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ICF
ECF
ISF
IVF
Fluid transfer:
- Capillary Starling balance (ECF): IVF - ISF
Capillary transfers
Edemas
hypoalbuminemic
hydrostatic
inflammatory
lymphatic = lymphedema
more fluid in
interstitium
RAAS stimulation
edema
hydrostatic edema
right sided heart failure
venous insufficiency (lower limbs)
venous thrombosis
portal hypertension
Ascites
portal hypertension
hypoalbuminemia
increased flow to the splanchnic vessels
exceeding the capacity of lymphatic
drainage
Inflammatory/allergic edema
increased vessel permeability
inflammatory or allergical mediators
dangerous larynx, intestine
Lymphedema
disturbance of lymphe drainage
nodulus blockage tumors, surgery,
filariosis
harder, sometimes bizarre
(elephantiasis)
VOLUME
- total
- intravascular circulation
Changes of IVF (i.e. fluid amount in blood and
vessel) are accompanied by important changes of
circulation CO, BP, HR, organ perfusion
OSMOLALITY
osmot. concentration in 1 kg of water (mOsm/kg
H2O)
OSMOLARITY
osmot. concentration in 1 L of solution (mOsm/l)
Osmosis
volume changes.
interstitium vessel
1 osmotic chages
2 oncotic pressure (proteins in plasma)
trancellular
fluid
cell
3
1
cell
ISF
cell
ISF
1 (hypotonic ISF)
ICF
ISF
ISF
IVF
(extravascular)
2 (decreased oncotic
plasmatic pressure)
plasma
Tests
OSMOLARITY
Transfers between ECF ICF
Measurement (osmometry)
Calculation (estimation of plasma osmolarity)
= 2 (Na+ + K+) + 5
or
= 2 Na+ + glucose + urea
Effective osmolarity
Part of osmolarity caused by non penetrating solutes (glucose,
sodium etc.) differently from solutes penetratign through
membrane, e.g. urea
Its differences cause changes of osmotic pressure:
-isotonicity
-hypertonicity
unofficial study material
-hypotonicity
HYPOVOLEMIA
?
osmotic changes
changes on
cellular level
thirst
ADH
volume/circulatory changes
venous return
water retention
preload
cardiac output
e.g. neurologic
changes
shock, collapse
activation of symp.nerves
vasoconstriction
tissue ischemia
kidney hypoperfusion
negative feedback
renin
angiotensin
aldosterone
unofficial study material
ANF
HYPOVOLEMIA
Isoosmotic hypovolemia
Loss of isoosmotic fluid
- blood loss
- burns
- 3rd space
- puncture of ascites
- postsurgery drainage
- diarrhea
- diuretics overdose
without changes in osmolarity no transfers of water between ICT and ECT
decrease of effective intravascular volume
circulation disturbances + compensatory mechanisms (RAAS)
urine highly concentrated with high sodium retention (concentration < 10
mmol/l)
increase of hematocrite
unofficial study material
Hyperosmotic hypovolemia
Pure water or hypoosmotic fluid losses
- vomitus, diarrhea
- sweating
- kidney disturbances
- diabetes insipidus
Decrease in pure water intake
osmotic fluid transfers, compensatory mechanisms are efficient:
volume (RAAS) + osmolarity (thirst, ADH)
dry mucosa, decrease in skin turgor, hematocrite not changed
unofficial study material
Hypoosmotic hypovolemia
Greater loss of solutes than water
- ofter from hyperosmotic hypovolemia (diarrhea, osmotic
diuresis) by drinking of pure water w/o electrolytes
- mineralocorticoid deficiency
- kidney disturbances
HYPERVOLEMIA
Two principle mechanisms
1. water transfer from vessels to the interstitium (IVF-ISF) with
the signalization of underfilling of vessels (decrease of effect.
vessel volume) and RAAS activation (increase of sodium + water
absorption)
secondary hyperaldosteronism
- congestive heart failure
- nephrotic syndrome
- liver cirrhosis and ascites
- hypoalbuminemia
2. primary kidney retention
unofficial study material
Isoosmotic hypervolemia
secondary hyperaldosteronism etc.
Hyperosmotic hypervolemia
sea water, primary hyperaldosteronism, kidney failure etc.
Hypoosmotic hypervolemia
SIADH
kidney failure
NATRIUM
plasma: 136-148 mmol/l
ICF: 12 mmol/l
total body content: 4000 mmol
functionally non penetrating solute induces water transfer across the
cell membrane
main function: extracellular fluid volume (ECF)
1 mmol of sodium (Na+) 3,6 mL of water
daily intake: 50-300 mmol
daily losses: urine 30-280 mmol
faeces 10 mmol
sweat 10 mmol
unofficial study material
Sodium losses
URINE
osmotic diuresis in chron. kidney failure
mineralocortikoids deficiency
GIT
diarrhea
vomiting
SWEATING
ASCITES
Sodium retention
high intake + usually in combination with the incapacity to
excrete sodium
hyperaldosteronism
- primary (Conn syndrome)
- secondary
unofficial study material
HYPERNATREMIA
Water deficit compared to sodium amount
Sodium stores
- decreased
- normal
- increased
* Mostly caused by loss of water
- loss of pure water (e.g. diabetes insipidus)
- loss of hypotonic fluid (e.g. osmotic diuresis,
vomiting, burns)
RENAL
U-(Na+) > 30 mmol/L
EXTRARENAL
U-(Na+) < 30 mmol/L
* Increased amount (delivery) of hypertonic fluids (often in
unofficial study material
therapy, primary hyperaldosteronism)
Intravascular fluid
hypertonic hypernatremia
with hypersmolality
sodium
potassium
unofficial study material
intravascular volume
HYPONATREMIA
* Hypotonic from dilution
Too much water in relation to sodium
Sodium stores
- Decreased
- normal
- increased
Volume of ECF can be
- normal,
- increased,
- decreased
unofficial study material
EC
IC
hypotonic hyponatremia
with hypoosmolality
hypotonic hyponatremia
w/o hypoosmolality
hypertonic hyponatremia
accumulation e.g.
glucose in EC
hypotonic hyponatremia
+ water retention
Sodium loss +
water retention
(diarrhea+pure water)
hypotonic hyponatremia
+ sodium retention
sodium
potassium
inperm.solute
Perm. Solut
POTASSIUM
plasma: 3,8-5,4 mmol/L
ICF: 120 mmol/L
Total body content: 3500-4000 mmol
Daily intake: 80 mmol (variable)
daily losses:
D. Cardiovascular
1. Orthostatic hypotension,
vasodilatation
2. Arrhytmias
3. ECG
a. flattened T waves
b. prominent U waves
c. ST depression
E. Renal
1. Metabolic alkalosis (intracellular
acidosis)
2. Polyuria, polydipsia
3. Decrease of GFR
4. Glucose intolerance
unofficial study material
K+mmol/l
8
7
6
H+
H+
K+
K+
3
D
2
1
A: Normal
6,9 7,0 7,1 7,2 7,3 7,4 7,5 7,6 7,7 7,8 pH
H+
H+
H+
H+
H+
H+
+
K
K+
K+
K+
K+
K+
B: Acidosis
exchange K+ for H+
C: Long
term
acidosis
unofficial
study
material
depletion of K+
Diagnostics: ECG
A. Early
1. Peaked T waves
B. Further
1. ST depression
2. AV block I. degree
3. QRS widening
C. Terminal
1. Biphasic QRS and fusion with T wave
2. Threat of cardiac arrest
D. Changes more pronounced in:
1. Hyponatremia
2. Hypokalcemia
3. Acidosis
unofficial study material
4. Hypermagnesemia
Hyperkalemia
ECG changes suggestive of an effect of hyperkalemia
on cardiac conduction include the following (in order of
appearance
Peaked T waves
Prolongation of the PR interval
Widening of the QRS (as seen in the image below)
Widened QRS complexes in a patient whose serum
potassium level was 7.8 mEq/L.
Loss of the P wave
Sine wave pattern
Sinus arrest
unofficial study material
eMedicine
eMedicine
eMedicine
Hyperkalemia
Kalium cca > 6 mmol/l: Tall peaked symmetrical
T waves in all leads, mainly visible in V2-4. The
QT interval is shorter.
Kalium cca 7 - 8 mmol/l: Prolongation of the PQ
interval, flattening of the P wave.
Kalium cca 8 - 10 mmol/l: QRS complex
deformities (widening), resulting in asystole or
more rarely in ventricular fibrillation.
Normalized ECG
Hyperkalemic ECG
K+ = 7.8. This ECG demonstrates peaked T waves, loss of
P wave amplitude and widening of the QRS complex. A
baseline waveform is provided for comparison.
Hyperkalemia
Written By: David Lane MD
Georgetown University Hospital and Washington Hospital Center
Washington, DC
Edited By: Dave Wald
Temple University School of Medicine
http://www.cdemcurriculum.org/ssm/endo/hyperkalemia/hyperkalemia.php Philadelphia, Pennsylvania
Hypokalemia
Kalium cca 3,0 3,8 mmol/l: Flattening or
inversion of T waves
Kalium cca 2,3 3,0 mmol/l: Q-T interval
prolongation (longer duration of the T wave),
visible U wave, mild ST depression (0,5 mm),
ventricular extrasystoles
Kalium cca < 2,3 mmol/l: torsades de pointes,
ventricular fibrillation.