BODY FLUIDS

AND HOMEOSTASIS
Alicja Bartkowska-Sniatkowska

Department of Pediatric Anesthesiology

and Intensive Therapy

Poznan University of Medical Sciences

1
 Important Constituents and Physical
Characteristics of Extracellular Fluid
Normal Value Normal Range Approximate Unit
Short-Term
Nonlethal Limit

Oxygen 40 35–45 10–1000 mm Hg

Carbon dioxide 40 35–45 5–80 mm Hg
Sodium ion 142 138–146 115–175 mmol/L
Potassium ion 4.2 3.8–5. 0 1.5–9.0 mmol/L
Calcium ion 1.2 1.0–1.4 0.5–2.0 mmol/L
Chloride ion 108 103–112 70–130 mmol/L
Bicarbonate ion 28 24–32 8–45 mmol/L
Glucose 85 75–95 20–1500 mg/dl
Body temperature 98.4 98–98.8 65–110 ∞F
(37.0) (37.0) (18.3–43.3) (∞C)
Acid-base 7.4 7.3–7.5 6.9–8.0 pH

2
 Chemical compositions of extracellular
and intracellular fluids
EXTRACELLULAR FLUID INTRACELLULAR FLUID
Na+ 142 mEq/L 10
K+ 4 mEq/L 140
Ca++ 2.4 mEq/L 0.0001
Mg++ 1.2 mEq/L 58
Cl- 103 mEq/L 4
HCO3 28 mEq/L 10
Phosphates 4 mEq/L 75
SO4 1 mEq/L 2
Glucose 90 mg/dl 0 to 20
Amino acids 30 mg/dl 200
Cholesterol
Phospholipids 0,5 g/dl 2 to 95 g/dl
Neutral fat
PO2 35 mmHg 20
PCO2 46 mmHg 50
pH 7.4 7.0
Proteins 2 g/dl 16
5 mEq/L 40

3
Blood plasma
Summary of ions

4
Extracellular fluid (interstitial fluid)
Summary of ions

5
 Comparison
Extracellular fluid

Interstitial fluid Blood plasma

Highly

permeable

capillary

membrane

Ionic composition is similar in the both fluid spaces 6

Intracellular fluid (e.g. muscle)
Summary of ions

Proteins:
4 times higher
as in the plasma

7
All molecules and ions in the body fluids, including water molecules and
dissolved substances, are in constant motion, each particle moving its
own separate way.

8
SIMPLE DIFFUSION

9
 Diffusion
Continual movement of molecules among
one another in liquids or in gases

Transport pathways through the cell membrane and

the basic mechanisms of transport
– Simple diffusion
– Facilitated diffusion
– Active transport

10
 Simple diffusion

kinetic movement of molecules or ions

through a membrane opening or through
intermolecular spaces without any
interaction with carrier proteins in the
membrane

• amount of substance available

• velocity of kinetic motion
• number and sizes of openings in the membrane

11
 Facilitated diffusion
(interaction of carrier proteins)

carrier protein aids passage of the molecules

or ions through the membrane by binding
chemically with them and shuttling them
through the membrane in this form

12
 Osmosis
process of net movement of water caused by
a concentration difference of water

water
NaCL solution
osmosis
Osmosis at a cell membrane when a sodium chloride solution is placed on one side of the
membrane and water is placed on the other side
13
 Osmotic pressure
The osmotic pressure exerted by particles in a
solution, whether they are molecules or ions, is
determined by the number of particles per unit
volume of fluid, not by the mass of the particles

14
 Active transport
situation when a cell membrane moves
molecules or ions “uphill” against
a concentration gradient (or “uphill” against
an electrical or pressure gradient)

sodium ions
potassium ions
calcium ions
iron ions
hydrogen ions
chloride ions
iodide ions
urate ions
several different sugars
most of the amino acids
15
 Primary and Secondary Active
Transport
PRIMARY
energy is derived directly from breakdown of adenosine
triphosphate (ATP) or of some other high-energy phosphate
compound
SECONDARY
energy is derived secondarily from energy that has been
stored in the form of ionic concentration differences of
secondary molecular or ionic substances between the two
sides of a cell membrane, created originally by primary active
transport

16
 Osmolality and Osmolarity
• Osmolality
Concentration is expressed as osmoles per
kilogram of water

• Osmolarity
concentration is expressed as osmoles per liter
of solution

17
OSMOLARITY AND OSMOLALITY

18
 Plasma Interstitial Intracellular
(mOsm/L H2O) (mOsm/L H2O) (mOsm/L H2O)

• Na+ 142 139 14

• K+ 4.2 4.0 140
• Ca++ 1.3 1.2 0
• Mg+ 0.8 0.7 20
• Cl– 108 108 4
• HCO3– 24 28.3 10
• HPO4–, H2PO4 2 2 11
• SO4– 0.5 0.5 1
• Phosphocreatine 45
• Carnosine 14
• Amino acids 2 2 8
• Creatine 0.2 0.2 9
• Lactate 1.2 1.2 1.5
• Adenosine triphosphate 5
• Hexose monophosphate 3.7
• Glucose 5.6 5.6
• Protein 1.2 0.2 4
• Urea 4 4 4
• Others 4.8 3.9 10

• Total mOsm/L 301.8 300.8 301.2

• Corrected osmolar activity 282.0 281.0 281.0
(osmotic effect of plasma proteins)
• Total osmotic pressure at 37∞C 5443 5423 5423
19
• The composition of extracellular fluid is carefully
regulated by various mechanisms, but especially by
the kidneys. This allows the cells to remain
continually bathed in a fluid that contains the proper
concentration of electrolytes and nutrients for
optimal cell function.

20
 ISOTONIC - No change
Solution is said to be isotonic because it neither shrinks
nor swells the cells
5% glucose ?
0,9% NaCl
Lactate of Ringer

cell

280 mOsm/l 21
Water will continue to diffuse into the cell, diluting the
HYPOTONIC - Cell swells
intracellular fluid while also concentrating the extracellular
fluid until both solutions have about the same osmolarity.
Less than
0,9% NaCl

cell

200 mOsm/l 22
Water will flow out of the cell into the extracellular fluid,
HYPERTONIC – cell shrinks
concentrating the intracellular fluid and diluting
the extracellular fluid.
Hypertonic NaCl
Colloids (HES, Tetraspan)
10-20-40% Glucose

cell

360 mOsm/l 23
 Isosmotic, Hyperosmotic,
and Hypoosmotic Fluids
• Solutions with an osmolarity the same as the cell are called
isosmotic, regardless whether the solute can penetrate the
cell membrane
• Hyperosmotic and hypoosmotic refer to solutions that have a
higher or lower osmolarity, respectively, compared with the
normal extracellular fluid, without regard for whether the
solute permeates the cell membrane.

24
Homeostasis of body fluids
The maintenance of
a relatively constant volume and
a stable composition of the body fluids
is essential for homeostasis

25
 Fluid Intake and Output
• Daily Intake of Water
1. Liquids or water in the food 2100 ml/day
2. Synthesis in the body as a result of oxidation of
carbohydrates, adding about 200 ml/day
• Daily Loss of Body Water
1. Insensible Water Loss 700 ml/day
2. Fluid Loss in Sweat 100 ml/day,
3. Water Loss in Feces 100 ml/day
4. Water Loss by the Kidneys 0.5 L/day – 2.0 L/day

26
 Varriables influencing on fluid intake
• Personal conditions
• Climate
• Habits
• Level of physical activity
• Temperature / infection / sepsis
• Surgical procedure
• Fasting before operation
…

27
 Insensible Water Loss 700 ml/day
1. diffusion through the skin 300-400 ml/day
This loss is minimized by the cholesterol-filled cornified layer of the skin, which provides a barrier against
(burns)
excessive loss by diffusion – for eaxample burned patient who can loose sometimes even 5l/day.
In cold weather, the atmospheric vapor pressure decreases to nearly 0, causing an even greater loss of water
2. respiratory tract 300-400 ml/day
from the lungs as the temperature decreases.
(cold weather)
This explains the dry feeling in the respiratory passages in cold weather.

Fluid Loss in Sweat 100 ml/day

1. is highly variable
2. depending on physical activity and environmental
temperature
3. very hot weather, heavy exercise e.g. increases to 1 to 2
L/hour!!!

28
 Water Loss in Feces 100 ml/day
• several liters/day in people with severe diarrhea
• Life threatening state if not corrected within a few days

Water Loss by the Kidneys 0.5 L/day – 2.0 L/day

• Normal ranges
1.0 ml/kg b.w./hour
• Oliguria
0.5-1.0 ml/kg b.w./hour
• Anuria
≤ 0.5 ml/kg b.w./hour

29
 Body fluid regulation

intake Plasma 3l output

Capillary membrane
Extracellular fluid
14l
Interstitial fluid 11l

Cell membrane

Intracellular fluid 28l

Average issues for 70 kg person

30
 Transcellular fluid 1 – 2 liters
• Synovial
peritoneal
pericardial
intraocular space
cerebrospinal fluid
• Another one type of extracellular fluid
These fluids may differ markedly from that of the plasma or interstitial fluid.

31
 Total percentage of body fluid
neonates 75% b.w.
babies and children 55%-60% b.w.
adults 50%-55% b.w.

Ageing is usually associated with an increased

percentage of the body weight being fat.
Women normally have more body fat than men,
they contain slightly less water than men .

32
 Body fluid among men, women and
neonates
% of body weight

Men Women Neonates

1. Total water 60 54 75

2. Blood plasma 5 5 5

extracellular and 15 15 30
extravascular fluid

interstitial fluid <2-3 <2-3 3

3. Intracellular fluid 40 34 40

33
 Daily fluid (water) demand
• Adult 25 – 40 ml/kg b.w./24 hours
• Children
< 1000 g 200 ml/kg b.w.
1000-1500 g 180 ml/kg b.w.
1500-2000g 160 ml/kg b.w.
>2500g 150 ml/kg b.w.

4-10 kg 100-120 ml/kg b.w.

10-20 kg 80-100 ml/kg b.w.
20-40 kg 60-80 ml/kg b.w.

• Sodium 50 – 80 mEq/24 h.
• Potassium 60 – 80 mEq/24 h.

34
Changing in extra- and intracellular
fluid in dehydratation
Extracellular Intracellular
20% b.w. 40% b.w.

Physiological conditions

Loss of water
Decreasing of both compartments

Loss of hypotonic water

Higher decreasing of extracellular
water than intracellular

Hypernatremia causing by
excess intake of sodium
Increasing of extracellular and
35
decreasing of intracellular volume
 Abnormalities of Body Fluid Volume
Regulation: Hyponatremia and Hypernatremia
Plasma Na+ Extracellular Intracellular
Abnormality Cause Concentration Fluid Volume Fluid Volume

1.Hypo-osmotic Adrenal insufficiency;

Dehydration overuse of diuretics,
diarrhea and vomiting

2.Hypo-osmotic Excess ADH;

Overhydration bronchogenic tumor

3.Hyper-osmotic Inhibits of ADH

Dehydration Diabetes insipidus
excessive sweating

4.Hyper-osmotic Cushing’s disease;

overhydration primary aldosteronism

36
 Edema:
Excess Fluid
in the Tissues

37
 Intracellular Edema
Causes:
• depression of the metabolic systems of the tissues
decreasing of delivery of oxygen

cell membrane ionic pumps depressing

deterioration in the sodium pumping out of the cell

osmosis of the water into the cell

• lack of adequate nutrition to the cells

• Inflammation
direct effect on the cell membranes and increasing their permeability

sodium diffusing with subsequent osmosis of water into the cells

38
 Extracellular Edema
Causes
• abnormal leakage of fluid from the plasma to the interstitial
spaces across the capillaries
• failure of the lymphatics to return fluid from the interstitium
back into the blood

The most common clinical cause of interstitial fluid

accumulation is excessive capillary fluid filtration

39
 Factors That Can Increase Capillary
Filtration

• Increased capillary filtration coefficient

• Increased capillary hydrostatic pressure
• Decreased plasma colloid osmotic pressure

40
I. Increased capillary pressure
A. Excessive kidney retention of salt and water
1. Acute or chronic kidney failure
2. Mineralocorticoid excess
B. High venous pressure and venous constriction
1. Heart failure
2. Venous obstruction
3. Failure of venous pumps
(a) Paralysis of muscles
(b) Immobilization of parts of the body
(c) Failure of venous valves
C. Decreased arteriolar resistance
1. Excessive body heat
2. Insufficiency of sympathetic nervous system
3. Vasodilator drugs
II. Decreased plasma proteins
A. Loss of proteins in urine (nephrotic syndrome)
B. Loss of protein from destroyed skin areas
1. Burns
2. Wounds
C. Failure to produce proteins
1. Liver disease (e.g., cirrhosis)
2. Serious protein or caloric malnutrition 41
III. Increased capillary permeability
A. Immune reactions that cause release of
histamine and other immune products
B. Toxins
C. Bacterial infections
D. Vitamin deficiency, especially vitamin C
E. Prolonged ischemia
F. Burns
IV. Blockage of lymph return
A. Cancer
B. Infections
C. Surgery
D. Congenital absence or abnormality of lymphatic vessels

42
 Blood volume
• extracellular fluid plasma
• intracellular fluid fluid in the red blood cells

blood volume 7% b.w.

60% = plasma 40% = red blood cells

43
 Blood volume - children

Age Blood volume ml/kg b.w.

Neonate 80 -85

Baby up to 2 years 75

2-15 years 72

44
 Hematocrit

fraction of the blood composed of

red blood cells

45
 Values of hematocrit
• Men 0.40
• Women 0.36

• Severe anemia - may fall as low as 0.10

value that is barely sufficient to sustain life
• Polycythemia - excessive production of red blood cells
hematocrit can rise to 0.65

46
 Blood loss
• Hypotension
• Tachycardia
• Vasoconstriction
• Pale skin

A patient’s response to blood loss depends on his existing

pathophysiology and volume status.
Healthy – can lose up to 15% of blood volume without
manifesting signes of shock
Hypovolemic patient – experiences profound shock with very
modest blood loss
47
 Fluid losses - Patient undergoing
anesthesia and surgery
• Before operation
respiratory tree losses
loss to sweat
urine output
prohibition of oral intake and compensation
min. 6 hours before negative balance about 500 ml
• Induction of anesthesia
cardiodepressant influence of intravenous anesthetic
drugs such as thiopental
hypotension negative balance about 250-500 ml
• Maintenance od anesthesia
loss of blood/fluids depending on the type of primary
disease and surgical procedure
0 – up to 5 litres of blood
48
 Hemorrhage could be sometimes
underestimated ???
Clinical example
* with intertrochanteric fracture of the femur there can be
sequestration of as much as 1 to 2 litres of blood without
external bleeding
* the patient may come to surgery with fairly normal vital signs
* during anesthesia autonomic block produced by the potent
anesthetics may antagonize the increased stimulation which is
responsible for the keeping blood pressure in relatively
normal ranges
* effect – hypotension
- patient needs rapid intravenous administration of
fluids
49
Shock

50
 What is Critical Illness?
Shock is the Critical Illness!

Critical illness is a condition where life

cannot be sustained without invasive
therapeutic interventions

51
 Clinical example
In septic shock is the profound vasodilatation.

Under normal conditions the cardiovascular system is able to

compensate for pathologic vascular tone by:

autotransfusion of extracellular fluid

increasing heart rate
increasing cardiac output

In severe sepsis uncontrolled release of cytokines and nitric

oxide along with the presence of a myocardial depressant
factor conspire to undermine the body’s compensatory
mechanisms, and hypotension and tissue hypoperfusion
results
52
Clinical example - continuation
The logical approach is
to support the cardiovascular system using
* fluids
and
*vasopressors

until the inflammatory response has finished and the source is

under control. Normal physiology is restored.

53
 Infusion of Hypertonic Saline
NaCl – 7,5% NaCl (4 ml/kg, starting from 0,1-1 ml/kg b.w.)

„small volume resuscitation”

Benefits
* osmotic mobilisation of extracellular fluid
* osmotic shrinking of cell membrane
* decreasing of extravascular edema
- improvement of oxygen diffusion
- increasing of oxygen utilisation
* direct stimulation of heart muscle
* increasing of catecholamine influence on vessel reactivity

54
 If 2 liters of a hypertonic
(3.0 per cent sodium chloride solution)
are infused into the extracellular fluid
compartment of a 70-kilogram patient whose
initial plasma osmolarity is 280 mOsm/L,
what would be the intracellular and
extracellular fluid volumes
and osmolarities after osmotic equilibrium?

55
Step 1. Initial Conditions

Volume Concentration Total

(Liters) (mOsm/L) (mOsm)
• Extracellular fluid 14 280 3,920
• Intracellular fluid 28 280 7,840
• Total body fluid 42 280 11,760

56
Step 2. Instantaneous Effect of Adding 2 Liters of 3.0 Per Cent
Sodium Chloride

Volume Concentration Total

(Liters) (mOsm/L) (mOsm)
• Extracellular fluid 16 373 5,971
• Intracellular fluid 28 280 7,840
• Total body fluid 42 280 11,760

57
 Step 3. Effect of Adding 2 Liters of 3.0 Per Cent Sodium
Chloride After Osmotic Equilibrium

Conclusion:
Volume Concentration Total
Adding 2 liters of a (Liters)
hypertonic sodium chloride
(mOsm/L)
solution
(mOsm)
causes more
Extracellular fluid than a 5-liter
19.2 increase in extracellular fluid
313.9 5,971
volume while
Intracellular fluid decreasing
24.98 intracellular
313.9 fluid volume 7,840
Totalalmost
by body fluid 3 liters. 44 313.9 13,811

!!! No solute or water has been lost from the body

and there is no movement of sodium chloride into or out of the cells,
then we can calculate the volumes of the intracellular and extracellular compartments

58
 intracellular fluid extracellular fluid

normal state add isotonic NaCl

300 300
osmolarity

add hypotonic NaCl add hypertonic NaCl

300 300

59
Monitoring of body fluids in the
physiological and
pathophysiological conditions

60
 Central venous pressure

CVP can be used to assess the adequacy of a

patient’s vascular volume and ventricular filling

International system of measuring

1.0 cm H2O = 0.74 mmHg
1 mmHg = 1.36 cm H20
1.0 kPa = 10.2 cm H2O

Normal ranges 2 – 12 cm H2O ( 1-10 mmHg)

61
 Decreased CVP
• HYPOVOLEMIA

Increased CVP
• Hypervolemia
• Right ventricle insufficiency
• Pulmonary artery emboli
• Heart tamponade

62
 Indication to monitoring CVP
• Operations with the high risk of blood loss
• Operations with the high risk of deteriorations in fluid
distribution
• Patients with hypovolemia e.g. ascites, forced urine output…
• Shock
• Severe trauma and multiple trauma, burn injuries
…etc.

63
Internal jugular vein

64
Subclavian vein

65
Femoral vein

66
 Bone marrow catheterisation

< 3 years upper part of bone > 3 years lower part of leg 67
Monitoring of arterial pressure
Arterial blood pressure

68
 Radial artery catheterisation
• Technical guide

69
How to check radial artery collateral
flow?

Allen Test

70
 Dorsal pedis artery catheterisation
• Technical guide

71
 Role of kidneys in homeostasis
• Excretion of metabolic waste products and foreign chemicals
• Regulation of water and electrolyte balances
• Regulation of body fluid osmolality and electrolyte
concentrations
• Regulation of arterial pressure
• Regulation of acid-base balance
• Secretion, metabolism, and excretion of hormones
• Gluconeogenesis

72
Body fluid regulation by kidney

73
 Urine Formation Results from Glomerular
Filtration, Tubular Reabsorption, and
Tubular Secretion

Urinary excretion rate

=
Filtration rate - Reabsorption rate + Secretion rate

74
 Renal Blood Flow

Blood flow through both kidneys is about 1100 ml/min, or about

22 % of the cardiac output.

Considering the fact that the two kidneys constitute only about
0.4% of the total body weight, one can readily see that they
receive an extremely high blood flow compared with other
organs.

75
 Urine output

Extremely high blood flow in kidney

=
the most quick reaction into the blood/fluid loss
=
Decreased urine output the most important
clinical sign of hypovolemia

76
 Autoregulation

• Feedback mechanisms intrinsic to the kidneys normally

keep the renal blood flow and GFR relatively constant, despite
marked changes in arterial blood pressure.

• These mechanisms still function in bloodperfused

kidneys that have been removed from the body, independent
of systemic influences.
This relative constancy of GFR and renal blood flow is referred
to as autoregulation

77
Summary

78
 Isotonic dehydratation
• Loss of equally amount of sodium and water
• Mainly plasma – clinical signs of abnormalities in circulatory
system, shock
• Plasma osmolarity no change
Na no change
K increased
hematocrite could be increased
• Treatment
intravenously fluids – NaCl, Lactate’s Ringer, colloids

79
 Hypertonic dehydratation
• Water loss > sodium loss
• Causes: unsatisfied water intake, loss of hypotonic fluids
(diarrhea, vomiting, high fever, sweating…)
• Plasma osmolarity > 290 mOsm/l
Na increased > 150 mEq/l
hematocrite no change ( due to dehydratation of red blood
cells)
• Treatment
no electrolytes fluids – 5% glucose in 48 hours
formula
Na (mEq/L) – 142 (mEq/L) x kg b.w. x 0.2
142 (mEq/L)
80
 Hypotonic dehydratation
• sodium loss > water loss
• Causes: NaCl loss (diabetes, polyuria stage in renal
insufficiency, brain steam trauma…)
• Plasma osmolarity < 270 mOsm/l
Na decreased < 130 mEq/l
• Very serious state – treat carafully!!!

If the osmolarity is in normal ranges – do not administer Na

81
Daily fluid requirements among
children

kg ml/kg/h

<3 6

3-10 4

11-20 2

> 20 1

82
Causes of increased and decreased
fluid requirements
Increased

Raised temperature (fever)

Raised ambient temperature
Neonates
Radiant heater / photoherapy
Burns

Decreased

Humidified gases
Neuro-muscular paralysis
Hypothermia
Renal failure
83
Symptoms and signs of dehydratation
Sign/symptom Mild Moderate Severe Notes
< 5% 5-10% > 10%
Decreased urine + + + Beware watery
output diarrhoea

Dry mouth ± + + Mouth breathers are

always dry

Decreased skin - ± + Beware the skin, use

turgor several sites

Tachypnoe - ± + Metabolic acidosis and

pyrexia worsen this

Tachycardia - ± + Hypovolemia, pyrexia

and irrability cause
this
84
Thank You Very Much for Your
Attention

and Good Luck

on the Medical Way

85