The Cellular Environment: Fluids and Electrolytes, Acids and Bases

Chapter 3

Distribution of Body Fluids

Total body water (TBW) 60% of total body weight

Intracellular fluid inside the cells Extracellular fluid not encased in cells

Interstitial fluid found in between cells and tissues Intravascular fluid- plasma found in circulatory system Lymph, synovial, intestinal, biliary, hepatic, pancreatic, CSF, sweat, urine, pleural, peritoneal, pericardial, and intraocular fluids are extracellular
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Water Movement Between the ICF and ECF

Osmolality the concentrations of solutes in water Osmotic forces solutes will influence the movement of water across membranes Aquaporins- water channel proteins in membranes Starling hypothesis

Net filtration = forces favoring filtration forces opposing filtration As fluid flows through capillary it looses water and create greater osmotic return of water as it flows toward veinule end of capillary
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Water Movement Between the ICF and ECF

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Net Filtration

Forces favoring filtration

Capillary hydrostatic pressure (blood pressure) Interstitial oncotic pressure (water-pulling) Plasma oncotic pressure (water-pulling) Interstitial hydrostatic pressure

Forces favoring reabsorption

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Osmotic Equilibrium

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Edema

Accumulation of fluid within the interstitial spaces Causes:

Increase in hydrostatic pressure Losses or diminished production of plasma albumin Increases in capillary permeability Lymph obstruction elephantitus, flibitus
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Edema

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Water Balance

Thirst perception

Osmolality receptors in medula respond to osmotic pressue of ECF

Hyperosmolality and plasma volume depletion

ADH secretion from posterior pituitary conserves water in kidney to maintain water balance
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Sodium and Chloride Balance

Sodium

Primary ECF cation Regulates osmotic forces Roles

Neuromuscular irritability, acid-base balance, and cellular reactions

Chloride

Primary ECF anion Provides electroneutrality

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Sodium and Chloride Balance

Renin-angiotensin system substanced produced in both liver and kidney Angiotensin produced by liver and coverted by enzymes activated by renin from Kidney Juxta Glomerular Aparatus to a powerful vasoconstrictor.

Aldosterone hormone from adrenal gland to regulate Na and K Atrial natriuretic peptide - hormone from heart Brain natriuretic peptide hormone from brain Urodilantin (kidney) Kidney hormone

Natriuretic peptides

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Alterations in Na+, Cl, and Water Balance

Isotonic alterations

Total body water change with proportional electrolyte and water change Isotonic volume depletion Isotonic volume excess

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Hypertonic Alterations

Hypernatremia

Serum sodium >147 mEq/L Related to sodium gain or water loss Water movement from the ICF to the ECF

Intracellular dehydration Intracellular dehydration, convulsions, pulmonary edema, hypotension, tachycardia, etc.
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Manifestations

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Water Deficit

Dehydration Pure water deficits Renal free water clearance Manifestations

Tachycardia, weak pulses, and postural hypotension Elevated hematocrit and serum sodium level
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Hypochloremia

Occurs with hypernatremia or a bicarbonate deficit Usually secondary to pathophysiologic processes Managed by treating underlying disorders

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Hypotonic Alterations

Decreased osmolality Hyponatremia or free water excess Hyponatremia decreases the ECF osmotic pressure, and water moves into the cell Water movement causes symptoms related to hypovolemia
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Hyponatremia

Serum sodium level <135 mEq/L Sodium deficits cause plasma hypoosmolality and cellular swelling

Pure sodium deficits Low intake Dilutional hyponatremia Hypoosmolar hyponatremia Hypertonic hyponatremia
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Water Excess

Compulsive water drinking Decreased urine formation Syndrome of inappropriate ADH (SIADH)

ADH secretion in the absence of hypovolemia or hyperosmolality Hyponatremia with hypervolemia

Manifestations: cerebral edema, muscle twitching, headache, and weight gain

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Hypochloremia

Usually the result of hyponatremia or elevated bicarbonate concentration Develops due to vomiting and the loss of HCl Occurs in cystic fibrosis

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Potassium

Major intracellular cation Concentration maintained by the Na+/K+ pump Regulates intracellular electrical neutrality in relation to Na+ and H+ Essential for transmission and conduction of nerve impulses, normal cardiac rhythms, and skeletal and smooth muscle contraction
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Potassium Levels

Changes in pH affect K+ balance

Hydrogen ions accumulate in the ICF during states of acidosis. K+ shifts out to maintain a balance of cations across the membrane.

Aldosterone, insulin, and catecholamines influence serum potassium levels

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Hypokalemia

Potassium level <3.5 mEq/L Potassium balance is described by changes in plasma potassium levels Causes can be reduced intake of potassium, increased entry of potassium, and increased loss of potassium Manifestations

Membrane hyperpolarization causes a decrease in neuromuscular excitability, skeletal muscle weakness, smooth muscle atony, and cardiac dysrhythmias
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Hyperkalemia

Potassium level >5.5 mEq/L Hyperkalemia is rare due to efficient renal excretion Caused by increased intake, shift of K+ from ICF, decreased renal excretion, insulin deficiency, or cell trauma

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Hyperkalemia

Mild attacks

Hypopolarized membrane, causing neuromuscular irritability

Tingling of lips and fingers, restlessness, intestinal cramping, and diarrhea

Severe attacks

The cell is not able to repolarize, resulting in muscle weakness, loss or muscle tone, and flaccid paralysis
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Calcium

Most calcium is located in the bone as hydroxyapatite Necessary for structure of bones and teeth, blood clotting, hormone secretion, and cell receptor function

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Phosphate

Like calcium, most phosphate (85%) is also located in the bone Necessary for high-energy bonds located in creatine phosphate and ATP and acts as an anion buffer Calcium and phosphate concentrations are rigidly controlled

Ca++ x HPO4 = K+ (constant) If the concentration of one increases, that of the other decreases
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Calcium and Phosphate

Regulated by three hormones

Parathyroid hormone (PTH)

Increases plasma calcium levels Fat-soluble steroid; increases calcium absorption from the GI tract Decreases plasma calcium levels
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Vitamin D

Calcitonin

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Hypocalcemia and Hypercalcemia

Hypocalcemia

Hypercalcemia

Decreases the block of Na+ into the cell Increased neuromuscular excitability (partial depolarization) Muscle cramps

Increases the block of Na+ into the cell Decreased neuromuscular excitability Muscle weakness Increased bone fractures Kidney stones Constipation
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Hypophosphatemia and Hyperphosphatemia

Hypophosphatemia

Hyperphosphatemia

Osteomalacia (soft bones) Muscle weakness Bleeding disorders (platelet impairment) Anemia Leukocyte alterations Antacids bind phosphate

See Hypocalcemia High phosphate levels are related to the low calcium levels

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Magnesium

Intracellular cation Plasma concentration is 1.8 to 2.4 mEq/L Acts as a cofactor in protein and nucleic acid synthesis reactions Required for ATPase activity Decreases acetylcholine release at the neuromuscular junction
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Hypomagnesemia and Hypermagnesemia

Hypomagnesemia

Hypermagnesemia

Associated with hypocalcemia and hypokalemia Neuromuscular irritability Tetany Convulsions Hyperactive reflexes

Skeletal muscle depression Muscle weakness Hypotension Respiratory depression Lethargy, drowsiness Bradycardia

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pH

Inverse logarithm of the H+ concentration If the H+ are high in number, the pH is low (acidic). If the H+ are low in number, the pH is high (alkaline). The pH scale ranges from 0 to 14: 0 is very acidic, 14 is very alkaline. Each number represents a factor of 10. If a solution moves from a pH of 6 to a pH of 5, the H+ have increased 10 times.
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pH

Acids are formed as end products of protein, carbohydrate, and fat metabolism To maintain the bodys normal pH (7.35-7.45) the H+ must be neutralized or excreted The bones, lungs, and kidneys are the major organs involved in the regulation of acid and base balance
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pH

Body acids exist in two forms

Volatile

H2CO3 (can be eliminated as CO2 gas) Sulfuric, phosphoric, and other organic acids Eliminated by the renal tubules with the regulation of HCO3

Nonvolatile

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Buffering Systems

A buffer is a chemical that can bind excessive H+ or OH without a significant change in pH A buffering pair consists of a weak acid and its conjugate base The most important plasma buffering systems are the carbonic acidbicarbonate system and hemoglobin
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Carbonic AcidBicarbonate Pair

Operates in both the lung and the kidney The greater the partial pressure of carbon dioxide, the more carbonic acid is formed

At a pH of 7.4, the ratio of bicarbonate to carbonic acid is 20:1 Bicarbonate and carbonic acid can increase or decrease, but the ratio must be maintained

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Carbonic AcidBicarbonate Pair

If the amount of bicarbonate decreases, the pH decreases, causing a state of acidosis The pH can be returned to normal if the amount of carbonic acid also decreases

This type of pH adjustment is referred to as compensation

The respiratory system compensates by increasing or decreasing ventilation The renal system compensates by producing acidic or alkaline urine
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Carbonic AcidBicarbonate Pair

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Other Buffering Systems

Protein buffering
Proteins have negative charges, so they can serve as buffers for H+ Renal buffering Secretion of H+ in the urine and reabsorption of HCO3 Cellular ion exchange Exchange of K+ for H+ in acidosis and alkalosis

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Buffering Systems

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Acid-Base Imbalances

Normal arterial blood pH

7.35 to 7.45 Obtained by arterial blood gas (ABG) sampling Systemic increase in H+ concentration Systemic decrease in H+ concentration
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Acidosis

Alkalosis

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Acidosis and Alkalosis

Four categories of acid-base imbalances:

Respiratory acidosiselevation of pCO2 due to ventilation depression Respiratory alkalosisdepression of pCO2 due to alveolar hyperventilation Metabolic acidosisdepression of HCO3 or an increase in non-carbonic acids Metabolic alkalosiselevation of HCO3 usually due to an excessive loss of metabolic acids
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Metabolic Acidosis

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Anion Gap

Used cautiously to distinguish different types of metabolic acidosis By rule, the concentration of anions () should equal the concentration of cations (+). Not all normal anions are routinely measured. Normal anion gap = Na+ + K+ = Cl + HCO3 + 10 to 12 mEq/L
(other misc. anions [the ones we dont measure]phosphates, sulfates, organic acids, etc.)
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Anion Gap

An abnormal anion gap occurs due to an increased level of an abnormal unmeasured anion

Examples: DKAketones, salicylate poisoning, lactic acidosisincreased lactic acid, renal failure, etc.

As these abnormal anions accumulate, the measured anions have to decrease to maintain electroneutrality
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Metabolic Alkalosis

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Respiratory Acidosis

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Respiratory Alkalosis

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