Dynamics of Body Fluids Movement

Endang Melati Maas

Department of Anesthesiologist and Reanimation

Faculty of Medicine Sriwijaya University Dr. Muhammad Hoesin General Hospital

Introduction
Fluid management, is a key factor for the survival of patients who have severe, acute hypovolemia. Volume replacement and restoration of capillary perfusion are essential for reversal of the ischemic changes that can lead to multiple organ failure and death.

 Anemia may tolerated better than hypo-volemia. EBM Not enough data to choose what type of fluids should be given.

understanding of physiology, pathophysiology of

body fluids and pharmacology of available intravenous fluid is very important.

Fluids Physiology

Fluids physiology (cont)

Total body water: (60% TBW) Intracellular Fluid / ICF (40%)

Extracellular Fluid / ECF (20%)

Plasma (5%)

Interstitial Fluid / ISF (15%).

Formulae for Blood Volume Blood Volume = Plasma volume x (100/100-Hct) Blood Volume = Red cell vol x (100/Hct) (where Hct = Haematocrit)

Plasma
5% TBW

Interstitial
15% TBW

Intracellular
40% TBW

Capillary membrane

endothel

Blood cell

Fig. Body fluids compartment

Intracellular Fluid
ICF >< ECF cell membrane that is highly permeable to water but not to most electrolytes. volume is maintained by sodium-potassium pump. the membrane

there are significant differences in the electrolytic composition of intracellular and extracellular fluid.

Extracellular Fluid
IVF >< ISF by capillary membrane.

Highly permeable to almost all solutes in the extracellular fluid except the proteins.

The ionic composition of plasma and interstitial fluid are similar but the plasma contains a higher concentration of protein.

Definition
Molarity:
is the number of moles of solute per litre of solution. Molecular weight of the substance expressed in grams. The MW of NaCl is about 58 so 58g of NaCl = 1 mole. If water added to a volume of 1l then the result will be a 1 molar solution (1 Mol/l).

Molality:
is the number of moles of solute per kg of solvent.

Osmole
the weight in grams of a substance producing an osmotic pressure of 22.4 atm. when dissolved in 1.0 litre of solution.

Definition (cont)
Osmolarity:
a measure of the osmotic pressure exerted by a solution across a semi-permeable membrane.
is the number of osmoles of solute per litre of solution.

Osmolality:
is the number of osmoles of solute per kilogram of solvent.

1 M Glucose + 1 M Sucrose 1 M NaCl

1 M Glucose 1 M Sucrose

water 1 L

1 M Na+

1 M Cl-

osmolarity 2 osm/l

osmolarity 2 osm/l

Definition (cont)
Colloids:
the large molecular weight (nominally MW > 30,000) particles present in a solution. In normal plasma, the plasma proteins are the major colloids present.

Colloids
contain large, oncotically active molecules.
natural products (eg, albumin, FFP)
Semisynthetic (gelatine, starches or dextrans).

more impermeable to intact capillary membranes than crystalloids.

smaller volumes of colloids than crystalloids are required for fluid resuscitation.

Movement of Body Fluid

Diffusion
Particles move from an area of high concentration to an area of low concentration until concentrations are equalized.
Simple diffusion
Substance small enough to pass through the protein pores ( ie urea, 02, carbon dioxide).

Facilitated diffusion
Substance moves by means of a carrier substance Large lipid-insoluble substance such as glucose must diffuse into the cell via a carrier substance.

Movement of Body Fluid (cont)

Osmosis

Movement of water across semipermeable membrane from area of lower solute concentration to an area of higher solute concentration until concentrations are equalized on both sided of the membrane.
Osmosis important in maintaining proper balance in volume of ECF and ICF.

Major force in body fluid movement and IV fluid therapy.

Movement of Body Fluid (cont)

Active Transport
Substances move across cell membrane from less concentrated solution to more concentrated one. Differs from diffusion and osmosis in that metabolic energy is used. Depends on availability of carrier substances usually enzyme.

Many important solutes are transported actively across cell membranes, including Na, K, H, glucose, and amino acids.

Movement of Body Fluid (cont)

Starling's Forces
this equation predicts the net flux of fluids across a membrane,
Jv = Kf.[(Pc-Pi) - s(pc-pi)]

where,
Jv = net water flux Kf = the filtration coefficient Pci = hydrostatic pressures pci = oncotic pressures s = Staverman reflection coefficient the Staverman reflection coefficient is a measure of capillary permeability to protein, s = 1 completely impermeable.

Starlings Hypothesis (1896) (cont)

fluid movement due to filtration across the wall of a capillary is dependent on the balance between the hydrostatic pressure gradient and the oncotic pressure gradient across the capillary.
NB: Starling's equation predicts the net movement of fluid across the capillary, it does not predict what happens to ISF volume

Starlings Hypothesis (1896) (cont)

Typical values of Starling Forces in Systemic Capillaries (mmHg)

Arteriolar end of capillary Capillary hydrostatic pressure Interstitial hydrostatic pressure Capillary oncotic pressure Interstitial oncotic pressure 25 -6

Venous end of capillary 10 -6

25
5

25
5

Movement of Body Fluid (cont)

Gibbs-Donnan Equilibrium:
"in the presence of a non-diffusible ion, the diffusible ion species distribute themselves such that at equilibrium their concentration ratios are equal. The sums of positive and negative charges on each side of the membrane must be equal, and the products of diffusible ions on each side must also be equal.

Gibbs-Donnan Equilibrium (cont)

Donnan effect dictates that,
[Na+]A.[Cl-]A = [Na+]B.[Cl-]B [Na+]A / [Na+]B = [Cl-]B / [Cl-]A

but to maintain electroneutrality,

[Na+]B = [Cl-]B Therefore,

[Na+]A > [Cl-]A

Side A Na+ ClSide B Na+ Cl-

Prot-

Fluid Pressures
Osmotic Pressure
Is the pressure required to prevent the movement of water from a dilute solution to concentrated solution across a semipermeable membrane.

Colloid Osmotic Pressure (COP)

Osmotic pressure due to colloid activity in the solvent.

= Oncotic pressure.

Fluid Pressures (cont)

Hydrostatic Pressure:
Pushing force of fluid against walls of the space, ex. Heart pumps blood which exerts pressure on the blood vessel wall.
= Filtration pressure (sometimes).

Tonicity:
Is the effective osmolality

Is equal to the sum of the concentrations of the solutes which have the capacity to exerts an osmotic force across the membrane.

Fluid Pressures (cont)

Serum osmolarity:
concentration of particles (major particles are sodium and protein) in the plasma. normal serum osmolarity 275-295 mOsm/L

Hypertonic Isotonic Hypotonic

> 275-295
mOsm/L

>

Chemical regulation of fluid balance

Antidiuretic hormone (ADH)
hormone synthesized by hypothalamus and secreted by posterior pituitary, which regulates water.

Aldosterone
Hormone produced by adrenal gland that conserves sodium in body by causing kidneys to retain sodium and excrete potassium in its place.

Glucocorticoids (cortisol)
Produced and released by adrenal gland when body stressed Promote renal retention of sodium and water.

Chemical regulation of fluid balance (cont)

Atrial natriuretic peptide (ANP)
Cardiac hormone found in atria of heart that is released when atria are stretched by high blood volume or high BP
Causes vasodilatation by direct effect on blood vessels and suppression of renin-angiotensin system Decreases aldosterone release by adrenal glands, causing increased urinary excretion of sodium and water Decreases ADH release by pituitary gland, causing increased urinary excretion of water Increases glomerular filtration rate, increasing rate or urine production and water excretion.

Chemical regulation of fluid balance (cont)

Thirst Mechanism
osmolarity TBW + Hypothalamic osmoreceptor + ADH release +

Thirst

Water retention

Volumes of Distribution
The plasma volume expansion effect is directly related to the volume of distribution. PVE (% of infused volume) = Plasma Volume

volume of distribution
Ex.:

NaCl 0.9% PVE 20%

Glucose 5% PVE 6.7%

Isotonic

Ringer acetate Ringer lactate NaCl 0.9%

ECF

ICF

ISF

Plasma

Hypotonic

D5W N4 NaCl 0.45%

ICF > ECF

+ Hyponatremia

ICF

ISF

Plasma

+ hyperglicemia

40

15

colloids

Plasma

ICF

ISF

Plasma

hyperoncotic

Properties of colloids
Magnitude and duration of plasma volume expansion.
The number, MW and the COP determine the initial degree of volume expansion.

Hemorrheological effects.
Blood viscosity, which is the tendency of fluids to resist flow, depends largely on hematocrit, red cell characteristics, and blood protein concentration.

 Hemostatic effects.
All the semisynthetic colloids have specific effects on hemostasis in addition to simple dilution of clotting factors.

Interaction with inflammatory cells.

Hydroxyethyl starch and dextran solutions interact with both endothelial and inflammatory cells.

 Adverse drug reactions.

Both naturally occurring and semisynthetic colloids are associated with a small but significant incidence of anaphylactic and anaphylactoid reactions. Histamine release is a predictable response to gelatin infusions and appears to be related to the anaphylactoid reactions that occur.

Conclusion
Movement of body fluids: Diffusion Osmosis Active transport Starlings forces Gibbs Donnan equilibrium. The plasma volume expansion effect of IV fluids is directly related to the volume of distribution.

Conclusion (cont)
the choice of fluid type in a variety of clinical situations can now be rationally guided by an understanding of physiology and pathophysiology of Body fluids and the physicochemical and biological properties of the various crystalloid and colloid solutions available.