Body Fluid
And
Electrolyte
Balance
Why women have less water
than men if they are the same
weight ?
The water content of adipose (fat)
tissue is less than that of muscle,
while women have more adipose
tissue at the effect of feminine
hormone
FLUID COMPARTMENTS
◼ An adult male is 60% water ; a female,
having more fat, is 55% water; newborn
infants are 75% water.
◼ The most important compartments are the
intracellular fluid (ICF) - 55% of body water -
and the extracellular fluid (ECF) - 45%.
◼ Extracellular fluid is further subdivided into
the plasma (part of the intravascular space),
the interstitial (Latin inter = between + sistere
= to stand; the fluid between the cells) fluid,
the transcellular water (e.g. fluid in the
gastrointestinal tract, the cerebrospinal fluid
(CSF) and aqueous humour).
Intracellular fluid (ICF)
◼ is two-thirds of TBW.
◼ The major cations of ICF are K+ and
Mg2+.
◼ The major anions of ICF are protein and
organic phosphates [adenosine
triphosphate
◼ (ATP), adenosine diphosphate (ADP),
and adenosine monophosphate (AMP)].
Extracellular fluid (ECF)
◼ is one-third of TBW.
◼ is composed of interstitial fluid and
plasma.
◼ The major cation of ECF is Na+.
◼ The major anions of ECF are Cl– and
HCO3–.
NORMAL WATER AND ELECTROLYTE BALANCE
◼ The precise water requirements of a
particular patient depend on size, age
and temperature.
◼ Surface area is the most accurate guide,
but it is more practical to use weight,
giving adults 30-40 ml / kg.
◼ Children require relatively more water
than adults.
Fluid losses occur by four routes
◼ Lungs. About 400 mL of water is lost in
expired air each 24 hours.
◼ Skin. In a temperate climate, skin (i.e.
sweat) losses are between 600 and 1000
mL/day.
◼ Faeces. Between 60 and 150 mL of water
are lost daily in patients with normal
bowel function.
◼ Urine. The normal urine output is
approximately 1500 mL/day
The following are the approximate daily
requirements of some electrolytes in
adults:
◼ Sodium: 50–90 mM/day;
◼ Potassium: 50 mM/day;
◼ Calcium: 5 mM/day;
◼ Magnesium: 1 mM/day.
◼ The average requirements of sodium and
potassium are 1 mmol / kg / day of each.
PRESCRIBING FLUID REGIMENS
◼ When prescribing fluids, remember : Basal
requirements , Pre-existing dehydration and
electrolyte loss , Continuing abnormal losses
over and above basal requirements.
◼ A careful assessment of the patient including
pulse, blood pressure and central venous
pressure, if available. Clinical examination to
assess hydration status (peripheries, skin turgor,
urine output and specific gravity of urine), urine
and serum electrolytes and haematocrit.
◼ Estimation of losses already incurred and their
nature: for example, vomiting, ileus, diarrhoea,
excessive sweating or fluid losses from burns or
other serious inflammatory conditions.
◼ Estimation of supplemental fluids likely to be
required in view of anticipated future losses
from drains, fistulae, nasogastric tubes or
abnormal urine or faecal losses.
◼ When an estimate of the volumes required has
been made, the appropriate replacement fluid
can be determined from a consideration of the
electrolyte composition of gastrointestinal
secretions.
Hypokalaemia in surgical patient
❑ Hypokalaemia means plasma potassium
level below 3.5 mEq/L [Normal 3.5 to 5].
◼ Chronic hypokalaemia
◼ Acute hypokalaemia
Chronic hypokalaemia
◼ GIT causes :
1. Vomiting
2. Nasogastric suction (commonly seen in
post operative patient)
3. Diarrhoea in ulcerative colitis and villus
adenomas of rectum where secreting
excessive mucus with loss of potassium.
4. Laxative abuse (inducing diarrhea)
5. External fistula of gut e.g. duodenal
fistula, ileostomy, etc.
◼ Renal cause of hypokalaemia:
1. Prolonged use of diuretics (loop diuretics such as
frusemide, thiazide diuretics)
2. Primary hyperaldosteronism (Conn‘s syndrome)
3. Secondary hyperaldosteronism (congestive heart
failure, cirrhosis of liver, nephritic syndrome, etc.)
4. Cushing‘s syndrome and steroid therapy
5. Renal diseases, such as acute renal tubular acidosis.
6. Trauma as produced by surgery results in loss of
potassium 50 mEq/day for 1st 2 days post
operatively through the kidneys.
Acute hypokalaemia
1. Diabetic coma treated with insulin.
2. Prolonged infusion of normal saline solution.
3. Hyperventilation during anaesthesia
◼ Clinical features:
1. Most of the cases, patient is asymptomatic.
2. Hypokalaemia produces it‘s adverse effects on-
◼ Heart- cardiac arrhythmia
◼ GIT- paralytic ileus, abdominal distension
◼ Neuromuscular function- Rapid shallow and
gasping respiration due to weakness of
respiratory muscles, slurred speech.
◼ Kidney- Hypokalaemic nephropathy-
Polyuria.
Investigations
◼ Estimation of serum potassium → ↓K+
◼ ECG change in hypokalaemia:
a. Prolongation of P-R and Q-T interval
b. Depression of ST-segment
c. Fat-T waves
d. Prominent- U waves.
Treatment
◼ Principles: Treatment of cause, Potassium
supplementation.
◼ If the patient is able to eat-
1. Diet- Milk, meat extract, fruit juice, etc.
2. Tab. Potassium chloride (KCl): 2 gm 6 hourly
(Why chloride? → because usually
hypokalaemia is associated with
hypochloraemic alkalosis). Intravenous
potassium chloride- 40 mmol/L of 5% DA or
5% DNS or normal saline 6-8 hourly slowly.
◼ Potassium preparation- 20 mmol in 10 ml
containing on e ampoule
◼ Potassium should never be injected in bolus dose
because there is chance of hyperkalaemia if
potassium is given in an anuric patient. So before
giving potassium adequate urine output should be
mandatory.
◼ SAFE RULE (Rule of 40)
➢Not more than 40 mmol in 1 litre
➢Not faster than 40 mmol/ hour
➢Urine output should be at least 40 ml/hour.
K+ deficit =
(normal K+ level – Patient‘s K+) x Kg x 0.2
Hyponatraemia
Hyponatraemia means plasma sodium level below 135
mEq/L. [Normal sodium level: 135-145 mEq/L].
Causes of Hyponatraemia
◼ GIT- causes
1. Small gut obstruction with vomiting of GIT
secretion
2. N-G suction
3. Diarrhoea due to ulcerative colitis,
pseudomembranous colitis, cholera, etc.
4. External fistulas- Duodenal, pancreatico-biliary
fistula. Ileostomy.
◼Renal causes
1. Prolonged diuretic therapy such as thiazide
diuretic
2. Addison‘s disease (Adrenal insufficiency)
3. CRF (Chronic renal failure)
4. Diuretic phase of ARF
❑ Skin loss – Third degree burn.
◼ Hyponatraemia with increased intravascular
fluid (Dilutional hyponatraemia)
1. Congestive heart failure
2. Cirrhosis of liver
3. Nephrotic syndrome
4. SIADH
5. Excessive sodium free IV fluid e.g. 5%
Dextrose.
◼ Clinical presentation:
1. Features of dehydration-
a. Sunken eye
b. Dry and dotted tongue
c. Loss or reduced skin elasticity
d. Anterior fontanelle depressed ( in child /infant)
2. Reduced blood pressure
3. Reduced urine output
4. Patient is weak, lethargic
5. Confused and drowsy
6. Seizures (in severe cases).
Investigations
1. Haematocrit (PCV) is typically increased –
reflecting reduction of intravascular fluid
volume without concomitant loss of
erythrocytes.
2. Reduced plasma Na+ concentration.
Calculation and administration of Na+
◼ Na Deficit= (140- Plasma sodium) x total body
water
◼ Total body water = (total body weight in kg) x 60%
◼ 80 kg adult, plasma Na = 120 mEq/L.
Total body water 60% of
80kg=80x60/100=80x0.6=48 L]
(140-120) x total body water = 20x (80x0.6) =20x48
=960 mEq
◼ Administration of calculated sodium deficit in
isotonic normal saline.
◼ When symptomatic hyponatraemia (seizers) then
administration of hypertonic saline IV slowly.
◼ Despite of calculation of deficit, use of hypertonic
saline is usually reserved for symptomatic
hyponatraemia when sodium concentration is
below 110 mEq/L.
Hypocalcaemia
◼ Hypocalcaemia means plasma calcium level below
4.5 mEq/L [Normal level: 4.5 to 5.5 mEq/L].
Common causes of hypocalcaemia:
1. Hypoparathyroidism, particularly after thyroid surgery
2. Hypomagnesaemia (malnutrition sepsis, Aminoglycosides)
3. Severe pancreatitis
4. Acute and chronic renal failure
5. Severe trauma, crush injury
6. Hyperventilation induced respiratory alkalosis → Plasma
protein bind with ionized calcium, instead of H+ → ↓↓Ca+
→ Hypocalcaemia.
Clinical presentation
1. Neuromuscular junction:
a. Acute hypocalcaemia (below 3.5 mEq/L) can
produce skeletal muscle spasm or tetany. Tetany
is manifested by laryngospasm, carpopedal
spasm.
b. On examination- Hyperactive deep tendon
reflex, Chvostek sign.
2. CNS : Numbness, circumoral paraesthesia can
progress to confusion and occasionally seizures.
3. Heart : Hypotension with nonspecific prolonged
Q-T intervals.
Investigation
1. Estimation of serum calcium level
2. ECG: Prolonged Q-T interval.
Treatment
1. Correction of co-existing respiratory or metabolic
alkalosis.
2. In case of symptomatic hypocalcaemia (Tetany),
Hypotension when plasma calcium below 3.5
mEq/L → infusion IV 10 ml 10% calcium chloride
or calcium gluconate is given. Calcium should be
repeated until plasma calcium level is 4 mEq/L or
ECG becomes normal.
3. In case of asymptomatic/chronic hypocalcaemia
oral Vit-D, oral calcium supplementation.
Aluminium hydroxide gel.
