬
.but during infection via the production of IL-2 the
thermostat is set at 38-39‫ء‬.

Fever is a type of energy, so some of this energy is transformed

to mechanical energy that appears as contraction of muscles in
general and mostly in the contraction of muscles around the
mouth. I.e. a patient with high fever, his body is trying to
eliminate the fever by perspiration. So in infection the
thermostat will change from 37 to 40. The human body tries to
regulate his thermostat to decrease the 40 to the normal. The
body tries to recompensate, if the body stays at high
temperature, the metabolism rate will be high.

We need to dissipate the high energy/fever; so the

body is trying to lose some of this energy by
inspiration and contraction of mouth muscles others
include rigor, chills, shivers and perspiration.

Gastric juice: is secreted from the stomach; this secretion

is around 1.5-2L containing chloride and other non-organic
factors like pepsin.
The small bowl: contains at least 8 L of fluids .Large bowl
contains less fluids; it contains the hard stools. Fluids in the
small bowl are subjected to excretion and absorption. Jejunum
is the main site of absorption, while in terminal ileum different
components are converted into triglycerides.

The bile: (from the GallBladder) around 800ml and what is

special for the bile is its enterohepatic circulation,
( entero=small bowl, hepatic =liver); The bile is secreted in the
liver ,stored in GB ,passes from GB to the duodenum ,goes to
the small bowl ,absorbed in the terminal ileum and part of the
colon then absorbed back to the liver again.

All These fluids stomach=1.5L, small bowl=8 L and bile =1L the
body benefits from them. It means these fluids are the
reservoir of fluids in the body.
List endogenous factors that affect renal control of Na+ and
water excretion:

The kidney is directed to excrete or retain sodium and water via

the action of aldosterone, antidiuretic hormone (ADH, or
vasopressin), atrial natriuretic peptide (ANP), and by Solvent
drag (It is when solvents in the ultrafiltrate are transported
back from the renal tubule by the flow of water rather than
specifically by membrane transport proteins).
The urine output is around 1-1.5L daily (human body loses 1.5L
of urine daily). A human should urinate ideally 50-60ml
urine/hour. Anybody should urinate more than 30ml /hour, if
less than 30 he definitely needs fluids.

The kidney filters the body to the outside, while the

liver is the filter from within the body.

Kidney is composed of nephron and the nephron is composed

of Bowman's capsule, proximal convoluted tubules, loop of
Henle, distal convoluted tubules and lastly the collecting
system. At each part there is exchange of electrolytes &
+
organic materials. E.g. the main site of K exchange is the
distal part of the distal convoluted tubules. All the electrolytes
are distributed, absorbed and excreted in a proper way in the
nephron.
Once renal failure occurs the kidney will be unable to excrete
toxic wastes to the outside so the patient starts to retain these
toxic electrolytes in a large amount e.g. accumulation of
Phosphorous and Calcium leads to itching.

List 6 symptoms or physical findings of dehydration:

Dehydration is caused by loss of normal fluids in the body. The

main cause is upper GI loss of fluids by vomiting, lower GI loss
by diarrhea, loss of fluids from intestine by abdominal trauma,
loss of fluids by fever or loss of fluids from the vascular
compartment (hemorrhage).

Dehydration is the chronic loss of fluids from the

body mainly by vomiting or diarrhea. The patient usually
starts to recompensate that by thirst. So the 1st sign of
dehydration is thirst ,2nd the patient will have all
the manifestations of cell dehydration; so he will be
tired, fatigued, hypotensive, having tachycardia, will have
sunken eyes and loss of subcutaneous fluids called loss of skin
turgor.

List & describe the objective ways of measuring fluid balance:

the best indicator for dehydration is the urine output; if you

would like to know if a patient is dehydrated or not look at the
patient’s urine if the urine is more than 50ml/hour this means
that the patient is not dehydrated, but if the urine is scanty
less than 30ml/hour this patient is dehydrated. Look
at the color of the urine if it is dark this means that this urine is
concentrated, contains ammonia and it means that this patient
is dehydrated so that patient needs fluids. The 1st and best
criterion is to measure the urine output.
If you go deep and ask about the electrolytes this will give
information about the level of dehydration (at cellular or extra
cellular level) and to know if this dehydration is hyponatremic
or hypernatremic.

The other criterion is the Blood Pressure. In case of fluid

loss the patient is expected to be hypotensive. This decrease in
BP is balanced by tachycardia.

The solutions available to be given to a dehydrated patient:

If there is loss of fluids, the best way is to

compensate for the same fluid component that is
lost.
Usually regarding pure fluid/water & electrolytes we have these
available solutions: (all these fluids are given IntraVenously)

 Normal (0.9%) saline: this is the ideal solution to be

given to a dehydrated patient. this saline is isotonic
compared to the fluids of the body (this saline and body fluids
are equivalent in tonicity; has the same solute
concentration).This 0.9% normal saline contains 154Na &
154K. In treatment usually start with normal saline but in
some situations like high BP, the normal saline can’t be given.
0.9% means that 0.9 of a Liter contains Na& K.
 ½ Normal saline: 1 L normal saline + 1 L Fluid (pure
water).
It contains 154/2=77 Na & K.

 Normal saline: 1 L normal saline + 2 L fluid (pure

water).

The previous 2 salines are used in pediatric age group and in

hypertensive patients.

 5% Dextrose in water: could be: 5%, 10% for diabetics,

20% or 30% for patient in need of glucose .5% means it
contains 5gm sugar /L.
There is also dextrose saline which is mixture of NaCl with
glucose. So we can mix these together; since there are daily
requirements of Na and K .e.g. the body needs 100 mEq of K
daily.

 Ringer’s lactate: a fluid containing lactate and Potassium,

it’s given in hypovolemic shock and burns. It contains 135 Na,
135 K &135 Cl.
So water + 0.9% NaCl = normal saline that is
isotonic to the fluids in the body. If we can’t give
NaCl because the patient is young or hypertensive
so divide the Na in the normal saline by water. Or
don’t give Na at all  dextrose water.
The daily requirements was calculated on a group of people
with low metabolic rate, it was found to be more than
60ml/hour (usually in adult 2400/24100ml/hour). So 60-
100ml is the daily requirements of the human body.

The amount of fluid given to the patient is equal to

the estimated fluid loss + daily requirements of that
patient.

In the following situations, indicate whether serum electrolytes

will remain stable, rise or fall:

 Excessive gastric loss: the stomach contains a high

mount of hydrochloric acid (HCl), so a patient with excessive
gastric loss, will have loss of hydrogen and loss of chloride ions.

 High volume pancreatic fistula: The pancreatic

secretion that is around 800ml /day will be lost, so this patient
will lose Na+, K+ and HCO3 _.

 Small intestinal fistula: The patient is losing fluids

causing a considerable fall in the electrolytes.

 Biliary fistula: Means that the bile goes from the body to
out, a considerable fall in the electrolytes.
*Fistula is an abnormal connection or passageway between two
organs that normally do not connect (an opening to outside the
body).
 Diarrhea: Loss of electrolytes with substantial loss of K+.
In the following situations, indicate whether serum electrolytes
will remain stable, rise or fall:

Acute tubular necrosis: The kidney tubules are necrotic.

The patient will lose the ability to excrete urine therefore the
fluids & electrolytes will accumulate within his body leading to
renal failure. A considerable rise in K+ at level of 8 mmol is
expected, leading to arrhythmia.
High K+ in the body leads to arrhythmia.

Dehydration: Causes Hypernatremia

Inappropriate ADH secretion (Anti Diuretic Hormone):

The patient will lose too much fluids by the kidney (3-4 L of
urine is lost daily) so hypernatremia results.

 Diabetes mellitus: Increase urination leads to decrease

Na and retention of K+ .so hyponatremia & hyperkalemia. Note
Diabetes insipidus causes the exact opposite.

Congestive Heart Failure: The patient tends to maintain

fluids in the subcutaneous tissue (peripheral edema),
hepatomegaly and pulmonary effusion (the accumulation of
fluids around the lungs).since this patient is having too much
fluids in an abnormal anatomical location we expect to find
hypernatremia.

Describe the possible causes, appropriate laboratory studies

needed and treatment of the following conditions:
Hypernatremia (Na above 145): The main cause is
dehydration. The clinical manifestations of hypernatremia are
(there is no fluids but Na+) thirst and fatigue.
Hyponatremia (Na at 125 becomes pathological): It occurs
in water intoxication; when a patient drinks a huge amount of
water or if you put the patient on IV fluid and you leave the
patient for 2-3 days ,he will have hyponatremia ,so the
hyponatremia is mainly by iatrogenic cause (caused
by the medical staff) while hypernatremia is a
pathological cause. Hyponatremia occurs with an increase
in body water. In the presence of excess water the level of
consciousness will deteriorate, the patient will get edema
everywhere even in the brain thus decreasing the level of
consciousness.

Hyperkalemia: Is caused by renal failure, once you have a

patient with renal failure ask about the potassium you’ll find it
high around 5.5- 6 you’ve to send him immediately to the
hospital, he may die from arrhythmia and cardiac arrest

Hypokalemia: The main cause is increased diuretic intake.

If K+ is found 2.8-3 send the patient immediately to the hospital
because he is having electrolyte disturbances and cardiac
problems.
Cardiac problems occur in hyper & hypokalemia. The
K+ interferes with the electrical activity of the heart.

 Hyperchloremia: Occurs in renal failure.

Hypochloremia: The main cause is vomiting.

Hyper and Hypochloremia is almost always

associated with other electrolyte abnormalities; like
K+ or mainly Na+ and the manifestations of abnormal Na+ are
the dominant scenario of hypochloremia .

Describe the concept of a “Third Space” & list conditions that

can cause fluid sequestration of this type:

Third space is a term applied to the accumulation of bodily

fluids in abnormal anatomical location which doesn’t participate
in the normal physiology of the body. Example: in case of
perforation of a viscous or presence of peritonitis.

 A patient with intestinal obstruction so the fluids will

accumulate in a segment of the intestine; this fluid in this
segment won’t be involved in the normal exchange of body
fluids (no excretion non absorption), this fluid is accumulated
/sequestrated.

 Once you have fluids outside the intestine in the free

abdominal cavity this is a third space (With pancreatitis,
fluids may leak out into the peritoneal cavity).
 With severe burns, the body losses the skin so the fluids
with proteins may pool in the burn site.

Third spacing is pathological, that body fluids may

collect in a "third" body compartment that isn't
normally filled with fluids.

What are the sequences of third space??

If the lost fluid is pure water  the patient will be dehydrated,
hypotensive, tachycardic and with dry skin.
If the lost fluid is blood the patient will be hypotensive.

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