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Antidiuretic Hormone ADH PowerPoint PPT Presentation


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H 2 O. ADH. Antidiuretic Hormone ADH. Collecting Duct. Hypertonic Interstitial Fluid. Urine. Calcitonin. Calcium. Estrogen. Calcium. Parathormone. Calcium. Blood pH = 7.4 (7.35-7.45). Blood pH regulated by 1. Kidneys 2. Lungs 3. Buffers in blood.

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Antidiuretic Hormone ADH

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Antidiuretic hormone adh l.jpg

H2O

ADH

Antidiuretic HormoneADH

Collecting Duct

Hypertonic Interstitial Fluid

Urine


Calcitonin l.jpg

Calcitonin

Calcium


Estrogen l.jpg

Estrogen

Calcium


Parathormone l.jpg

Parathormone

Calcium


Blood ph 7 4 7 35 7 45 l.jpg

Blood pH = 7.4(7.35-7.45)

Blood pH regulated by

1. Kidneys

2. Lungs

3. Buffers in blood


H secreted hco 3 resorbed l.jpg

H+ Secreted HCO3- Resorbed

Blood

H+

Kidney Nephron

Urine

HCO3-


Kidneys regulate ph l.jpg

Kidneys Regulate pH

  • Excreting excess hydrogen ions, retain bicarbonate

    • if pH is too low

  • Retaining hydrogen ions, excrete bicarbonate

    • if pH is too high


Lungs regulate ph l.jpg

Lungs Regulate pH

  • Breathe faster to get rid of excess carbon dioxide if pH is too low

    • Carbon dioxide forms carbonic acid in the blood

  • Breathe slower to retain carbon dioxide if pH is too high


Carbon dioxide and acid l.jpg

Carbonic Acid

Carbon Dioxide and Acid

CO2 + H2O H2CO3H++ HCO3-


More carbon dioxide more acid lower ph l.jpg

More Carbon Dioxide = More Acid = Lower pH

  • Breathing slower will retain CO2 , pH will

    • decrease (more acid)

  • Breathing faster will eliminate more CO2 pH will

    • increase (less acid)


Blood ph drops to 7 3 how does the body compensate l.jpg

Blood pH Drops to 7.3How does the body compensate?

  • Breathe faster to get rid of carbon dioxide

    • eliminates acid


Blood ph increases to 7 45 how does the body compensate l.jpg

Blood pH Increases to 7.45How does the body compensate?

  • Breathe slower to retain more carbon dioxide

    • retains more acid


The role of adh l.jpg

PG

The role of ADH:

  • ADH = urinary concentration

  • ADH = secreted in response to ⇑ osmolality;

    = secreted in response to ⇓ vol;

  • ADH acts on DCT / CD to reabsorb water

  • Acts via V2 receptors & aquaporin 2

  • Acts only on WATER


Calculation of osmolality l.jpg

PG

Calculation of osmolality

  • Difficult: measure & add all active osmoles

  • Easy = [ sodium x 2 ] + urea + glucose

  • Normal = 280 - 290 mosm / kg


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PG

Fluid shifts in disease

  • Fluid loss:

    • GI: diarrhoea, vomiting, etc.

    • Renal: diuresis

    • Vascular: haemorrhage

    • Skin: burns,sweat

  • Fluid gain:

    • Iatrogenic:

    • Heart / liver / kidney failure:


Prescribing fluids l.jpg

PG

Prescribing fluids:

  • Crystalloids:

    • 0.9% saline - not “normal” !

    • 5% dextrose

    • 0.18% saline + 0.45% dextrose

    • Others

  • Colloids:

    • Blood

    • Plasma / albumin

    • Synthetics eg gelofusion


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PG

The rules of fluid replacement:

  • Replace blood with blood

  • Replace plasma with colloid

  • Resuscitate with crystalloid or colloid

  • Replace ECF depletion with saline

  • Rehydrate with dextrose


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PG

How much fluid to give ?

  • What is your starting point ?

    • Euvolaemia ?( normal )

    • Hypovolaemia ?( dry )

    • Hypervolaemia ? ( wet )

  • What are the expected losses ?

  • What are the expected gains ?


Signs of hypo hypervolaemia l.jpg

PG

Signs of hypo / hypervolaemia:

Signs of …

Volume depletionVolume overload

Postural hypotension Hypertension

Tachycardia Tachycardia

Absence of JVP @ 45o Raised JVP / gallop rhythm

Decreased skin turgor Oedema

Dry mucosae Pleural effusions

Supine hypotension Pulmonary oedema

Oliguria Ascites

Organ failure Organ failure


What are the expected losses l.jpg

PG

What are the expected losses ?

  • Measurable:

    • urine ( measure hourly if necessary )

    • GI ( stool, stoma, drains, tubes )

  • Insensible:

    • sweat

    • exhaled


Slide21 l.jpg

  • Electrolyte (Na+, K+, Ca++) Steady State

  • Amount Ingested = Amount Excreted.

  • Normal entry: Mainly ingestion in food.

  • Clinical entry: Can include parenteral administration.


Case 1 l.jpg

PG

Case 1:

  • A 62 year old man is 2 days post-colectomy. He is euvolaemic, and is allowed to drink 500ml. His urine output is 63 ml/hour:

    1. How much IV fluid does he need today ?

    2. What type of IV fluid does he need ?


Case 2 l.jpg

PG

Case 2:

  • 3 days after her admission, a 43 year old woman with diabetic ketoacidosis has a blood pressure of 88/46 mmHg & pulse of 110 bpm. Her charts show that her urine output over the last 3 days was 26.5 litres, whilst her total intake was 18 litres:

    1. How much fluid does she need to regain a normal BP ?

    2. What fluids would you use ?


Case 3 l.jpg

PG

Case 3:

  • An 85 year old man receives IV fluids for 3 days following a stroke; he is not allowed to eat. He has ankle oedema and a JVP of +5 cms; his charts reveal a total input of 9 l and a urine output of 6 litres over these 3 days.

    1. How much excess fluid does he carry ?

    2. What would you do with his IV fluids ?


Case 4 l.jpg

PG

Case 4:

  • 5 days after a liver transplant, a 48 year old man has a pyrexia of 40.8oC. His charts for the last 24 hours reveal:

  • urine output:2.7 litres

  • drain output:525 ml

  • nasogastric output:1.475 litres

  • blood transfusion:2 units (350 ml each)

  • IV crystalloid:2.5 litres

  • oral fluids:500 ml


Case 4 cont l.jpg

PG

Case 4 cont:

  • On examination he is tachycardic; his supine BP is OK, but you can’t sit him up to check his erect BP. His serum [ Na+ ] is 140 mmol/l.

  • How much IV fluid does he need ?

  • What fluid would you use ?


Case 5 l.jpg

Case 5

  • 30yo girl

  • SOB, moist cough, chest pain

  • ESKD

  • Very little urine output

  • Has missed dialysis last 3 sessions


Case 528 l.jpg

Case 5

  • What next?

    • Current weight 78kg

    • IBW 68kg

    • JVP twitching her ear

    • No peripheral oedema

    • Coarse crackles to mid zones

    • BP 240/110

    • P 100

    • Gallop rhythm

    • 4cm of liver in RUQ


Case 529 l.jpg

Case 5

  • Assessment

    • Acute significant overload

    • Probably about 10kg


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Case 6

  • 55yo lady

  • Presents to dialysis for her routine session

  • BP 78/30

  • History of dizziness for the last 6 hours

  • Current weight 58kg

  • IBW 59kg


Case 631 l.jpg

Case 6

  • P 120

  • Chest clear

  • HS dual

  • No oedema

  • Admits to 24hours of diarrhoea

  • Thirsty

  • No JVP visible


Case 632 l.jpg

Case 6

  • Dehydrated

  • Volume constricted

  • Hypotensive due to decreased circulating fluid volume

  • Resuscitation?


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The End


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Acknowledgements

  • Paddy Gibson – 4th year teaching ppt 2009

  • Robert Harris – Fluid Balance ppt 2009

  • Heather Laird-Fick – Fluid and electrolyte disorders ppt 2009

  • JXZhang Lecture 14 – ppt 2009

  • Dennis Wormington – fundamentals of fluid assessment ppt 2009


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