Section E: Body Fluids & Electrolytes

An understanding of the basics of body fluids and electrolyte physiology and their application in
health and disease

A: To explain the distribution of body fluids and their measurement

Total Body Water 3- distribution 6, compartments 2 + division within compartments, content,
determinants of distribution
Distribution of body fluids 2

Body composition - 60% water, 18% protein, 7% mineral, 15% fat

Total body water  60% or 600mL/kg  42L in 70kg man

60% body weight males
50% body weight females

Body fluid compartments – water exists in physiologically significant

collections or compartments. They are virtual compartments.

 Intracellular fluid  55% body water (40% body weight) 23L

 Extracellular fluid  45% body water (20% body weight) 19L

1. Interstitial fluid 20% Functional
2. Intravascular fluid 7.5% Functional
3. Transcellular fluid 2.5% Functional
4. Water in dense CT 7.5% Kinetically slow
5. Water in bone 7.5% Kinetically slow

Functional component of ECF  30% TBW

Ratio of ICF: functional ECF 55%:30%  2:1

Important in acute fluid shifts

ICF : 330 mL/kg (55% bw = 23L)

ECF : 270 mL/kg (45% bw = 19L)
180ml/kg kinetically active (30%bw = 12.6L)
ISF : 120 mL/kg (20%bw = 8.4 L)
Plasma : 45 mL/kg (7.5% ECF = 3L)

Transcellular fluid – fluids formed by transport activities of cells & found in epithelial lined spaces in contact
with ICF not ISF e.g. CSF, synovial fluid, aquoes humor, bile, urine, bowel fluid & fluid in other body cavities.

Circulating blood volume

Blood volume: 70mL/kg  5L 7%bw = plasma 3.2L & cellular elements of blood 1.8L

 Control of H2O distribution between ICF & ECF? = ECF osmolality

Water moves easily across cell membranes (solutes do not) & will move until osmolality is the same on both sides
of a membrane. ECF:ICF distribution is dependent on osmolality of ECF (or ICF but ECF is easier to sample).
Water moving into or out of the body does so via the ECF.

ECF osmolality controls H2O distribution & also cell volume.

 ECF osmolality  net movement out of cells until ICF osmolality = ECF osmolality
 ECF osmolality  net movement into cells until ICF osmolality = ECF osmolality

Sodium is the major ECF cation & together with its obligatory associated anions accounts for 86% ECF
osmolality + 92% ECF tonicity (higher because ineffective osmoles e.g. urea, glucose are not counted).
distribution of TBW between ECF & ICF is determined by ECF sodium + its control mechanisms.

 Local intracellular solute regulation

Cells can regulate their solute content to allow volume adjustment against extracellular tonicity. E.g. Neurons
produce idiogenic osmoles when cell volume decreases due to extracellular hypertonicity, which draws water
back into the cell to restore cell volume.

Measurement of body fluid compartments 3

Compartment volumes are measured by determining the volume of distribution of a tracer substance.
1. A known amount of a tracer is added to a compartment.
2. The tracer concentration in that compartment is measured after allowing sufficient time for uniform
distribution throughout the compartment.
3. The compartment volume is calculated…
Volume = Amount of tracer / Concentration of tracer

Ideal Tracer
1. Non-toxic
2. Rapid + even distribution through the compartment to be measured without entering any other
compartment
3. Not metabolised or excreted during distribution period - Urinary loss can be measured & corrected for.
With metabolism - a series of measurements can be made and assuming exponential decline (first order
kinetics), the volume of distribution can be determined by extrapolation back to zero time.
4. Easy to measure
5. No interference with body fluid distribution

 Total Body Water

Estimated by measuring the volume of distribution of isotopes of water. Tritium oxide (THO) is used because it
is a weak beta emitter making it easy to measure in a liquid scintillation counter. Rapid mixing of tritiated water
throughout all compartments occurs during a 3 to 4 hour equilibration period. Results are accurate and
reproducible to within 2 percent.

 Extracellular Fluid - the slow ECF pool (bone & dense CT) takes  24hours to equilibrate.
1. Ionics (82Br, 35SO4, chloride isotopes) - small and distribute throughout the ECF but there is
some entry into cells  ECF is overestimated.
2. Crystalloids (Inulin, mannitol) - larger and less diffusable throughout the ECF. They do not
enter cells but the lack of full ECF distribution  underestimate of ECF.

 Plasma Volume
Requires a tracer which is mostly limited to this compartment  a tracer which binds to albumin is used e.g.
Evan’s blue dye or radio-iodine labelled serum albumin (RISA). Distribution is rapid but no equilibrium is
reached because of continuous disappearance of albumin from the vascular space.
This is overcome by taking serial measurements and plotting the disappearance curve of the label  an
exponential decline (1st order) which gives a straight line when plotted on a logarithmic scale. Extrapolation back
to zero time allows estimation of the virtual concentration at this time. The volume is determined via the dilution
principle using this concentration at zero time.

 Blood Volume
The patient’s RBCs are tagged with radio-chromium (51Cr-red cells). The labelled red cells are centrifuged,
resuspended in saline and reinfused. The volume of distribution is determined after about 10 minutes. As the
radioactive label distributes throughout the whole intravascular compartment, the measured VD = the blood
volume (rather than the red cell volume).
However, the distribution is not uniform because the haematocrit is different in different parts of the circulation.
the amount of the label in a red cell sample is measured and therefore to directly measure the red cell volume.
Plasma volume or red cell volume can be determined indirectly if the blood volume and haematocrit are known.
Blood Volume = Plasma volume x (100/100-Hct)
Blood Volume = Red cell vol x (100/Hct)

Problems in estimating an average or ‘whole body’ haematocrit:

1. Haematocrit measured in the laboratory overestimates true haemotocrit because 4-8% of plasma remains
trapped with RBCs in the tube
2. Blood from capillaries has a lower Hct than in larger vessels because of axial streaming of red cells. (Hct
in muscle capillaries is typically only 0.20!)
3. Large vein haematocrit is higher then in arteries because the various reactions in the RBC due to CO2
transport lead to an increase in the number of particles intracellularly and an osmotic increase in water
content.
 Accounting for these effects, the whole body haematocrit can be estimated as about 91% of large vein haematocrit
and this value should be substituted in the equations.

 Interstitial Fluid = ECF – plasma volume

There is no tracer which is distributed only throughout this compartment. ISF is determined indirectly as the
difference between concurrently measured ECF & plasma volumes. Measurement error is the sum of the errors of
the two individual measurements and can be significant.

 Intracellular Fluid = TBW – ECF Intracellular water measurement 3

There is no tracer available so ICF is measured indirectly as the difference between concurrently measured total
body water and ECF. The volume of ICF decreases with increasing age and this accounts for most of the age-
related decline in total body water.

 Transcellular Fluid
There is no tracer for the measurement as a whole of the myriad components of transcellular water. Methods exist
for the estimation of the various components individually.

IV fluids 2 – contents 1L Hartmanns, normal saline composition

Sodium CSL Gelofusine Albumin 4% Sodium Bicarbonate

chloride 8.4%
Volume 1000mL 1000mL 500mL 500mL 100mL
Weight NaCl 9g NaCl 6g Succinylated bovine gelatine Human plasma NaBicab 8.4g
NaLactate 3.22g 20g proteins 20g Disodium edatate 10mg
KCl 400mg NaCL 3.51g Protein N2 3.2g
CaCl 270mg NaOH 680mg
N2 2.53g
Composition Na 150mmol Na129mmol Na 77mmol Na 70mmol Na 100mmol
Cl 150mmol Cl 109mmol Cl 60mmol Cl 64mmol Bicarb 100mmol
Bicarb 29mmol Octanoate 3.2mmol
K 5mmol
Ca 2mmol
pH 4-7 5-7 7.4  0.3 6.7-7.3 7-8.5
Osmolality 300mOsm 274mOsm 283mOsm 260mOsm 1720mosm/L
Tonicity Isotonic Hypertonic
Other MW average 30000 dalton Viral inactivation –
Number average 23200 dalton pasturised +
incubated at low pH

Effects of various IV fluids 2

The water of dense connective tissue & bone is significant in volume (15% of total body water), but as a
kinetically slow compartment it is not important in consideration of short term fluid distribution. Transcellular
fluids are small in volume and usually slow so they too are excluded from this clinical analysis.This leaves three
big compartments:

• Intracellular fluid (55% of TBW, 23 liters)

• Interstitial fluid (20% of TBW, 8.4 liters)
• Intravascular fluid (Plasma 7.5% of TBW, 3.2 liters and Red cell volume 1.8 liters).

The IVF is the blood volume with 5L in total. The red cell volume is part of the ICF but also is part of the blood
volume.

Ratio of ICF to ECF is about 2:1. The ratio of ISF to plasma volume is about 3:1.

• TBW is one-third ECF & two-thirds ICF

• ECF is one-quarter plasma & three-quarters ISF
• The threshold of the volume receptors is 7-10% change in blood volume
• The osmoreceptors are sensitive to a 1-2% change in osmolality.
 • Plasma osmolality is normal prior to the transfusion (ie 287-290 mOsm/kg)

Distribution & Excretion 1000mL Dextrose 5%

Distribution: Iso-osmotic maintenance fluid which does not cause haemolysis. The glucose is rapidly taken up by
cells. The net effect is of administering pure water, so it is distributed throughout the total body water. Each
compartment receives fluid in proportion to its contribution to the TBW.
• ICF 670mls
• ECF 330mls: ISF 250mls + plasma 80mls.
Volume: Intravascular volume increases from 5000 to 5080 mls. A volume increase < 2% which will not be
sensed by the volume receptors.
Osmolality: The osmolality of plasma (3,200 mls) will decrease by: [ 287 - (287 x 3.20 / 3.28) ] which is about 7
mOsmoles/L or 2.5%. This is detected by the osmoreceptors  ADH release and renal water excretion. A
delay will occur because the changes have to be detected centrally and then ADH levels need 3 half-lifes to fall to
a new steady state.

Effects of drinking 2L water

Distribution: 2/3 ICF = 1340mL and 1/3 ECF = 660mL: ISF 500mls + plasma 160mls
Volume: Intravascular volume increases from 5000  5160mL. A volume increase of 3.2% which will not be
sensed by volume receptors.
Osmolality: of plasma will decrease by: 287 – (287 x 3.2/3.36) = 13.7 mOsmoles/L or 4.8%. This is detected by
the osmoreceptors  ADH release and renal water excretion.

Distribution & Excretion 1000mL 0.9% Normal saline Fate 1L 0.9% Normal saline
Distribution: Normal saline is an ECF replacement fluid. Its [Na+} is similar to ECF which limits its distribution
to this compartment. ECF = 1000mL: ISF 750mls + plasma 250mls
This is why blood loss of 1,000 mls requires about 3 to 4 times the volume of IV replacement fluid to restore
normal intravascular volume.
Osmolality: Plasma osmolality and tonicity will be unchanged because normal saline is isosmotic. The
osmoreceptors do not contribute anything to the excretion of normal saline.
Volume: Blood volume increases to 5250 mls 5%. This is below the sensitivity of the volume receptors.
Excretion: It seems that the body has no clear way of excreting this excess fluid as neither osmoreceptors nor
volume receptors are stimulated. However, experiments have shown that ‘replacement fluids’ are excreted the
most rapidly of all these groups. An additional mechanism is relevant here. Normal saline contains no protein so
the oncotic pressure in the blood is slightly lowered following the saline infusion. This has 2 effects…
1. Movement of fluid into the ISF is favoured (Starling’s Hypothesis)
2. Glomerulo-tubular imbalance: the lowered oncotic pressure immediately leads to an increase in GFR
and a smaller reabsorption of water in the proximal tubule. Urine flow increases. This is a strictly local
effect without any hormonal intermediary. The urine flow increases immediately. Fluid then moves back
into the intravascular compartment and the urine flow continues until all the transfused fluid is excreted.

Effects of 2L IV Normal Saline

Distribution: ECF = 2000mL: ISF 1500mls + plasma 500mls
Volume: Intravascular volume increases from 5000  5500mL. A volume increase of 10% which will be
sensed by volume receptors  ADH levels and excretion of the excess water.
Osmolality: of plasma will not change.

Effects of oral sodium load – sustained sodium intake

Distribution & Excretion 1000mL hypertonic saline Effects 1L of 3N saline 2

Hypertonic saline 3% has an osmolality (900 mosm/l) three times that of plasma. The Na + content limits the
distribution of the infused fluid to the ECF. The hypertonic solution will also draw water out of cells decreasing
intracellular fluid volume.

Prior to infusion:
Total body solute content = 42 x 290 = 12,180 mOsm.
ECF solute content = 19 x 290 = 5,510 mOsm
ICF solute content = 23 x 290 = 6,670 mOsm.

Post infusion :
Total body water = 42 + 1 = 43 liters
Total body solute content = 12,180 + 900 = 13,080 mOsm.
ECF solute content = 5,510 + 900 = 6,410 mOsm
ICF solute content = 6,670 mOsm (ie unchanged)

Final osmolality = 13,080 / 43 = 304 mOsm/l

ECF volume = 6,410 / 304 = 21.1 litres.
ICF volume = 6,670 / 304 = 21.9 litres.

Osmolality: Plasma osmolality has increased by 4.8%. Osmoreceptors  ADH release and renal water
excretion. Thirst will also occur.
Volume: increase in ECF volume is 2.1 litres with 500 mls intravascularly. blood volume 10%. Volume
(low pressure baroreceptors) receptors respond  ADH levels and excretion of the excess water. Volume
stimuli tend to be less sensitive but more potent than osmotic stimuli.
Sodium: The volume expansion will stimulate secretion of atrial natriuretic peptide. Secretion of aldosterone will
be inhibited because of a renin and angiotensin II production. ANP also inhibits renin secretion.
Overall outcome is natriuresis and excretion of the excess water. The osmolality ADH which will tend to
inhibit the rate of excretion of the excess water.
Clinical effects - decrease ICF volume  cerebral cellular dehydration and hypertonicity  confusion and
mental obtundation. The function of other organs or tissues in unlikely to be significantly affected. The increase in
ISF volume is not sufficient to cause oedema or interfere with gas transfer or nutrient and waste transfers between
cells and capillaries.

Distribution & Excretion 1000mL Plasma Protein Solution

Distribution: Plasma protein solution is a colloid and is distributed only to the intravascular fluid
Volume: Blood volume increases from 5,000 mls to 6,000 mls; an increase of 20%. This is above the 7 to 10%
threshold for the volume receptors  ADH levels and excretion of the excess water.
Osmolality: tonicity is unaltered.

This water loss tends to increase the plasma oncotic pressure and water moves from the ISF to the IVF. Vascular
reflexes are important also in causing venous pooling and a decrease in the ‘effective’ circulating volume. These
mechanisms tend to slow the excretion of the water load. The albumin is partly redistributed to the ISF and
metabolised. These changes are slow so the effect of plasma protein infusion on blood volume is both more
pronounced and more prolonged.

The pressure-volume control mechanisms important in long term regulation of blood volume are slow in onset but
become relevant here as the blood volume change is more significant and more prolonged and occurs without
change in osmolality (or initially in plasma oncotic pressure either).

Overview
 Dextrose 5% - treated by the body as pure water and a significant percent moves intracellularly. Useful to
replenish intracellular fluid but does so at the expense of tonicity. Inappropriate for intravascular volume
replacement. It is excreted because ADH levels decline in response to the drop in plasma osmolality.
 Normal saline - ECF ‘replacement fluid’ because it adds only to the ECF volume. Only about a third
remains intravascularly. To replace intravascular volume will require transfusion with about 3 times the
volume of blood lost. It is cheap and readily available. It is excreted because the small drop in plasma
oncotic pressure causes glomerulotubular imbalance. ADH is not affected.
 Plasma protein solutions (e.g 5% human albumin) - excellent for replacing intravascular volume. ISF and
ICF will not be replenished. Albumin is slow to be excreted and the transfused volume is excreted much
slower than with replacement solutions. Plasma protein solutions are expensive and supply is limited. The
fluid is initially excreted because of a fall in ADH level 2 falling stimulation of the volume receptors.
95B5 Outline the effects of IV administration of 500 mls of 20% mannitol, and the potential problems
 80%
associated with its use.

Distribution & Excretion hypertonic mannitol

Mannitol is low MW (182) monosaccharide which is easy to produce and stable in solution. Available in 10 or
20% solution. The hypertonicity causes passive movement of water across lipid barriers in response to the osmotic
gradient. Poorly absorbed orally & results in an osmotic diarrhoea must be given parentally.

Uses
1. Renal protection -  urine volume (12.5g every 1-2hrs) as prophylaxis against acute renal failure caused by
a high pigment load e.g. rhabdomyolysis.
2. To reduce intracranial pressure (1-2g/kg) – Brain extracellular fluid passes across the BBB & into the
plasma ICP. Greater water excretion results in water leaving cells & reduction in pressure. Also
decreased rate of CSF production. Commences in 15mins & effective for 2hrs. If the BBB is not intact
mannitol can enter the brain causing cerebral oedema. Initially causes vasodilation of vascular smooth
muscle which can transiently raise intracranial pressure (dilation of intracranial vessels & shift of fluid from
intracellular to extracellular compartments). Therefore infuse slowly over 10mins and use in conjunction
with corticosteroids and hyperventilation.
3. To reduce intraoccular pressure

Mannitol cannot be used for a prolonged time as metabolic derangements occur & the body adapts to
hyperosmolarity. Some also slowly enters the brain  rebound intracranial hypertension. The brain cells also
compensate for continued hypertonicity by the intracellular production of idiogenic osmoles. This increases
intracellular tonicity and allow brain cell volume to return towards normal.

Renal effects – The proximal tubule & descending loop of Henle are freely permeable to water. Mannitol is freely
filtered (within 30-60mins) at the glomerulus, not secreted or reabsorbed in the renal tubules, resist metabolism &
are pharmacologically inert. They increase the osmolarity of the plasma, glomerular filtrate & tubular fluid, where
they cause water retention and an osmotic diuresis. The high flow of retained tubule fluid tends to have a flushing
effect and washes fluid and solutes from the kidney. Sodium is diluted in this fluid & increased urine flow
decreases the contact time between fluid & the tubular epithelium, reducing Na+ absorption. Overall there is
increased excretion of water, sodium, chloride & bicarbonate. Urinary pH is unchanged.

Intravascular volume effects - Increased plasma osmolarity draws fluid from intracellular to extracellular spaces
and from extracellular to plasma. Initially prior to diuresis, the tissue dehydrating effect will increase ECF & 
intravascular volume with the risk of precipitating CCF, APO, hypertension, headache & N+V. Subsequently, the
diuretic effect may result in hypovolaemia (and hypernatraemia).

Other effects - The intravascular water volume decreases the RBC concentration (decreased haematocrit) with a
resultant decrease in blood viscosity. This may improve flow and oxygen delivery to some areas.

Osmotic Effects (due hypertonicity)

Intracellular dehydration
Expansion of ECF volume (except brain ECF)
Haemodilution
Diuresis due osmotic effects and ECF expansion

Non-Osmotic Effects
Decreased blood viscosity (with improved tissue blood flow)
Possible Cytoprotective effect (due free radical scavenging)
Cardiovascular effects secondary to expanded intravascular volume e.g increased cardiac output, hypertension,
heart failure, pulmonary oedema

Side Effects
Precipitation of APO.
Headahce & N+V – due to dilation of intracranial vessels.
Prolonged use  hypovolaemia, dehydration, hyperosmolarity, & electrolyte disturbances.
Cerebral oedema if BBB not intact.
Anaphylaxis
Vein irritation
 1994 Compare the advantages and disadvantages of synthetic colloids and SPPS in volume
 
replacement

Crystalloids: N/Saline Crystalloids: Colloids: Synthetic e.g. Colloids: Albumin

Hartmanns dextrans, gelatins + starches
Manufacturing Cheap + available Cheap + available More expensive than crystalloids, Expensive
but cheaper than albumin
Physicochemical Easy to store Easy to store Haemacel – sterile, progen free,
Long shelf life Long shelf life no preservatives, can store for
3yrs. no infection risk
Distribution ECF  require higher ECF  require higher Intravascular volume  lower Intravascular volume  lower
volumes volumes volumes volumes
Uses No compatability No compatability testing Better for resuscitation Better for resuscitation
testing No religious abjections Replace albumin in
No religious abjections hypoalbuminaemia
Side Effects Minimal adverse Minimal adverse Anaphylaxis Anaphylaxis
reactions reactions Dextrans – more severe allergic Viral/bacterial contamination -
reactions than gelatins or starchs from pooled human store
Can dilute Hb less than Can dilute Hb less than Can dilute Hb Can dilute Hb
colloids colloids Can dilute coagulation factors Can dilute coagulation factors
Can dilute coagulation Can dilute coagulation
factors – less than factors – less than
colloids colloids
Interactions Calcium precipitates out Dextran 70 – interferes with
with citrate in stored crossmatching + haemostasis
blood (induces acquired vonWillebrands
state) – max. dose 20ml/kg

Infusion of 8.4% Sodium bicarbonate

This is a molar solution of NaHCO3. Dissociation into Na+ & HCO3- in solution results in a solution with an
osmolality of 2,000 mOsm/kg or x7 plasma osmolality! Infusion of this solution has effects because it is:

Hypertonic - 2,000 mOsm/l with a high [Na+]

Distributed to ECF due to high sodium concentration. The hypertonic nature of the solution draws water out of
cells until the ECF and ICF tonicities are equal. The increase in ECF volume will be greater than the volume of
solution administered into it.
The ECF [Na+] will increase, but water drawn out of the cells will tend to minimise this increase. Has been used
for emergency treatment of acute hyponatraemia particularly where there was also a perceived benefit of the
alkalosis.

Alkalinising - HCO3- load.

The ECF [HCO3-] will increase and this exogenous administration of base will cause a metabolic alkalosis. This
causes intracellular movement of K+ and ECF [K+] will decrease. This is why NaHCO3 is used for the
emergency treatment of hyperkalaemia. If the plasma bicarbonate rises above 27 mmol/l then HCO3- is rapidly
excreted in the urine. A metabolic alkalosis will rapidly correct unless there is some additional factor which
maintains it. Because of the brief nature of the alkalosis, the compensatory hypoventilation is minimal.

ADH levels
A rise in extracellular tonicity of 1 to 2% or more will increase ADH levels (via hypothalamic osmoreceptors).
An increase in blood volume of 7 to 10% or more will decrease ADH levels (via low pressure baroreceptors) 
water excretion. An increase in blood volume due to NaHCO3 infusion will cause a fall in plasma oncotic
pressure and water reabsorption in the proximal tubule will decrease slightly due to glomerulotubular imbalance.

1994 Outline the effects of a rapid injection of 100mls of hypertonic Iodine containing angiography
 
contrast medium in an otherwise healthy adult.
B: To describe the function, distribution and physiological importance of sodium, potassium,
magnesium, calcium and phosphate ions

Electrolyte composition of the body fluids Distribution of major ions 2

Requirements:
UO - 0.5-1 ml/kg/day
K+ - 1mmol/kg/day (N/G losses-add K as H/K exchanged in kidneys)
NaCl - 2mmol/kg/day
Mg2+ - after 3-4d need 20mmol/day

 Sodium
Sodium: regulation, distribution, intake/absorption
Intake = 150mmol/day

Total body Na+ 60 mmol/kg

ICF - 5% [Na+] 12mmol/L (RBC ~20) *Low because of membrane permeability & Na+:K+-ATPase
ECF - 50% [Na+] 140mmol/L
Bone - 45% (not readily mobilised)

Exchangable Na+  70% - measured with 24Na+

Sodium in ECF = ISF because of PLASMA SOLIDS EFFECT

Plasma = 93%plasma water & 7% plasma solids (mainly plasma proteins).
The Gibbs-Donnan effect causes [Na+] in plasma water to be higher than ISF by 6-7mmol/L. However Na + is
measured as if it was present in the whole sample as opposed to just plasma water. This gives a falsely low
reading the ECF measurement = ISF measurement.

Makes up 86% osmolality & 92% of tonicity.

Exchangable Na+ (that not in bone crystal) is ~ 70% total. Measure using 24Na+.

Absorption – see GIT section

Regulation – see renal section
 Potassium
Potassium 2: distribution 3, regulation
Intake = excretion 70-100 mmol/day

Total body K+ 40-45 mmol/kg.

ICF - 90% [K+] 150 mmol/L
ECF - 2% [K+] 3.5-5 mmol/L
Bone - 8% (not readily mobilised) assume 98% of exchangable K+ is intracellular (90/92=97.8%)

Measurement
1. Total body - Naturally occurring isotope 44K = 0.0117% of K+ in the body. Measure with whole body
scanner & calculate total. Bone K+ is included is larger then the exchangeable pool.
2. Exchangeable – by injecting radioactive isotope 42K
40K+ (total) or 42K+ (exchangable).

Functions
1. Major component of intracellular tonicity.
2. Involved in NaK-ATPase in all cell membranes
3. Membrane potentials - RMP, AP, neuromuscular excitability
4. Regulation of intracellular processes e.g. protein & glycogen synthesis.

HYPERKALAEMIA – ECG changes

1. Increased T wave height Severe: K+ > 8mmols/l or marked ECG changes
2. Shortened QT Moderate: K+ 6-8mmols/l without marked ECG changes
3. Prolonged PR Mild: K+ 5-6mmols/l
4. P wave flatening
5. Widened QRS
6. Sine wave, VF, asystole

Rx
1. IV calcium – stabilises myocardial membrane (excitability) & risk of arrhythmias. K+ unchanged.
2. Glucose & insulin – K+  intracellularly
3. Sodium bicarbonate - K+  intracellularly
4. Resonium – ion exchange resin (1mmol Na+:K+) in colon – net K+ loss & Na+ gain
5. Dialysis
6. Correct of cause

HYPOKALAEMIA - ECG changes Hyperpolarises membrane (ie. should RMP)

1. Prolonged PR
2. ST depression
3. U wave (deflection after T)
4. Falsely prolonged QT (if T+U merge)
5. T wave inversion (late)

Rx: KCl
2-5 mmol bolus (arrest situation)
Infusion rate max: 20 mmol/h (adults/monitored), 0.4 mmol/kg/h (children)

Regulation
Filtered K+ is removed by active reabsorption in the proximal tubules. K+ is then secreted by distal tubular cells.
The amount secreted is proportional to tubular flow: rapid flow  opportunity for the tubular K+ concentration to
rise to a value that stops further secretion. K+ secretion is approximately equal to intake & balance is maintained.
Much of the K+ movement is passive. However there is coupling in that intracellular migration of Na + lowers the
potential difference across the tubular cell which favours K+ movement into the lumen. K+ excretion is decreased
when there is decreased Na+ reaching the distal tubule and when H+ secretion is increased.
Hyperkalaemia - H+ secretion is inhibited (due to intracellular alkalosis) and K + secretion & excretion is
facilitated. Vice versa in hypokalaemia.
 Magnesium Magnesium: distribution, functions
Total body Mg2+ 1000 mmol (15mmol/kg in 70kg man)
ICF - 49%
ECF - 1% [Mg2+] 0.7-1mmol/L or 1.4-2.0mEq/L
Bone - 50%

Functions - major intracellular cation

1. Catalyses/activates 300+ enzymes. Co-factor for inotropic effects of catecholamines. Needed for production of
ATP, DNA, RNA + protein function.
2. Cofactor for all enzymes catalising phosphate transfer e.g. Na+:K+-ATPase, oxidative phosphorylation & all
reactions involving ATP
3. Muscle & nerves - inhibit neurotransmitter release and excitation-contraction coupling (antagonistic to Ca 2+).
Reduce nerve & muscle membrane excitability (same as Ca2+)
4. Smooth muscle - causes vasodilation (deficiency  coronary vasospasm + angina)
5. CNS – various effects including blocking NMDA receptor

Hypermagnesaemia: [Mg2+] mmol/L Reversed by calcium

0.7-1 Normal
2-3.5 Therapeutic range
2.5-5 ECG changes - inc PR, wide QRS
>4.0 Symptomatic - nausea, vomiting, drowsiness.
5.0 Loss of patella reflex
6-8 Respiratory paralysis
7.5 Complete heart block
12 Asystole

Magnesium sulphate
Physicochemical – inorganic sulphate
Presentation – clear, colourless solution containing 2.03mmol/ml of ionic magnesium
1g MgSO4 = 4.06 mmol = 8.12 mEq
2.5 g in 5 mL = 10 mmol in 5 mL (2 mmol/mL) or 50% solution in 50mL (ie. 25 g)

Uses
1. Pre-eclamsia + eclamsia – presynaptic inhibition of ACh release at neuromuscular junction
2. Tocolytic
3. Hypomagnesaemia – malabsorption
4. AMI
5. Torsades + other ventricular arrhythmia
6. Asthma
7. Tetany spasms
8. Hyperreflexia

Effects
 CVS - Vasodilation  hypotension. Slows SA node firing, prolongs SA conduction time, PR
interval + AV refractory time. Attenuates vasoconstrictor + arrhythmogenic actions of adrenaline
 Resp – bronchodilator, attenuates HPV
 CNS – depressant + anticonvulsive properties. High doses inhibit catechol release from adrenergic nerve
terminals + adrenal medulla
 GIT – orally  osmotic laxative
 Renal – renal vasodilator + diuretic effect
 Uterus - tone + contractility. Placental perfusion can increase 2 to vascular resistance.
 Other – prolongs clotting time of whole blood & inhibits platelet aggregation

SE’s – can cause neonatal hypotonia + depression. Warmth, flushing, dizziness, somnolence, arreflexia, AV
conduction disorders, muscle weakness + cardiac arrest.
 Calcium
Total Body Calcium  380mmol/kg =1100g /average adult, ~ 27.5 mol of Ca2+
Daily requirement ~ 0.11 mmol/kg
99% Bone - crystalline form in skeleton + teeth
0.9% extracellularly in soft tissues
0.1% ECF - 50% is protein bound or complexed with PO 43- & 50% is freely diffusable in plasma & ISF (this is the
biologically active part that is subject to regulation)

Important Functions…
Cytoplasm
1. Excitation contraction coupling in all muscle
2. Enzyme cofactor
3. Regulation of mitotic activity

Cell membrane
1. Excitability of nerve / muscle membrane - setting the threshold Vm for excitation
2. Automaticity - smooth muscle, SA & AV nodes
3. Neurotransmitter release at nerve terminals (NMJ)
4. Neuro-hormonal release & activity e.g. -adrenergic (smooth muscle, hepatic glycogenolysis, salivary
secretion), ACh (smooth muscle), ADH, oxytocin, angiotensin II (aldosterone secretion from Z.G), CCK
(pancreatic secretion), histamine, GIT smooth muscle contraction

Extracellular
1. Coagulation cascade - I, II, VII, IX, X - hypocalcaemia low enough to cause coagulopathy is not
compatible with life
2. Complement cascade
3. Bone & teeth formation - Ca2+ hydroxyapetite

HYPOCALCAEMIA: total corrected Ca2+ 2.1 mmol/L (R: 2.10-2.55 mmol/l)

corrected calcium ~ total [Ca++] + 0.02[44 - albumin (g/l)] mmol/l
Clinical Features
CNS - increased irritability, tetany & convulsions
NMJ - reduced threshold Vm, reduced ACh release NMJ
Resp - stridor ± laryngospasm
CVS - reduced SVR, negative inotropyhypotension, negative chronotropy, prolonged QT, atrial & ventricular
ectopics
Treatment - Ca Gluconate 10%, Vit. D - calciferol ~ 1.25 mg twice weekly,

HYPERCALCAEMIA: total corrected Ca2+ > 2.6 mmol/l (R: 2.10-2.55 mmol/l)
Clinical Features
CNS - mental disturbance, paraesthesia, headache, fever, thirst
CVS – bradycardia, asystolic arrest, shortened QT, bradyarrhythmia, AV blockade
NMJ - increased ACh release, increased excitation / contraction, increased threshold Vm (but decreased
sensitivity of motor EP weakness, fatigue, paralysis
Renal – polyuria (nephrogenic DI 2° to impaired tubular reabsorption), nephrocalcinosis
Bone pain, arthralgia
GIT - nausea, vomiting, abdominal pain, constipation, anorexia, weight loss
Treatment - ABC - ventilatory/CVS support, correct dehydration - replace deficit with normal saline, initiate
diuresis (frusemide 20-40 mg IV q4-8h + saline), correct hypokalaemia + hypomagnesaemia +
hypophosphataemia
1992 Write short notes on serum calcium. Write short notes on the regulation of calcium
 
1990 Calcium metabolism 2
Plasma – 2.2-2.55mmol/L
Free Ca2+ - 50%
Bound to albumin – 40-45%
Ca2+ complexes – 5-10%

ICF – 100nM extremely low. Free Ca2+ gradient across cell membrane is
10000:1 (ECF 1mM: 100nM ICF)
Total 1mmoL/L - 1% free, 99% bound to enzymes in SR, cisternae, & tubules

Calcium metabolism requires control of…

4. Homeostasis - immediate adjustments to maintain plasma [Ca 2+] by rapid
exchanges between bone & ECF
5. Balance - ensures intake = excretion over a long period by regulating
intestinal absorption + secretion.

Plasma [Ca2+] is tightly regulated by…

1. Parathyroid hormone
2. Calcitonin
3. Calcitriol (1,25 dihydroxycholecalciferol = active vitamin D)

Effects of parathyroid hormone

PTH – essential for life, 84aa hormone, Plasma [Ca2+], Plasma [PO43-]
Regulation - solely by plasma [Ca2+].
Bone: mobilises hydroxyapatite crystals. Induces fast efflux of calcium from the small labile pool in bone fluid &
promotes bone resorption by osteoclasts (via osteoblasts which no & activity of osteoclasts). Both bone
formation & reabsorption occur, but net effect is bone reabsorption.
Kidneys: activates vitamin D, Ca2+ (distal tubule) & Mg2+ (proximal tubule) resorption & phosphate, aa’s,
bicarbonate, sodium, chloride & sulfate) resorption.
Calcium-sensing receptor is a G-protein, 7 transmembrane domain, very sensitive to extracellular calcium &
found on Chief + parafollicular (cacitonin) cells.
Function – increases release of PTH during hypocalcaemia & suppresses release of PTH during hypocalcaemia

PTHrP
Acts in exactly the same way as PTH & in a paracrine manner at a cellular level. It is the predominant parathyroid
hormone produced in the fetus. It is increased in lactating mothers & also very high in the actual breast milk.
Squamous cell cancers (particularly bronchogenic) produce it, which leads to bone reabsorption & PTH
suppression – malignant hypercalcaemia.

Formation & effects of 1,25 dihydrocholecalciferol

Vitamin D – 7-dehydrocholesterol (vit D precursor in skin) is activated via sunlight (UV radiation) to vit D 3
which can be directly absorbed from the diet. Steroid hormone. Liver enzymes convert to 25-OH D 3 (calcifediol)
and finally kidney enzymes convert to the active form 1,25-(OH) 2 D3 (calcitiol). Circulates on the carrier protein
vitamin D binding protein.
GIT: Calcitriol promotes both calcium & phosphate absorption. It also increases the bones responsiveness to PTH
& stimulates osteoblasts which stimulate osteoclasts to promote bone reabsorption.
Regulation: PTH & low plasma phosphate stimulate the 1’ hydroxylase enzyme in the kidney.

Calcitonin – peptide produced by thyroid c-cells. Lowers serum calcium & phosphate by actions on the bone &
kidneys. Inhibits osteoclastic bone reabsorption, & decreases both calcium & phosphate reabsorption in the
kidney. Useful in the treatment of Paget’s, hypercalcaemia & osteoporosis. Low levels of basal secretion are
increased by a rise in serum calcium or gastrin.
Glucocorticoids – antagonize vitamin D stimulated intestinal calcium transport  renal calcium excretion &
blocks bone formation. Prolonged administration results in osteoporosis & growth stunting in children. Useful for
hypercalcaemia associated with lymphomas & granulomatous diseases e.g. sarcoid.
Eostrogens – prevent accelerated postmenopausal bone loss. Act by reducing the bone resorbing action of
parathyroid hormone. There are also eostrogen receptors in bone – complete deficiency  osteopaenia & failure
of epiphyseal closure.
 Phosphate
Normal adult content ~ 1000 g, of which 85% is in bone
Plasma: inorganic phosphate ~ 0.9-1.5 mmol/l

Functions – involved in most metabolic processes & bone structure.

Regulation
Absorption - HPO4 is well absorbed from the GIT.
Excretion - Urinary excretion is the major homeostatic regulator for total body phosphate balance
~ 5-12% is protein bound, therefore ~ 90% is filterable at the glomerulus
~ 75% is actively reabsorbed, mostly in the PT in co-transport with Na+ (absorptive Tmax for phosphate is very
close to normal filtered load small increases in plasma concentration  large increases in renal excretion).
Na+ loss phosphate loss.
Factors affecting tubular reabsorption of phosphate: PTH Glucagon Dietary Phosphate 1,25-(OH)2D3
Insulin 

Hyperphosphataemia
Effects - hypocalcaemia - ectopic calcification, keratopathy, 2° hyperparathyroidism - renal osteodystrophy
Treatment – diuresis or in renal failure - oral Al(OH)3 & dialysis

Hypophosphataemia: H2PO4 0.8 mmol/l

Symptoms - anorexia, dizziness, weakness, paraesthesia, bone pain (osteomalacia), dyspnoea - respiratory muscle
weakness

C: To outline the composition and functions of lymph

Lymph 2- flow, formation
Lymph is interstitial fluid that enters the lymphatic vessels.

Production
Net plasma ultrafiltrate 20 mL/min (so 18 mL/min returns to capillary at venous end) lymph produced 2
mL/min or 120 mL/h at rest (higher during exercise). The normal 24hr lymph flow is 2-4L.
100 mL/h (83%) of this returns to circ via thoracic duct (junction L subclavian & IJV).

Composition
Clotting factors - lymph will clot in a test tube
Variable amounts of proteins (liver>heart>GIT>lung>skin & none from the brain)
[albumin plasma] 40 g/L
[total protein plasma] 70-80g/L
[protein ISF] 20 g/L,
[protein hepatic lymph] 60 g/L,
[protein thoracic duct] 50 g/L.
Water insoluble fats from the intestine - turns the lymph milky after a meal

Functions…
1. Return of interstitial fluid to the circulation & turnover of tissue fluid
2. Return of plasma proteins - 25-50% of the circulating plasma protein enters the lymphatics (mainly
from interstitial fluid in the liver & intestines) – otherwise oedema ensues.
3. Transport of long-chain fatty acids & cholesterol from the intestine (chyle)
4. Provide mechanism for lymphocytes to enter the circulation. Lymph & lymph tissue involved in
immunological protection (circulation of immune cells & bacteria removal).

There are 2 types of lymphatic vessels…

1. Initial - lack valves & smooth muscle, found in places like intestine & skeletal muscle, tissue fluid enters
through loose junctions between endothelial cells & is massaged by muscle contractions of the
organs/arterioles/etc that they are associated with. Pressure 1mmHg. Present in all tissues except CNS &
bone.
2. Collecting – drain initial lymphatics, have valves + smooth muscle. They contract in a peristaltic fashion.
Flow is aided by skeletal muscle pump, negative intrathoracic pressure & suction effect of high velocity veins
into which they terminate.
D: To define osmotic pressure and to explain the factors that determine it
Osmosis 2 – the diffusion of solvent (i.e. water) from a lower to a higher concentration of solute to which the
membrane is impermeable. This process can be prevented by applying pressure to the more concentrated solution
= osmotic pressure.

Osmotic pressure 9 – measurement 2

Osmotic pressure = the hydrostatic pressure that would need to be applied to a body of water separated from a
solution of ions by a semi-permeable membrane to oppose the net movement of water across that membrane.

"...that which must be applied to a solution to prevent passage into it of a solvent when solution and pure solvent
are separated by a membrane permeable only to the solvent."

E: To outline the significance of oncotic pressure, colloid osmotic pressure and reflection
coefficients
Oncotic pressure = colloid osmotic pressure 3
Colloids - collectively refers to the large molecular weight (nominally MW > 30,000) particles present in plasma
that are too large to cross the capillary membrane. The plasma proteins are the major colloids.
Colloids are solutes & contribute to the total osmotic pressure of the solution. This is typically a small percent
of the total osmotic pressure. It is referred to as colloid osmotic pressure or the oncotic pressure.

Normal oncotic pressure = 25 mmHg or 0.5% of total osmotic pressure of 5540 mmHg.
This is a small percent of total osmotic pressure, but because colloids cannot cross the capillary membrane easily,
oncotic pressure is extremely important in transcapillary fluid dynamics.
Normal albumin 45 g/dL - contributes  75% of oncotic pressure
Globulins - 20%
Fibrinogen - <5%

Clinically signicicant oedema does not occur until plasma oncotic pressure < 11 mmHg (albumin 20 g/dL) there
is a wide safety margin.

Oncometers – measure oncotic pressure

2 chambers are enclosed and separated from each other by a semi-permeable membrane which is…
1. Permeable to water and small MW substances
2. Impermeable to molecules with a MW greater then 30,000
Relative to this membrane, the colloids are the only effective solutes present. The reference chamber contains
isotonic saline and the test solution is added to the sample chamber. If the test solution contains colloids, water
moves from the reference chamber to the sample chamber. The decrease in pressure in the test chamber is
detected by a pressure transducer (strain gauge). Modern oncometers can provide accurate results with samples as
small as 50 microlitres.
Osmolarity 9 – measurement 3

Van't Hoff Equation

Osmotic pressure and oncotic pressure can be measured by instruments. They can also be calculated for an ideal
solution by appropriate substitutions in the van’t Hoff equation.

The van’t Hoff Equation

Osmotic pressure = n x (c/M) x RT

where:

 n is the number of particles into which the substance dissociates ( n = 1 for plasma
proteins)
 c is the concentration in G/l
 M is the MW of the molecules
 c/M is thus the molar concentration of the substance
 R is the universal gas constant

 T is the absolute temperature (K)

For a typical plasma sample:

T = 310K (ie temp of 37C)
R = 0.082
n = 1 (for plasma proteins as they do not dissociate)
Total plasma osmotic pressure = 1 x 0.082 x 310 x 0.001 x 760 x 280 = 5409 mmHg

Multiplying by 0.001 to convert from Osmoles to mOsmoles

Multiplying by 760 to convert the result from atmospheres to mmHg
Multiplying by 280 to convert the osmotic pressure per mOsm/kg to a value for plasma with an osmolality of 280
mOsm/kg

For a plasma osmolality of 280 mOsm/kg at 37C, total osmotic pressure is about 5409mmHg (ie about 7.1 ATM!)

Each mOsm/kg of solute contributes about 19.32mmHg to the osmotic pressure

Plasma proteins alone the colloid osmotic (oncotic) pressure:

Using typical values for concentration & MW of the plasma proteins, the protein concentration is about 0.9
mOsmol/kg which predicts an oncotic pressure of 17.3 mmHg (ie 19.32 x 0.9). Measurement in an oncometer
shows the actual plasma oncotic pressure is about 25 mmHg which is equivalent to a plasma protein concentration
of 1.3 mmol/kg. There a difference between the actual measured value and the value calculated using the van't
Hoff equation because…
1. Proteins are charged & non-permeant  Gibbs-Donnan effect
As protein is both charged and non-permeant across the capillary membrane, it sets up a Gibbs-Donnan
equilibrium which affects the concentration of the diffusable ions on both sides of the membrane. The net result in
this case is an increase in the number of particles per unit volume on the intravascular side of the membrane. The
protein concentration appears to be larger than it is because of these extra particles and the effective oncotic
pressure is therefore increased.
2. The proteins are large  ‘Excluded Volume’ effect
As protein molecules are large the volume they occupy in the solution is significant and this is another reason for
the discrepancy from the van’t Hoff equation which is derived for infinitely dilute (ie ‘ideal’) solutions. This
second effect is known as the excluded volume effect.
The extra particles which are contributing an extra 7 to 8 mmHg (equivalent to about 0.4 mOsm/kg) to the
measured oncotic pressure are mostly Na+ ions as these are the cations present in by far the highest concentration.
The [Na+] in plasma is increased by about 6 to 7 mmol/l because of the Gibbs-Donnan effect.
This increase of 6 to 7 mmol/l is much more than the 0.4 mOsm/l required to account for the increase in oncotic
pressure. What is the explanation for this apparant discrepancy? The answer is that there is also a decrease in
anion concentration which counteracts much of the increase in cation (ie Na+) concentration so the net change in
concentration is an increase of 0.4 mOsmoles/l.
Reflection coefficients
Starling’s hypothesis states that the fluid movement due to filtration across the wall of a capillary is dependent
on the balance between the hydrostatic pressure gradient and the oncotic pressure gradient across the capillary.
The balance of these forces allows calculation of the net driving pressure for filtration.
Hydrostatic pressure in the capillary (Pc) - the capillary hydrostatic pressure falls along the capillary from the
arteriolar to the venous end and the driving pressure will decrease (& typically becomes negative) along the length
of the capillary
Hydrostatic pressure in the interstitium (Pi)
Oncotic pressure in the capillary (pc )
Oncotic pressure in the interstitium (pi )

Net Driving Pressure = [ ( Pc - Pi ) - ( pc - pi ) ]

 Typical values of Starling Forces in Systemic Capillaries (mmHg)

Arteriolar end of capillary Venous end of capillary

Capillary hydrostatic pressure 25 10

Interstitial hydrostatic pressure -6 -6

Capillary oncotic pressure 25 25

Interstitial oncotic pressure 5 5

The net driving pressure is outward at the arteriolar end and inward at the venous end of the capillary. This change
in net driving pressure is due to the decrease in the capillary hydrostatic pressure along the length of the capillary.
Net fluid flux is proportional to this net driving pressure. In order to derive an equation to measure this fluid flux
several additional factors need to be considered:

The reflection coefficient

The reflection coefficient can be thought of as a correction factor which is applied to the measured oncotic
pressure gradient across the capillary wall. The small leakage of proteins across the capillary membrane has two
important effects:
1. The interstitial fluid oncotic pressure is higher then it would otherwise be.
2. Not all of the protein present is effective in retaining water so the effective capillary oncotic pressure is
lower than the measured oncotic pressure (in the same way that there is a difference between osmolality
and tonicity).
Both these effects decrease the oncotic pressure gradient. The interstitial oncotic pressure is accounted for as its
value is included in the calculation of the gradient.
The reflection coefficient is used to correct the magnitude of the measured gradient to take account of the
‘effective oncotic pressure’. It can have a value from 0 to 1.
E.g. CSF & glomerular filtrate have very low protein concentrations and the reflection coefficient for protein in
these capillaries is close to 1. Proteins cross the walls of the hepatic sinusoids relatively easily and the protein
concentration of hepatic lymph is very high. The reflection coefficient for protein in the sinusoids is low. The
reflection coefficient in the pulmonary capillaries is intermediate in value: about 0.5.

The filtration coefficient (Kf )

The net fluid flux (due to filtration) across the capillary wall is proportional to the net driving pressure. The
filtration coefficient (Kf) is the constant of proportionality in the flux equation which is known as the Starling’s
equation.

The filtration coefficient consists of two components as the net fluid flux is dependent on:
1. The area of the capillary walls where the transfer occurs
2. The permeability of the capillary wall to water. (This permeability factor is usually considered in terms
of the ‘hydraulic conductivity’ of the wall.)
The filtration coefficient is the product of these two components: Kf = Area x Hydraulic conductivity
A ‘leaky’ capillary (e.g. due to histamine) would have a high filtration coefficient. The glomerular capillaries are
naturally very leaky as this is necessary for their function; they have a high filtration coefficient.
F: To describe the measurement of osmolality and the control mechanisms involving the
regulation of osmolality

Mole (mol) = gram molecular weight of a substance. Each mol consists of 6x1023 molecules.
Millimoble (mmol) = 1/1000 of a mole
Micromole (mol) = 1/1000000 of a mole

The molecular weight of a substance is the ratio of the mass of one molecule of a substance to 1/12 the mass of a
carbon-12 atom (it is dimensionless, because it is a ratio). The Dalton (Da) is the unit of mass = 1/12 the mass
of a carbon-12 atom

Molarity = the number of moles of solute per litre of solution

Molality = the number of moles of solute per kilogram of solvent

Osmole = the gram molecular weight of a substance divided by the number of freely moving particles that each
molecule liberates in solution. E.g. NaCl dissociates into Na+ & Cl- ions one mole of solution liberates 2
osmole.

Osmolarity = the number of osmoles per liter of solution (Osm/L) *this alters with temperatures changes because
of expansion of the solution.
Osmolality = the number of osmoles per kilogram of solvent (Osm/kg)

Osmolarity & osmolality are almost the same for dilute aqueous solutions because 1L water weighs  1kg.

Tonicity = the effective osmolality of a solution i.e. it only measures the solutes that are capable of exerting an
osmotic force.
This definition is necessary because some solutes e.g. Urea are capable of moving across cell membranes. If
excess urea is infused water will move extracellularly due to the increased extracellular osmolality. But Urea
would then equilibrate across the membrane & the water would move back intracellularly.
tonicity is what’s important for determining fluid distribution across cell membranes. Hypothalmic
osmoreceptors respond to extracellular tonicity rather than osmolality.
Osmolality is easy to measure & tonicity can be estimated as osmolality minus urea & glucose (only ineffective
solutes as any significant concentration.
5% glucose is isoosmolar but hypotonic
Hypertonic urea can be used in ICP because urea crosses the BBB slower than water.
Glucose becomes an effective osmole in diabetes because it is unable to enter fat + muscle cells.

Osmolar gap = Osmolality - Osmolarity

The value measured in the laboratory is usually referred to as the ‘osmolality’. The value calculated from the
solute concentrations is reported by the laboratory as the ‘osmolarity’. The osmolar gap is the difference between
these two values.
ECF osmolality = 285-290 mOsmoles/kg
This could produce an osmotic pressure of 5545 mmHg.

ICF osmolality = ECF osmolality because water crosses cell membranes easily and abolishes any gradient.

Osmolality 5 – measurement 3
Osmolality = the number of osmoles per kilogram of solvent (Osm/kg)

 it is a measures the number of particles present in solution and is independent of the size or weight of the
particles. It can be measured only by use of a property of the solution that is dependent only on the particle
concentration. These properties are collectively referred to as colligative properties.

Colligative properties 6
Colligative properties are the properties of a solution which depend on the particle concentration (i.e osmolality)
1. Osmotic pressure
2. Freezing point depression
3. Vapour pressure depression
4. Boiling point elevation.

E.g. Freezing point decreased by 1.86C per osmole solute. This is why salt is used to melt ice on roads.

Measurement
Serum osmolality can be measured by use of an osometer or it can be calculated as the sum of the concentrations
of the solutes present in the solution….

= 1.86 x [Na] + [urea] + [glc] mOsm/kg

When [glucose] & [urea] are in mg/dL

= 1.86 x [Na+] + [glucose]/18 + [urea]/2.8

- x1.86 because NaCl does not dissociate completely at physiological concentrations

- /18 to convert mg/dl to mOsm/kg (as 180 mg glc = 1 mOsm)
- /28 to convert mg/dl to mOsm/kg (as 28 mg urea = 1 mOsm)

Osmometer
An instrument which uses one of the colligative properties as the basis for its measurement. Currently they use
either freezing point depression or vapour pressure depression. Freezing point depression is more accurate as they
can detect all the volatile alcohols which can abnormally increase the osmolar gap. However vapour point
depression needs a much smaller sample can measure sweat osmolality.
The freezing point of a substance e.g. plasma, urine is measured (by supercooling the liquid, then using a vibrating
stirrer to initiate freezing, then warming the substance until a steady freezing point has occurred) and compared
to ?water. The freezing point depression is found, however modern osometers are calibrated to give a direct
osmolality reading, rather than having to calculate it knowing that freezing point is decreased by 1.86C per
osmole solute.
01A1 Outline the determinants and regulation of extracellular fluid volume 68%

1. ECF volume is determined by the relative distribution of osmotically active solute, primarily sodium and
chloride ions.
Functional ECF normally makes up ~ 30% of total body water, and total ECF ~ 45%.
Determinants of Na+and Cl- ion distribution and amount thus determined ECF volume. Changes in Cl - occur
largely due to changes in Na+ concentration. Na+ is the most important determinant of ECF volume

99.4% filtered Na+ is reabsorbed by the kidneys which are the primary site of controlling ECF Na +
concentration. Regulation of sodium balance involves….

2. Angiotensin II - ACE from lung endothelium activates Angiotensin I (converted from angiotensinogen by
renin released from the kidneys) to from Angiotensin II which has the following effects…
1. Na reabsorption (PCT)
2. Vasoconstriction
3. Thirst
4. ADH (antidiuretic hormone) release
5. Aldosterone secretion
6. increased SNS activation

3. Antidiuretic hormone release

Release stimulated by AII action on hypothalamus, hypotension detected by high pressure baroreceptors in
coronary sinus and aorta, and stimulation of hypothalamic osmoreceptors. Volume receptors override
osmoreceptors if both activated water excretion occurs.
Leads to increased water absorption from collecting ducts through insertion of aquaporin channels in luminal
membrane.

4. Aldosterone secretion
Stimulated by AII  Na+ reabsorption (and thus Cl-) and K+ loss, increasing ECF volume, through actions on
DCT and CD.
Primary means of fine-controlling Na+ reabsorption.

5. ANP (atrial natruiretic peptide)

Released by atria in response to atrial stretch, and thus hypervolaemia.
Act to increase Na+ loss in the urine and thus decrease ECF volume.

6. Tubuloglomerular feedback
Increased solute delivered to thick ascending LOH and DCT detected by macular densa, leading to afferent
arteriole vasoconstriction and decreased GFR. even if GFR changes the fraction of sodium reabsorbed should
remain constant.
Decrease in ECF volume increases TG feedback sensitivity.

7. Tuboglomerular balance
PCT maintains a constant fraction of Na+ reabsorbed from filtered fluid despite changes in GFR.

8. Sympathetic nervous system activation

Increased renin sensitivity & secretion
Increased Na reabsorption by renal tubular cells

9. Sodium is also lost in sweat

05A11 Describe how the body detects and responds to a water deficit
50%
01A7

**Water deficit not volume deficit**

Normal body water in an adult male is ~ 60% or 600mL/kg  42L for 70 kg male.
 Intracellular fluid  55% body water (40% body weight) 23L

 Extracellular fluid  45% body water (20% body weight) 19L

Interstitial fluid 20% Functional
Intravascular fluid 7.5% Functional
Transcellular fluid 2.5% Functional
Water in dense CT 7.5% Kinetically slow
Water in bone 7.5% Kinetically slow

Functional component of ECF  30% TBW

Water deficit causes:

 Increased solute concentration osmolality (the concentration of osmotically active molecules in
a fluid) & tonicity (effective osmolality of a solution).

Increased tonicity detected by hypothalamic osmoreceptors, in anterior hypothalamus (outside BBB). 1-2%
osmolality is threshold for hypothalamic ADH response  release of ADH from the posterior pituitary.
ADH - neural peptide hormone. Synthesised in the hypothalamus (supraoptic and paraventricular nuclei),
transported in secretory granules down the neuronal axon to the post pituitary. Causes water reabsorbtion in the
collecting ducts of the nephron through insertion of aquaporin channels in the luminal membrane of collecting
duct cells. ADH has a short half life (18 min) and is inactivated by the liver and kidney. Negative feedback effect
 secretion once water absorption has occurred.
water is absorbed in excess of solutes & concentrated urine is produced.

Increased osmolality also increases thirst.

 Intravascular depletion and hypovolaemia.

Hypovolaemia detected by low pressure baroreceptors in atria and walls of large veins & pulmonary circulation.
Decreased afferent outflow with falls in CVP lead to…
1. ADH release from posterior pituitary
2. SNS activation  HR, contractility + vasoconstriction.
3.  renin release & renal sensitivity to rennin
4. Direct afferent vasoconstriction to decrease GFR and thus water loss.

Less sensitive than osmoreceptors (requires 7-10% change in intravascular volume), but more powerful output.
Significant intravascular depletion (ie. ~ 10%) requires large water losses ~ 4L total body water.

High pressure baroreceptors in carotid sinus and aortic arch respond to hypovolaemia only if this is severe enough
to effect systolic blood pressure which is unlikely. Decreased firing of baroreceptors onto sensory area A2,
increases sympathetic outflow from area A2. Also increases ADH release.

 Cellular shrinkage due to water loss from intracellular compartment.

96A7 In the diagram below indicate how the solvent and solute move a cross a semipermeable
 
membrane and give a brief explanation of the principles involved.

BLOOD
K+ 6.5 mmol/L Urea 40 mmol/L Osmolarity 320 mmosmol/L Pressure 100 mmHg

Semipermeable membrane

DIASYLATE
K+ 3.5 mmol/L Urea 0 mmol/L Osmolarity 346 mosmol/L Pressure 10 mmHg

Assuming that the membrane is permeable to K +, urea and water, but not to proteins or other solutes in the
solution. Movement of substances across a semipermeable membrane is by Fick's law of diffusion.

Solute movement occurs from areas of high concentration to

areas of low concentration, in order to establish an equilibrium.
K+ moves from the blood to the diasylate - if no other forces
were acting and the volumes of both compartments were equal,
then K+ would be at 5 mmol/L in both compartments. In reality
the disaylate is likely to be continually flushed, maintaining a
K+ of 3.5 in this solution, such that blood K + will also tend
towards 3.5 = ‘convection’.
Urea moves in a similar fashion, from blood to diasylate, with
a similar equilibrium attempting to be established.

Solvent (ie. water) movement occurs across the membrane from areas of low osmolarity to areas of high, in
order to equilibrate solvent concentration. water moves by 'osmosis' from the blood to the diasylate, in an
attempt to dilute the solute concentration in the diasylate and establish an equilibrium.
The movement of solute (ie. urea and K+) will lead to a rise in diasylate osmolality (and a fall of that in blood) and
thus tend to drag water with it = 'solvent drag'.

The movement of fluid is also demonstrated by the balance of Starling's forces which describe the balance of
oncotic and hydrostatic pressures across a capillary wall.
Where rate of filtratate formation (ie. fluid movement) is given by: Kf.(Pb-Pd)-r.(Ob-Od)
Kf = filtration coefficient (quantifying surface area and permeability of membrane)
r = reflexion coefficient (quantifying the impermeability to proteins/colloids)
Pb = blood hydrostatic pressure (100 mmHg here)
Pd = diasylate hydrostatic pressure (10 mmHg here)
Ob = blood oncotic pressure, tending to keep fluid within the blood (not provided).
Od = diasylate oncotic pressure, tending to keep fluid in diasylate.

NB: oncotic pressure (mmHg) is that component of osmotic pressure (the pressure (mmHg) arising from the
osmolarity (mosmol/L) of the solution) which is derived from protein/colloid content, which cannot cross the
membrane.
In this example, the higher hydrostatic pressure in blood greatly encourages filtrate movement across into the
diasylate. The net result is movement of both solute and solvent. Due to the ready movement of water, it is likely
that it would move faster than the solute.
1992 Write short notes on osmoreceptors  

Osmoreceptors
Specialised cells in the hypothalamus which respond to changes in extracellular
tonicity (rather then to changes in osmolality).

Location: Hypothalamus & several other structures, including the organum

vasculosum of the lamina terminalis (OVLT) and the subfornical organ (SFO).
Mechanism: exact mechanism unknown. Possibly that changes in cell volume
affect the concentration of certain critical intracellular molecules or affect the
activity of ion channels in the cell membrane.
As Na+ (and its obligatory associated anions - mostly Cl-, HCO3- & protein-)
account for 92% of ECF tonicity, these receptors (during normal physiology)
function essentially as monitors of ECF [Na+].

Sensitivity: They respond to a change as small as a 1 to 2% increase in tonicity.

Water intake can vary greatly but plasma osmolality varies only one to two percent
because of the efficient and powerful control system coupled to these
osmoreceptors.

These receptors are monitoring 'water balance' indirectly because they look at the
effect of an excess or deficit of water by its effect on tonicity. This could cause a
problem, if for example, both ECF water and solute increased together so that [Na+]
and tonicity remained constant. This is what happens with an intravenous infusion of
normal saline (ie an isotonic expansion of the ECF). Fortunately the body has several
mechanisms of recognising changes in intravascular volume.

Low Pressure Baroreceptors

Effective intravascular volume can be independently assessed by the low pressure
baroreceptors (volume receptors) which also provide input to the hypothalamus.
Location: right atria and great veins
Mechanism: Respond to the transmural pressure in vessel walls.
Sensitivity: Baroreceptors are less sensitive but more potent than the osmoreceptors.
The threshold of the volume receptors for causing changes in ADH secretion is an 8
to 10% change in blood volume. But when stimulated they cause ADH levels to be
much higher than that seen with osmoreceptor stimulation.

Hypovolaemia is a more potent stimulus for ADH release than is hyperosmolality. A

hypovolaemic stimulus to ADH secretion will override a hypotonic inhibition and
volume will be conserved at the expense of tonicity. The maximum levels of ADH
reached with a significant (20%) volume depletion is about 40pg/ml which is larger
than the 12-15pg/ml reached with a maximum isovolaemic increase in osmolality.

High Pressure Baroreceptors

The high pressure baroreceptors input to the hypothalamus via adrenergic pathways.
Location: carotid sinus and respond to changes in mean arterial blood pressure.

The input to the hypothalamus from the volume receptors and the high pressure
baroreceptors rarely conflicts as hypovolaemia tends to be associated with
hypotension (and vice versa).
C: To compare the pharmacology of colloids (albumin, gelatin derivatives, polysaccharide derivatives &
starch solutions) with crystalloids (lactate solutions & normal saline).

Crystalloids Why use? Inexpensive, easy to store, long shelf life, readily available, low incidence of adverse
reactions, a variety of formulations are available, effective for use as replacement fluids or maintenance fluids, no
special compatibility testing & no religious objections to their use

1. Replacement Solutions

These solutions are used to replace ECF. They are all isotonic. They have a [Na+] similar to that of the
extracellular fluid which effectively limits their fluid distribution to the ECF. The fluid distributes between the
ISF and the plasma in proportion to their volumes. Intracellular fluid volume does not change. If used to replace
blood loss, 3 to 4 times the volume lost must be administered as only 1/3 to 1/4 remains intravascularly. In healthy
adults with a normal initial haemoglobin level, up to 20% loss of blood volume (loss of approx 1,000 mls) can be
safely replaced with a 3,000-4,000 ml infusion of replacement solution without any adverse effects.

Hartmann’s solution contains lactate as a bicarbonate precursor. The metabolism of lactate in the liver results in
production of an equivalent amount of bicarbonate. These anions (eg lactate) are the conjugate base to the
corresponding acid (eg lactic acid) and do not contribute to development of an acidosis as they are administered
with Na+ rather than H+ as the cation.

2. Maintenance Solutions

These solutions are used to provide maintenance fluids. They are isosmotic as administered and do not cause
haemolysis. Following administration, the glucose is rapidly taken up by cells so the net effect is of administering
pure water. Dextrose 5% contains no Na+ so it is distributed throughout the total body water with each
compartment receiving fluid in proportion to its contribution to the TBW.

Some maintenance solutions also have Na + so they can be prescribed to provide the daily maintenance
requirements for water and Na+. Supplemental K+ can be added as required. The normal daily Na+ intake of 1.5 to
2 mmol/kg can be given in this way by appropriate fluid selection. The Na + content does alter the fluid distribution
but this is predictable.

Hartmann’s solution contains Ca++ and this can cause problems if administered with stored blood. Citrate is the
anticoagulant used in stored blood and it works by complexing with and removing Ca ++ from solution. It is
possible for the Ca++ in Hartmann’s to cause clotting of blood in the infusion tubing particularly if the blood is
given slowly or the tubing contains reservoir areas (eg as in pump sets). For this reason, it has become standard
practice to administer normal saline before and after a blood transfusion to prevent blood and Ca ++ mixing in the
infusion tubing.

Colloids
Colloids are large molecular weight (nominally MW > 30,000) substances. In normal plasma, the plasma proteins
are the major colloids present. Colloids are important in capillary fluid dynamics because they are the only
constituents which are effective at exerting an osmotic force across the wall of the capillaries. Albumin solutions
are available for use as colloids. In addition, various other solutions containing artificial colloids are available.

Problems with colloid solutions are: much higher cost & small but significance incidence of adverse reactions
(especially anaphylactoid reactions).

Molecular Weight Two molecular weights are quoted for colloid solutions:

Mw : Weight average molecular weight & Mn : Number average molecular weight

The Mw determines the viscosity and Mn indicates the oncotic pressure. Albumin is said to be monodisperse
because all molecules have the same molecular weight (so Mw = Mn). Artificial colloids are all polydisperse with
molecules of a range of molecular weights.

The Ideal Colloid Solution An oncotic pressure similar to plasma will permit replacement of plasma volume
without distribution to other fluid compartments and this is the key element that makes a solution a colloid
solution.
 Table 7.3 The Properties of an Ideal Colloid

General

• Distributed to intravascular compartment only

• Readily available
• Long shelf life
• Inexpensive
• No special storage or infusion requirements
• No special limitations on volume that can be infused
• No interference with blood grouping or cross-matching
• Acceptable to all patients & no religious objections to its use

Physical Properties

• Iso-oncotic with plasma

• Isotonic
• Low viscosity
• Contamination easy to detect

Pharmacokinetic Properties

• Half-life should be 6 to 12 hours

• Should be metabolised or excreted & not stored in the body

Non-Toxic & No Adverse Affect on Body Systems

• No interference with organ function even with repeated administration

• Non-pyrogenic, non-allergenic & non-antigenic
• No interference with haemostasis or coagulation
• Not cause agglutination or damage blood cells
• No affect on immune function including resistance to infection
• No affect on haemopoiesis
• Not cause acid-base disorders
• Not cause or promote infection (bacterial, viral or protozoal)

Dextrans - highly branched poysaccharide molecules which are available for use as an artificial colloid. They are
produced by synthesis using the bacterial enzyme dextran sucrase from the bacterium Leuconostoc mesenteroides
(B512 strain) which is growing in a sucrose medium. The formulations currently available are:

• Dextran 40 (Mw 40,000 & Mn 25,000) [‘Rheomacrodex’] - used to improve microcirculatory flow in association
with certain procedures (eg microsurgical reimplantations).

• Dextran 70 (Mw 70,000 & Mn 39,000) [‘Macrodex’] - duration of action of 6 to 8 hours. Interference with
crossmatching occurs so the laboratory should be notified that dextrans have been used. Dextran interferes with
haemostasis, it induces an acquired von Willebrand’s state. Consequently, there is a maximal dosage
recommendation of 20 mls/kg (about 1,500 mls in an adult).

The dextrans cause more severe anaphylactic reactions than the gelatins or the starches. The reactions are due to
dextran reactive antibodies which trigger the release of vasoactive mediators. Incidence of reactions can be
reduced by pretreatment with a hapten (Dextran 1).

Gelatins - Gelatin is the name given to the proteins formed when the connective tissues of animals are boiled.
They have the property of dissolving in hot water and forming a jelly when cooled. Gelatin is thus a large
molecular weight protein formed from hydrolysis of collagen.
Gelatin solutions were first used as colloids in man in 1915. The early solutions had a high molecular weight
(about 100,000). This had the advantage of a significant oncotic effect but the disadvantages of a high viscosity
and a tendency to gel and solidify if stored at low temperatures. Reducing the molecular weight reduced the
tendency to gel but smaller molecular weight molecules could not exert a significant oncotic effect. The need was
for a modified gelation product that had a moderate molecular weight (for oncotic pressure) but a low gel melting
point.

Several modified gelatin products are now available; they have been collectively called the New-generations
Gelatins. There are 3 types of gelatin solutions currently in use in the world:

 Succinylated or modified fluid gelatins (eg Gelofusine, Plasmagel,Plasmion)

 Urea-crosslinked gelatins (eg Polygeline)

 Oxypolygelatins (eg Gelifundol)

Polygeline (Haemaccel) is available in Australia. The gelatin is produced by the action of alkali and then boiling
water (thermal degradation) on collagen from cattle bones. The resultant polypeptides (MW 12,000 - 15,000) are
urea-crosslinked using hexamethyl di-isocyanate. The branching of the molecules lowers the gel melting point.
The MW ranges from 5,000 to 50,000 with a weight-average MW of 35,000 and a number-average MW of
24,500.

Properties - Polygeline is supplied as a 3.5% solution of ‘degraded gelatin polypeptides cross-linked via urea
bridges’ with electrolytes (Na+ 145, K+ 5.1, Ca++ 6.25 & Cl- 145 mmol/l). It is sterile, pyrogen free, contains no
preservatives and has a recommended shelf-life of 3 years when stored at temperatures less than 30C.

Handling by the Body - It is rapidly excreted by the kidney. Following infusion, its peak plasma concentration
falls by half in 2.5 hours. Distribution (as a percent of total dose administered) by 24 hours is 71% in the urine,
16% extravascular and 13% in plasma. The amount metabolised is low: perhaps 3%.

Indications - replacement of intravascular volume e.g. correcting hypovolaemia due to acute blood loss. It is also
used in priming heart-lung machines.

Advantages

• Lower infusion volume required as compared to crystalloids

• Cheaper and more readily available then plasma protein solutions
• No infection risk from the product if stored and administered correctly
• Only limit to the volume infused is the need to maintain a certain minimum [Hb]. (Dextrans have a 20ml/kg
limit).
• Readily excreted by renal mechanisms
• Favourable storage characteristics: long shelf life, no refrigeration
• No interference with blood cross-matching
• Compatible with other IV fluids except Ca++ can cause problems with citrated blood products.

Disadvantages

• Higher cost then crystalloids

• Anaphylactoid reactions can occur
• No coagulation factors and its use contributes to dilutional coagulopathy

Starches

These polydisperse colloid solutions are produced from amylopectin which has been stabilised by
hydroxyethylation to prevent rapid hydrolysis by amylase. Hydroxyethylstarch is removed from the circulation by
renal excretion and by redistribution. Anaphylactoid reactions occur in about 0.09% of cases. Some patients
experience severe pruritis. A particular concern is the possibility that starch preparations can affect the
coagulation process. This issue has not been resolved but it seems prudent to avoid its use in patients with a
coagulopathy. The maximum recommended dose is 20 mls/kg so its use in major resuscitation is limited.