H2O ADH Antidiuretic HormoneADH Collecting Duct Hypertonic Interstitial Fluid Urine
Blood pH = 7.4(7.35-7.45) Blood pH regulated by 1. Kidneys 2. Lungs 3. Buffers in blood
H+ Secreted HCO3- Resorbed Blood H+ Kidney Nephron Urine HCO3-
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 • 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
Carbonic Acid Carbon Dioxide and Acid CO2 + H2O H2CO3H++ HCO3-
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 7.3How does the body compensate? • Breathe faster to get rid of carbon dioxide • eliminates acid
Blood pH Increases to 7.45How does the body compensate? • Breathe slower to retain more carbon dioxide • retains more acid
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
PG Calculation of osmolality • Difficult: measure & add all active osmoles • Easy = [ sodium x 2 ] + urea + glucose • Normal = 280 - 290 mosm / kg
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:
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
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
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 ?
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
PG What are the expected losses ? • Measurable: • urine ( measure hourly if necessary ) • GI ( stool, stoma, drains, tubes ) • Insensible: • sweat • exhaled
Electrolyte (Na+, K+, Ca++) Steady State • Amount Ingested = Amount Excreted. • Normal entry: Mainly ingestion in food. • Clinical entry: Can include parenteral administration.
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 ?
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 ?
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 ?
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
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 • 30yo girl • SOB, moist cough, chest pain • ESKD • Very little urine output • Has missed dialysis last 3 sessions
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 5 • Assessment • Acute significant overload • Probably about 10kg
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 6 • P 120 • Chest clear • HS dual • No oedema • Admits to 24hours of diarrhoea • Thirsty • No JVP visible
Case 6 • Dehydrated • Volume constricted • Hypotensive due to decreased circulating fluid volume • Resuscitation?
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