M Shuja Tahir, M Abid Bashir

Faisalabad, Pakistan IR-026

Critical Care

FLUID AND ELECTROLYTES -1

FLUID COMPARTMENTS

Infants TOTAL BODY WATER cation and chloride and bicarbonate

It is the amount of water content are the principle anions.
75%
present in the body.
25% It is 75% of total body weight in a new INTRAVASCULAR FLUID
born infant. It is the part of extracellular fluid
It is 55% of total body weight in adult present in intravascular compartment.
Total Body Water Solids males. It is 5% of body weight or 1/4 of ECF
It is 50% of total body weight in adult (2.8 liters in 70 kg adult).
Males females.
55% Intra-vascular fluid is present as a
The difference in the percentage of component of blood which is
45% body water is due to excess amount of composed of cells (red cells, white
fat present in the females. cells, platelets) and plasma (fluids with
dissolved protein).
Total Body Water Solids
The amount of total body water content
(60% of total body weight or 42 liters in INTERSTITIAL FLUID
Females
70 Kg patient) is an accepted average It is the part of the extracellular fluid
50% in adults for clinical calculations. present in the interstitial space (15% of
50%
body weight or 3/4 of ECF).
INTRACELLULAR FLUID (ICF)
Two third (66%) of total body water The interstitial fluid is further compli-
Total Body Water Solids (40% of total body weight) is present in cated by having a rapidly equilibrating
the intracellular compartment. Largest or functional compartment as well as
Average proportion of this water is present in several more slowly equilibrating or
skeletal muscle mass. Because of the relatively non functioning components.
60% - 42 litres
smaller muscle mass in female, the These non functioning components
40%
percentage of intracellular water is comprise connective tissue water as
lower than in males. well as transcellular water including;
! Cerebrospinal fluid.
Total Body Water Solids The principle cations of intracellular ! Peritoneal fluid.
compartments are potassium and ! Joint fluids.
Fluid Compartments magnesium and principle anions are ! Secretions of the
66% Extra cellular fluid phosphates and proteins. gastrointestinal tract.
Interstitial fluid
11.2 liters (15%)
! Fluid in renal tubules.
EXTRACELLULAR FLUID (ECF)
Intra vascular fluid
34% 2.8 liters (5%)
Transcellular fluid
0.5 liter (3 %) One third (33%) of the total body water This non functioning component
(20% of body weight) is present in the normally represents only 10% of the
Intracellular fluid Extra cellular fluid
extracellular compartment. It is further interstitial fluid volume (1-3% of body
subdivided into intravascular and weight).
interstitial fluid compartments.
MOVEMENT OF WATER
In the ECF, sodium is the principle The fluids keep on shifting between all

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these compartments to keep the
electrical and osmolar equilibrium.
Main factor controlling this fluid shift
are pressure gradients (hydrostatic and
osmotic pressure) and permeability of
the membranes separating these
compartments. (Cell membrane
between the ICF and ECF and capillary
membrane between intravascular and
interstitial compartment).
Osmosis is the movement of solvent
particle from an area of lower solute
concentration to higher solute
concentration when both are
separated by a semi-permeable
membrane which allows the passage of
solvent molecule but not the solute
molecule.
The physiological and chemical activity
of electrolytes depends upon number
of particles present per unit volume
(osmoles per litre) and number of
electrical charges per unit volume
(equivalents per litre).
It is important to note that number of
particles and not the amount or weight
of solute is important in maintaining
osmolality and osmotic pressure.
Plasma osmolality is calculated
according to the following formula.
+ +
Posm (mosm/kg) = 2[Na (mmol/L) + K
(mmol/L)] + [BUN(mg/dl)/2.8]
+[Glucose(mg/dl)/18]
Putting average values in the equation
we get;
Posm = 2 [140+4] + 20/2.8 + 90/18
= 300
April to June, 2010 INDEPENDENT
Normal plasma osmolality is 280-310
mosm/L.
Sodium is the main ion responsible for
extracellular osmolarity as it is clear
from the equation that 280 out of 300
mOsmol of plasma osmolality are
contributed by sodium alone.
Although the concentration of different
solutes is different in various compart-
ments, the membranes are freely
permeable to water. Therefore osmo-
lality of these compartments is same.
Similarly electrical equilbirium is also
maintained between all these compart-
ments.
TONICITY
Tonicity can be defined as osmolality
due to effective solute.
Effective solutes are those solutes
which can not permeate the cell
membrane and, therefore, are
restricted to ICF or ECF. These are
mainly responsible for water transport
across the cell membrane.
Ineffective solutes can freely cross the
cell membrane and are unable to effect
the shift of water across the membrane.
Therefore, these solutes contribute to
total body osmolality but not to tonicity.
NORMAL CONTROL OF FLUIDS
Kidneys play a major role in
maintaining fluid, electrolyte and acid
base balance.
In the glomerulus, almost everything is
filtered out of plasma. Glomerular
filtration rate (GFR) is mainly
dependent upon the hydrostatic
pressure in the glomerular capillaries
and capillary flow rate which is
REVIEWS 128
 dependent upon the renal blood flow.
In hypovolaemia, renal blood flow
decreases, decreasing the GFR.
In the proximal convoluted tubules,
sodium is actively re-absorbed.
Chloride passively follows the sodium
to maintain the electrical equilibrium
leading to water re-absorption by
osmosis. The net result is decrease in
volume of the filtrate but osmolality
remains the same.
In the loop of Henle, complex counter
current mechanism is responsible for
further re-absorption of water and
salts. In the descending limb, the
volume is further decreased by water
re-absorption leading to increased
osmolality. In ascending limb, further
salts and water are re-absorbed. The
fluid entering the distal convoluted
tubules is hypo-osmolar.
In distal convoluted tubules, further re-
absoption of water and sodium takes
place but it is hormone dependent.
Aldosterone is the most important
hormone which is secreted from the
renal medulla in response to renin
angiotensin system. It acts on the distal
convoluted tubules to stimulate water
and sodium re-absorption. It increases
the ECF volume.
Antidiuretic hormone (ADH) is secreted
by the posterior pituitary gland. It
increases the permeability of collecting
ducts to water leading to water re-
absorption and increase in the ECF
volume.
129 April to June, 2010
Atrial natriuretic hormone (ANH) is
secreted from atria in response to
increase ECF volume. It is responsible
for increased GFR and decreased
sodium re-absorption. The net result is
increased excretion of water and
sodium and decreased ECF volume.
CLASSIFICATION OF FLUID AND
ELECTROLYTE CHANGE
VOLUME CHANGES
Addition or subtraction of isotonic
fluids from body would lead to
significant change in ECF volume but
little or no change is noticed in ICF.
CONCENTRATION CHANGES
Addition or subtraction of water or
sodium alone would lead to changes in
volume as well as tonicity of the ECF. It
will lead to significant shift of water
across the cell membrane i.e addition
of water or subtraction of sodium
would lead to hypotonicity of ECF and
water will move into the cell to balance
the osmolality and vice versa.
COMPOSITION CHANGES
Changes in concentration of ions other
than sodium would not lead to volume
or concentration change but can have
significant changes in the composition
of the ECF. These ions includes K ,
+
Ca+2, Mg+2, Cl-, H+ and OH-.
DISTRIBUTIONAL CHANGES
The volume is redistributed to third
space (tissues in trauma and burns, GIT
in intestinal obstruction) leading to
distributional hypovolemia. Total water
may be normal or even more, but
effective intravascular volume
significantly falls.
INDEPENDENT REVIEWS
REFERENCES
1. Shires III, GT, Borber AB, Shires GT. Fluid &
Electrolyte management of the surgical
patient, In Shwortze I, Shires GT, Spencer
FC, Doly JM, Fisher JE, Galloway AC. (Ed).
Principles of surgery 7th Ed. 1999. Mc
Grath Hills New York PP 53-76.
2. Shires GT, Canizoro PC. Fluid, Electrolyte
management of surgical patient. In
sabiston DC (Ed). The text book of surgery.
The biological bases of modern surgical
practice 14th Ed. 1991. W.B Sanden Co.
Philadelphia PP 57-76.
3. Doly JM, Barie PS, Dudnch SI. Preparation
of the patient. In Nylium (Lm), Baker RJ,
Fischer JE. (Ed) Mastery of surgery 3rd Ed.
1997, Little Drown, Co. Boston. PP. 22-49.
4. Gnerlich JL, Buchman TA. Fluid,
Electrolyte, Acid base disorders. In
Klingensmith ME, Chen LE, Glasgow SC,
Goer TA, Melby SJ, (Eds) Washington
Manual of surgery 5th Ed. 2008. Lippincott
Williams & Wilkins, Philadelphia. PP 71-
91.
5. Steele RJC, Patients with metabolic
disorders. In Cuschieni A, Steelw RJC,
Moosa AR (Ed). Essential surgical practice
4th Ed. 2000. Butterworth Heinmann
Oxford PP. 205-14.

SUMMARY

Fluid and Electrolytes Movement of water across compartments

Body fluid compartments Normal control of fluids
! Intracellular fluid compartments Classification of fluid & electrolyte changes
! Extracellular fluid compartments

The author :
Muhammad Shuja Tahir
FRCS (Ed), FCPS (Hon)
is professor and head of the
department of Surgery at
Independent Medical
College Faisalabad.
shuja@iu-hospital.com

The author :
Muhammad Abid Bashir,
FCPS
is associate professor in
department of Surgery at
Independent Medical
College Faisalabad and
®
instructor of ATLS .
abidbashir@hotmail.com

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