water and electrolyte physiology

1. Body fluid and Electrolyte
disturbance

2. Body fluids
 Definition: The watery matrix in which the biochemical reactions of cellular
metabolism occur.
 Presence: Body fluids, bodily fluids, or biofluids are liquids within the human body.
** In lean healthy adult men, the total body water is about 60% (60–67%) of the total body
weight;
** it is usually slightly lower in women (52-55%).
**The exact percentage of fluid relative to body weight is inversely proportional to the
percentage of body fat and age. A lean 70 kg (160 pound) man, for example, has about 42
(42–47) liters of water in his body.

3. -The total body of water is divided into fluid compartments
** intracellular fluid (ICF) compartment (also called space, or volume) and
** extracellular fluid (ECF) compartment (space, volume) in a two-to-one ratio: 28 (28–
32) liters are inside cells and 14 (14–15) liters are outside cells.
 Compartments by location:
• intracellular fluid or volum (ICF), which consist of cytosol and fluids in the cell nucleus.
• Extracellular fluid
• Intravascular fluid or volum (blood plasma)(4 L), conceptually useful but
unmeasurable
• Interstitial fluid (12L) including lymphatic and transcellular)
• Lymphatic fluid (sometimes included in interstitial fluid)(6-8L)
• Transcellular fluid(4L)

5. Function : Achieving stability of the two major functions of body fluids:
1--maintenance of body osmolality within narrow limits,
2--maintenance of extracellular fluid and blood volume at adequate levels. And
3—act as a solvent
4—cellular support
5—configuration

6. Body fluid homeostasis
 water balance primarily controls
osmotic homeostasis, and
solute balance largely controls volume homeostasis.
 This is accomplished through finely regulated activities of
the cardiovascular system,
the endocrine system, and
the central and peripheral nervous systems.

7. Body fluid disturbance
 Causes of increased body water:
increasing water intake ( hypothalamic disease, psychic polydipsia)
decreased excretion (SIAD)
 Causes of decreased body water:
decreasing water intake
increased excretion (DI)
 All will discussed in endocrine diseases

8. How to calculate body water
 Total body water = 0.6 multiplied in body weight
TBW = 0.6 (B wt)
 Body water deficit=
Total body water multiplied in (1-ideal Na level/calculate Na level)
= TBW (1-140/Na level)

13. Electrolytes
 Definition: Electrolytes are all electrical charge
minerals in your body.
 Presence: They are present in your tissues, blood,
urine, and other body fluids.
 What is the electrolytes: Sodium, potassium,
calcium, phosphate, chloride, magnesium and others are
all electrolytes. All taken from the foods and fluids.

14.  Function : of Electrolytes
. To regulate energy production
. Responsible for hormones and enzymes release and function
. To balance the amount of water in your body (sodium)
. Balance of acid/base (pH) level
. Regulate activity of muscles (smooth and striated muscles) .
. Move nutrients into your cells (potassium (phosphorus)
. Move wastes out of your cells (sodium. Magnesium)
. Good cellular function of all organs (calcium and phosphorus)

15. Normal range of electrolyte IN BLOOD
Sodium : 135-145 mEq/L
Potassium : 3.5-5.0 mEq/L
Calcium : 8.6-10.2 mg/dl
Phosphorus : 2.5-4.5 mg/dl
Magnesium : 1.5-2.5 mEq/L
Less than this range means hypo
More than this range means hyper

16. SODIUM
Definition Na normal level 135-145 mEq /L
Distribution : intracellular and extracellular
But mainly extracellular
Function : Na important for - regulation of body water
- regulation of plasma osmolality
-To maintain normal blood pressure
- to maintain normal cellular action potential
-To maintain normal nerve action and muscle contraction

17. Hyponatremia
 Definition : Na level <135 mEq/L
 Symptoms : may include:
• Nausea and vomiting
• Headache
• Confusion
• Loss of energy, drowsiness and fatigue
• Restlessness and irritability
• Muscle weakness, spasms or cramps
• Seizures
• Coma

18. . Causes
• Heart, kidney and liver problems. all can cause fluids to accumulate in your
body, which dilutes the sodium in your body,
• Syndrome of inappropriate anti-diuretic hormone (SIADH). causing your
body to retain water instead of excreting it normally in your urine.
• Chronic, severe vomiting or diarrhea and other causes of
dehydration. This causes your body to lose electrolytes, such as sodium, and
also increases ADH levels.
• Drinking too much water and Hormonal changes As adrenal gland
insufficiency (Addison's disease) and recreation drugs as amphetamine.
• Certain medications. Some medications, such as some water pills (diuretics),
antidepressants and pain medications

19. Risk factors
• Age. >50 years ,who taking certain medications or developing a
chronic disease that alters the body's sodium balance.
• Certain drugs. thiazide diuretics as well as some antidepressants
and pain medications. In addition, the recreational drug Ecstasy has
been linked to fatal cases of hyponatremia.
• Conditions that decrease your body's water excretion. kidney
disease, syndrome of inappropriate anti-diuretic hormone (SIADH)
and heart failure, among others.
• Intensive physical activities. drinking too much water while taking
part in marathons, ultramarathons, triathlons and other long-
distance,

20.  Prevention
• Treat associated conditions. such as adrenal gland insufficiency,
can help prevent low blood sodium.
• Educate yourself. If you have a medical condition that increases your
risk of hyponatremia or you take diuretic medications, be aware of the
signs and symptoms of low blood sodium. Always talk with your doctor
about the risks of a new medication.
• Take precautions during high-intensity activities. Athletes should
drink only as much fluid as they lose due to sweating during a race.
Thirst is generally a good guide to how much water or other fluids you
need.

21. • Consider drinking sports beverages during demanding
activities. Ask your doctor about replacing water with sports
beverages that contain electrolytes when participating in
endurance events such as marathons, triathlons and other
demanding activities.
• Drink water in moderation. Drinking water is vital for your health,
so make sure you drink enough fluids. But don't overdo it. Thirst
and the color of your urine are usually the best indications of how
much water you need. If you're not thirsty and your urine is pale
yellow, you are likely getting enough water.

22.  Treatment ; started if there is acute and sever manifestation or
complication of hyponatremia
fluid resuscitation should be done early to prevent systemic
hypoperfusion and end-organs tissue injury by isotonic saline (o.9%) or
ringer lactate slowly IV with monitoring of vital sign and urine output.
If the patient is euvolemic, you can give sodium preserved diuretics.
If the patient is hypervolemic, you must restrict water drinking and give
sodium preserved diuretics.
Plus management of the cause &management of complication.

23. Hypernatremia
 Definition : Na level more than 145 mEq/L
Symptoms
 excessive thirst.
 lethargy, which is extreme fatigue and lack of energy,
 confusion.
 muscle twitching or spasms. That’s because sodium is important for how
muscles and nerves work.
 With severe elevations of sodium, seizures and coma may occur.
 Severe symptoms are rare and usually found only with rapid and large
rises of sodium in the blood plasma.


24.  Cause
. 1- Hypernatremia with Low volume : In those with low volume or
hypovolemia:
. Inadequate intake of free water
. Excessive losses of water from the urinary tract glycosuria,
or mannitol) and some cases of chronic renal failure .
. extreme sweating , burn and sequestration .
. Severe watery diarrhea (osmotic diarrhea ),vomiting and Ryle
• 2- Hypernatremia with Normal volume.
• Excessive excretion of water from the kidneys caused by diabetes
insipidus, which involves either inadequate production of the
hormone vasopressin, from the pituitary gland or impaired responsiveness
of the kidneys to vasopressin.

25.  3- Hypernatremia with High volume.
• Intake of a hypertonic fluid (as sodium bicarbonate and soy sauce )
solution.
• Ingesting seawater, dialysis
• Mineralcorticoid excess due to a disease state such as Conn's
syndrome and Cushing.
• Salt poisoning is the most common cause in children. It has also been
seen in a number of adults with mental health problems. Too much salt
can also occur from drinking seawater or.

26.  Risk factors
 Older adults are at an increased risk for hypernatremia. because they’re more likely
to have a decreased sense of thirst and more prone to illnesses that affect water or
sodium balance.
 Certain medical conditions, including:
• dehydration
• severe, watery diarrhea
• vomiting
• fever
• delirium or dementia
• certain medications
• poorly controlled diabetes
• larger burn areas on the skin
• kidney disease
• diabetes insipidus

27. Treatment
 The cornerstone of treatment is administration of free water to
correct the relative water deficit.
 Water can be replaced by oral water intake or intravenous fluid
infusion.
 Enteral preferred if no contraindication
 Water alone cannot be administered intravenously (because of
osmolality issues leading to rupturing of red blood cells in the
bloodstream), but rather can be given intravenously in solution
with dextrose (sugar) or saline (salt).

28.  However, overly rapid correction of hypernatremia is potentially very
dangerous. The body (in particular the brain) adapts to the higher
sodium concentration. Rapidly lowering the sodium concentration with
free water, once this adaptation has occurred, causes water to flow into
brain cells and causes them to swell. This can lead to cerebral edema,
potentially resulting in seizures, permanent brain damage, or death.
 thiazide diuretics : can be used in cases of hypernatremia associated
with hypervolemia
 In hypernatremia associated with euvolemia, you can give 5%dextrose
in water replaced over 24 to 48 hours aiming for correction of no more
than 1-2 mEq/L/H to avoid cerebral edema
 With follow up monitoring of blood sodium.

29. Potasium
 Normal potassium level : 3.5-5.2 meq/L
 Distribution : intracellular and extracellular ,but mainly intracellular
 Function : important for
- the release of hormones and enzymes
- maintain normal metabolism.
- cellular action potential
- muscular contraction

30. hyperkalemia
 Definition : potassium level > 5.2 mEq/L
 Types of hyperkalemia: mild----from 5.2 to 6.0 mEq/L
Moderate----from 6.1 to 7.0 mEq/L
sever ----more than 7.0 mEq/L
 According to the Mayo Clinic, a normal range of potassium is between 3.6 and
5.2 millimoles per liter (mmol/L) of blood. A potassium level higher than 5.5
mmol/L is critically high, and a potassium level over 6 mmol/L can be life-
threatening. Small variations in ranges may be possible depending on the
laboratory.

31.  Causes :
 Hyperkalemia can happen if your kidneys don’t work properly, as renal
failure and renal tubular acidosis
 Diseases that lower the production of aldosterone hormone, such
as Addison's disease, can lead to hyperkalemia.
 certain factors can shifting potassium extracellular like (acidosis,
hyporinsulinemia, hypoglycemia and B antagonist) .

32.  Some health problems interfere with how potassium moves out of the
body's cells.
 Sometimes, cells release too much potassium. Releasing too much
potassium can result from:
• Breakdown of red blood cells, called hemolysis
• Tumor lysis syndrome.
• Breakdown of muscle tissue, called rhabdomyolysis
• Burns, trauma, or other tissue injuries (infection ,inflammation,
ischemia, infarction)
• Uncontrolled diabetes

33. Drug-Induced Hyperkalemia
.Blood pressure drugs called angiotensin-converting enzyme (ACE) inhibitors
•Blood pressure drugs called angiotensin-receptor blockers (ARBs)
•Blood pressure drugs called beta-blockers
•Herbal supplements, including milkweed, lily of the valley, Siberian ginseng,
Hawthorn berries, or preparations from dried toad skin or venom.
•Heparin, a blood thinner
•Nonsteroidal anti-inflammatory medications (NSAIDs)
•Potassium supplements
•Potassium-
sparing diuretics including amiloride (Midamor), spironolactone (Aldactone,
Carospir), and triamterene (Dyrenium)
•Antibiotics, including amoxicillin

34. Symptoms of Hyperkalemia
Potassium helps your nerves and muscle to function properly so increase
level of K leads to skeletal muscle weakness up to paralysis, lethargy and
cardiac arrhythmia
The mineral allows brain cells to communicate, both with each other and
with cells that are farther away.
Changes in potassium levels have been linked to learning, the release of
hormones, and metabolism.

35. Treatment for Hyperkalemia
 Going on a low-potassium diet
 Stopping or changing meds that are contributing to the hyperkalemia
 Taking medicine to lower the potassium in your body. (diuretics).
 Treating your kidney disease, which may include dialysis,
 Other treatments depend on the cause of hyperkalemia.
 Some medications work as potassium binders:
Patiromer (Veltassa)
Sodium polystyrene sulfonate (Kayexalate)
Sodium zirconium cyclosilicate (Lokelma)
 You take them by mouth to prevent hyperkalemia. Neither should be used in
emergencies.

36. Treatment of emergency hyperkalemia
 We must do firstly electrocardiogram to see if there is sign of
hyperkalemia ,as hyper acute T wave, prolonged P wave
,prolongation of QRS wave.
 If present ,we must give calcium gluconate to protect the heart .
 Help to shift potassium intracellular by glucose insulin infusion, B
stimulant and bicarb
 Help potassium excretion in urine by aid of diuretics
 Dialysis, if blood potassium still high
 With treatment of the cause

37. Complications of Hyperkalemia
Hyperkalemia can cause life-threatening heart
rhythm changes, or cardiac arrhythmias. It can
also cause paralysis and weakness.

38. Hypokalemia
 Definition : potassium level < 3.5 mleq/L
 Causes :
1- should measure K level in urine: if low
1- someone is not getting enough potassium as
insufficient dietary intake,
anorexia, nausea
malnutrition, alcohol
2- A person may also loss potassium in case of
• persistent diarrhea
• prolonged vomiting and gastric Ryle
• Ileostomy and colostomy
 However, dietary hypokalemia it is unusual .

39.  Many foods contain potassium, and the kidneys are usually capable of reducing the excretion of
potassium if the body is not getting enough.
3- Hypokalemia can also occur when there is an “intracellular shift” of the potassium in the body, which
stops the correct transmission of potassium between cells. It can occur as a side effect of various
medications.as (hyperinsulinemia, hyperglycemia, B agonist, alkalosis)
If high: kidney issues
• Syndromes in which kidney can't preserve potassium, causing loss of potassium in urine as
• Bartter syndrome
• Gitelman syndrome
• Gullner syndrome
• Liddle syndrome
• Hyperaldosteronism (primary and secondary)

40. Follow up causes of hypokalemia
2- You should measure blood pressure of the patients to see
 If it is high , you must search for
1--suprarenal gland adenoma or hyperplasia
2--If there is intake of mineralocorticoid or corticosteroid
3--If there is renal artery stenosis
4--Glomerulonephritis
5--Renal infarction
6—apparent mineralocorticoid

41. Symptoms of hypokalemia
 When a person’s hypokalemia is mild, they will often not experience any
symptoms.
 However, people who have moderate or severe hypokalemia, are older, or have
heart or kidney issues can experience symptoms that relate to severe muscle
weakness.

42.  According to the National Organization for Rare Disorders, these
symptoms can include:
• muscle weakness that can result in paralysis
• respiratory failure
• low blood pressure
• muscle twitching
• cramping during exercise
• feeling very thirsty
• excessive urination
• loss of appetite
• nausea
• heart irregularities

43. Treatment
 Once a doctor has determined the underlying issue that is causing hypokalemia,
they can recommend a suitable treatment.
 For example, if a person has hypokalemia as a result of prolonged vomiting,
treating the cause of the vomiting will also address the hypokalemia.
 Alternatively, if a particular medication is making a person hypokalemic, then
reducing or replacing that medication may resolve the problem.

44.  If a person’s hypokalemia is severe or causing muscular issues, they
may receive a prescription for additional potassium supplements to
respond to these symptoms immediately. The supplement will often be in
the form of syrup and tablets (ACE,ARBS and NSAI), but intravenous
delivery might be necessary if the hypokalemia is severe.
 Doctors may also instruct people to eat foods that are rich in potassium,
such as bananas, avocados, chard, and other plant-based foods.
However, the authors of an article in the journal American Family
Physician note that, although changing the diet can be beneficial, it is
usually far less effective than taking potassium supplements.

45. magnesium
Normal blood level of magnesium :
Adult: 1.3-2.1 mEq/L or 0.65-1.05 mmol/L (SI units)
Distribution : intracellular and extracellular , but mainly intra cellular (bone and
muscles)
Function:
* Regulation of other electrolytes (Ca, K, Na),
 For normal neuromuscular activity. CNS(headache, migraine, stroke and
Alzheimer),muscle (heart failure, ischemia and arrhythmia)
 cofactor for various enzymes, transporters, and nucleic acids that are essential
for normal cellular function, replication, and energy metabolism.
 Important for synthesis of 1,25(OH)2 vit.D. and function of insulin
 Important for normal function of PTH. sympathetic activity(aneixity) and insulin

46. hypermagnesemia
 Definition : blood magnesium more than 2.5 mEq/L
Causes : . Iatrogenic (often with renal failure)
. Diuretic (80 mg/day of furosemide or thiazide)
. Antacids or enema containing magnesium
. Laxative abuse
. Parenteral nutrition
. Magnesium therapy for eclampsia or premature labor
. Lithium intoxication [3]
. Renal failure
. Dehydration diabetic ketoacidosis prior to therapy
. Hypothyroidism
. Addison disease and after adrenalectomy
. Accidental ingestion of large amount of seawater

47. symptoms
 Hypermagnesemia causes vasodilation and neuromuscular blockade
hypotension refractory to volume expansion is an early sign of
hypermagnesemia.
 Muscular weakness, paralysis, respiratory failure, and coma, with decreased
tendon reflexes,
 Paralytic ileus, flushing of face, dilation of pupils,
 paradoxical bradycardia, heart block, and prolongation of PR, QRS, and QT
intervals are other features of magnesium toxicity.
 Asystole may occurs in sever cases.

48. treatment
 Fluid replacement , oral or intravenous .
 Dialysis if the patient not responding
 Treatment of the cause

49. hypomagnesemia
Definition : blood magnesium less than 1.5 mEq/L
Causes :
1- Gastrointestinal disease - Malabsorption, ulcerative colitis, Crohn disease,
villous adenoma, carcinoma of colon, laxative abuse, vomiting,
Primary infantile hypomagnesemia and hypomagnesemia with secondary
hypocalcemia are 2 rare genetic disorders that result in hypomagnesemia poor
absorption from the gut.
2- Renal disease - Chronic glomerulonephritis, chronic pyelonephritis, renal tubular
acidosis, diuretic phase of acute tubular necrosis, most obstructive diuresis, drug injury,
Bartter syndrome, Gitelman syndrome
3- drugs :
Antibiotics (aminoglycosides, amphotericin B, ticarcillin, carbenicillin)
Digitalis

50. Antineoplastic: cisplatin, cyclosporine,
Diuresis caused by glucose, urea, mannitol
4- Primary renal magnesium wasting
5- Extracellular fluid volume expansion
6- Hypercalcemia and Phosphate depletion

51. symptoms
 it may cause unexplained hypocalcemia and hypokalemia,
 Digitalis sensitivity and toxicity frequently occurs with hypomagnesemia.
 Because deficiency can exist with normal or borderline serum
magnesium level, a 24-hour urine test may be indicated.
 , ataxia, nystagmus, vertigo, tetany, tremor, seizures, apathy, depression,
irritability, delirium, and psychosis.
 Sinus tachycardia, other supraventricular tachycardia's, and ventricular
arrhythmias may occur (QT prolongation may lead to torsade's).
Prolonged PR or QT intervals, flattening or inversion, of T-wave and ST
straightening may appear in EKG.

52. treatment
 Oral magnesium salts are used to treat mild hypomagnesemia. But it
may result in diarrhea.
 Severe hypomagnesemia should be treated with intravenous
magnesium chloride or magnesium sulfate. But it may cause
hypocalcemia

53. A 56 y old male comes in with SIADH and a Na of 100, active seizures.
You plan to give 3%. How would you give it?
Give 100ml of 3%Nacl bolus and repeat it maximum of 3 times within the first hour
Give 3%Nacl at a faster rate of about 100cc/hr till Na is around 114 and
Then correct 0.5Meq/L for the remainder of the 24 hours
Give 3%Nacl at around 60cc.hr and correct 0.5meq/L for the 24 hours
Give v2 receptor antagonist
Give 2%Nacl at 200cc/hr for 24 hours

54. In management of a case of hyperkalemia, we can
use all of the following except
 Calcium gluconate
 Glucose insulin infusion
 Diuretic, potassium sparing
 dialysis

55. All of the following causing hypernatremia with hypervolemia
except.
 Drowning
 Dialysis
 Diuretics
 diarrhea

56. Which of these leading to hyperkalemia except (Point the
odd one out!
Proximal Renal Tubular Acidosis
Gordon's Syndrome
Diarrhea
Ureteroileostomy

57.  Labs on presentation: Na 117, K 1.5, Normal renal function. Exam consistent
with volume depletion. EKG changes consistent with hypokalemia.
Hyponatremia is asymptomatic
 Treatment?
 A. Treat hyponatremia first and then hypokalemia
 B. Treat hyponatremia and hypokalemia simultaneously
 C. Treat hypokalemia first and then hyponatremia

58.  just aggressive correction of K leading to fast Na correction. fast
Na correction leading to fast relieve of brain edema

59.  WHICH OF THE FOLLOWING ARE POTENTIAL CAUSES OF DEATH IN
DIABETIC KETOACIDOSIS(DKA?)
 Hyperkalemia
 Aspiration
 Hypokalemia
 Relative hypoglycemia
 Underlying lesion and complications
 All of the above

60. Thank you