MAJOR INTRA- AND EXTRACELLULAR 3.

Plasma or vascular fluid (4-5% of

ELECTROLYTES body weight)
- Extracellular fluid – includes both
- The body’s fluids are solutions of inorganic
interstitial and vascular fluids
and organic solutes
- The concentration balances of the various
components are maintained in order for the
cells and tissues to have a constant
environment (homeostasis)
- To maintain this internal homeostasis, there
are regulatory mechanisms that control pH,
ionic balances, osmotic balances etc.
Functions:
- Muscle contraction
- Nerve impulses
- Cellular signaling
- Cellular transport
- Waste excretion
- Maintaining pH balance
- Breathing
There are large number of products under the
general heading of replacement therapy which can
be used by the physician when the body itself is
unable to correct an electrolyte imbalance due to a
change in the composition of its fluids
These products include electrolytes, acids and
bases, blood products, carbohydrates, amino acids
Fluid Electrolyte Concentrations:
and proteins
- Each fluid compartment has a distinct solute
Edema – condition in which fluid accumulates in
pattern (as seen in the previous table)
the interstitial compartment. Sometimes due to
- The solution in each compartment is
blockage of lymphatic vessels or by a lack of
ionically balanced
plasma proteins or sodium retention
Thus, sodium and chloride are found in the plasma
Fluid balance and interstitial fluids while potassium, magnesium
2−¿¿
- Amount in = amount out and phosphate (as phosphate esters, HPO4 ) are
- Average daily intake is 2500ml (fluids, food, found in intracellular fluid
and metabolic water)
- Average daily output is 2500ml (urine, Expression of Concentrations
feces, perspiration, insensible perspiration) - The concentrations of individual ions are
expressed by mEq/l (milliequivalents/liter)
Compartments rather than weight/volume (w/v)
- Dosages of individual ions are expressed in
- The electrolyte concentration will vary with a mEq/l
particular fluid compartment - Equivalent weight is obtained by dividing the
- The three compartments are: atomic or molecular weight by the valence
1. Intracellular fluid (45-50% of body - mEq/l = mg of substance/l ÷ Mol.wt/valence
weight) = mg of substance/l ÷ Mol.wt/valence
2. Interstitial fluid (12-15% of body - calculation of weight of salt necessary to
weight) yield the required number of mEq:
- mg/liter = (mEq/l)(Eq.wt) = (MeQ/L) X
(Mol.wt/valence)
 Hyperchloremia
MAJOR PHYSIOLOGICAL IONS:
- Dehydration
Chloride - Decreased renal blood flow found in
- it is the major extracellular anion congestive heart failure
- principally responsible for maintaining - Severe renal damage
proper hydration, osmotic pressure and - Excessive chloride intake
normal cation-anion balance in the
extracellular fluid compartments Bicarbonate
- food is the main source of chloride with the
- The bicarbonate ion acts as a buffer to
anion being almost completely absorbed
maintain the normal levels of acidity (pH) in
from the intestinal tract
- chloride is removed from the blood by blood and other fluids in the body
glomerular filtration and possibly is - Bicarbonate levels are measured to monitor
reabsorbed by the kidney tubules the acidity of the blood and body fluids
functions: - The acidity is affected by foods or
- chloride travels primarily with sodium and medications that we ingest and the function
water and helps generate the osmotic of the kidneys and lungs
pressure of body fluids - Disruptions in the normal bicarbonate level
- it is an important constituent of stomach may be due to diseases that interfere with
hydrochloric acid (HCl), the key digestive respiratory function, kidney diseases,
acid metabolic conditions
- chloride is also needed to maintain the
body’s acid-base balance. Chloride may Phosphate – it is the principal anion of the
also be helpful in allowing the lover to clear intracellular fluid compartment
waste products
Physiological functions:
Chloride deficiency
- Hexoses are metabolized as phosphate
- chloride deficiency can arise from diarrhea,
esters
vomiting or sweating
- The phosphoric acid anhydride linkage is
- it can lead to metabolic alkalosis (body
the body’s means of storing potential
fluids becoming too alkaline), low fluid
chemical energy is adenosine triphosphate
volume and urinary potassium loss
(ATP)
- this can cause further problems in acid-base 2−¿¿ −¿ ¿
balance - The HPO4 / H 2 PO 4 is an important
buffer system, both biochemically and
Hypochloremia pharmaceutically
- It is caused by: - Calcium metabolism
a. Salt-losing nephritis (inflammation of - Phosphorous is essential for normal bone
the kidney) associated with chronic and tooth development- component of
pyelonephritits (inflammation of the hydroxyapatite
kidney and its pelvis) leading to a Hyperphosphatemia
lack of tubular reabsorption of
chloride - It is found in Hypervitaminosis D (which
b. Metabolic acidosis such as found in increases intestinal phosphate absorption
diabetes. Mellitus and renal failure, along with calcium), renal failure due to the
causing either excessive production inability to excrete phosphate into the urine
or diminished excretion of acids and hypoparathyroidism (lack of parathyroid
leading to the replacement of hormone permits renal tubular reabsorption
chloride by acetoacetate and of phosphate which results in decreased
phosphate urinary phosphate and a rise in serum
c. Prolonged vomiting with loss of phosphate)
chloride as gastric hydrochloric acid - Treatment: basic aluminum carbonate is
used to remove dietary phosphate by
 excreting it in the faces as slightly soluble  Severe dehydration
aluminum phosphate  Certain types of brain injury
 Excess treatment with sodium salts
Hypophosphatemia
Sodium & Hypertension
- It can be caused by:
 Vitamin D deficiency (rickets) - There is a good correlation between sodium
 Decreased intestinal calcium absorption content of the tissues (as NaCl) and
 Hyperparathyroidism hypertension. If sodium concentrations
 Long term aluminum hydroxide gel increase in the body and is not eliminated
antacid then water is retained in the tissues to
maintain osmotic balance so edema occurs
Sodium
and the build-up of fluids puts an added
- It is the principal cation in the extracellular burden on heart
fluid - Treatment: low salt diets, diuretics,
- More than adequate amounts of sodium are cardionic drugs
contained in the daily diet with nearly
Potassium
complete absorption from the intestinal tract
- Excess sodium is excreted by the kidneys - It is the major intracellular cation, present in
which make them the ultimate regulator of a concentration approximately 23 times
the sodium content of the body higher than the concentration of potassium
- 80-85% of the sodium in the glomerular in the extracellular fluid compartments
filtrate is reabsorbed and this reabsorption - This concentration differential is maintained
is under hormonal control by an active transport mechanism
- During transmission of a nerve impulse,
Function:
potassium leaves the cell and sodium
- Sodium regulates the total amount of water enters the cell
in the body and the transmission of sodium - Sodium-potassium pump – the active
into and out of individual cells also plays a transport mechanism
role in critical body functions - Potassium in the diet is rapidly absorbed
- Many processes in the body, especially in - Excess potassium is rapidly excreted by the
the brain, nervous system, and muscles, kidneys
require electrical signals for communication
Functions
- The movement of sodium is critical in
generation of these electrical signals - Maintains the electrolyte balance in your
body’s cells
Hyponatremia
- Manages your blood pressure and keeps
Causes: your heart functioning properly
- Assists nervous system by aiding in the
 Extreme urine loss such as seen in correct function of tissues needed for
diabetes insipidus sending nerve impulses
 Metabolic acidosis in which the sodium - Helps the muscles contract
is excreted - Enhances muscle control, the growth and
 Addison’s disease with decreased health of your cells
excretion of ADH hormone, aldosterone - Promotes efficient cognitive functioning by
 Diarrhea and vomiting helping to deliver oxygen to the brain
 Kidney damage
Hypokalemia
Hypernatremia
- It can occur from vomiting, burns,
Causes: hemorrhages, diabetic coma, intravenous
 Hyperadrenalism (Cushing’s syndrome) infusions of solutions lacking in potassium,
with increased aldosterone production overuse of thiazide diuretics
 - Hypokalemia can cause changes in - Functionally, 99% of al body Ca is
myocardial function, flaccid and feeble supportive, being found in bone as
muscles and low blood pressure hydroxyapatite
- The remaining ionic Ca is involved in
Hyperkalemia
neurohormonal functions, muscle
- Usually occurs during kidney damage contraction, blood clotting
- It causes the heart muscle to become - Ca is essential for blood clotting. Anti-
flaccid (by displacing calcium in the cardiac coagulant is added to whole blood to
muscle) and leads to possible cessation of complex the blood Ca and thereby prevent
heart (potassium arrest/cardiac arrest) the clot formation in the clotted blood

Magnesium Hypercalcemia

- It is the second most plentiful cation in the - It can be caused by hyperparathyroidism,

intracellular fluid compartment hypervitaminosis D and some bone
- Uses: it is an essential component of many neoplastic disease
enzymes including phosphate metabolism, - Symptoms include fatigue, muscle
protein synthesis and smooth muscle weakness, constipation, anorexia and
functioning of the neuromuscular system cardiac irregularities
- Causes of negative magnesium level are - If the conditions persists, Ca may be
malnutrition, dietary restrictions, chronic deposited in kidney and blood vessels
alcoholism, faulty absorption,
Hypocalcemia & Bone malformation
gastrointestinal diseases, medications and
parathyroid hormone imbalances - It can be caused by hypoparathyroidism,
- Magnesium cation has a definite vitamin D deficiency, osteoblastic
pharmacological action metastasis, acute pancreatitis
- Magnesium is not readily absorbed from the hyperphosphatemia
gastrointestinal tract because its absorption - Associated with the above condition are
is retarded by alkaline media disorders in bone metabolism
- Most of the absorption takes place in the - Bone is the dynamic tissue involving
acid medium of the duodenum constant exchange of calcium and
- Due to the slow absorption of magnesium phosphate ions with the body fluids
ions, a saline laxative action occurs upon - Much of this exchange is under hormonal
the ingestion of any water soluble control
magnesium compound - Bone, in addition to providing structural
support, is also storage tissue for calcium
Calcium
- Bone degeneration commonly associated
- 99% of body calcium is found in bones. The with aging is osteoporosis, which is reduced
remaining Ca is found largely in volume of anatomical bone
extracellular fluid - As the condition progresses, the bones
- Ca is absorbed from the upper part of the become more weaker and fragile
small intestine where the intestinal contents - There are several reasons –
are still acidic - Decreased Ca absorption
- As the intestinal contents remain neutral to - Vitamin D deficiency
basic, Ca is precipitate as the CaHPO4, - Increased sensitivity to parathyroid
carbonate, oxalate and sulfate salts hormones
- Actual absorption is controlled by - Bone dissolution
parathyroid hormone and metabolite of - Treatments:
Vitamin D  Increased calcium and Vitamin D intake
 Increased phosphate
Function:  Sodium fluoride
 Administration of calcitonin
ELECTROLYTES USED FOR REPLACEMENT Potassium Chloride
THERAPY
- Occurs as colorless, elongated, prismatic or
Sodium Chloride cubic crystals or as a white, granular
powder
- Occurs as colorless cubic crystals or as a
- Freely soluble in water, more soluble in
white, crystalline powder having a saline
boiling water, insoluble in alcohol
taste
- It is the drug of choice for oral replacement
- Freely soluble in water, more soluble in
of potassium
boiling water, soluble in glycerin and slightly
- It is irritating to the gastrointestinal tract and
soluble in alcohol
solutions must be well diluted and the
- Uses:
tablets must be enteric coated.
 Replacement therapy, manufacture of - Potassium chloride is given alone as an
isotonic solutions, flavor enhancer isotonic solution, in an isotonically balanced
 In order to be isotonic, a salt should be sodium chloride solution or as 500ml of 5%
0.9% w/v glucose (dextrose) solution containing
- Isotonic solutions are used as wet 40mEq of potassium
dressings, for irrigating body cavities or
tissues, as injections when fluid and Indications:
electrolytes have been depleted
- Hypopotassemia
- Build up of excessive extracellular may lead
- Paralysis
to pulmonary and peripheral edema
- Antidote in digitalis intoxication
- Usual dose: oral 1gm 3x a day
- As an adjunct to drugs used in the treatment
 Iv infusion, 1L of a 0.9% solution
of myasthenia gravis (severe muscle
 Topically to wounds and body cavities
weakness)
 As a 0.9% solution for irrigation
Available Forms of Potassium Chloride:
Available Forms of Sodium Chloride:
 Potassium Chloride Injection
 Sodium Chloride Injection
Available as concentrates: 1.5 g in 10ml;
Contains 0.9% NaCl
3g in 12.5ml
Category: fluid and electrolyte
 Potassium Chloride Tablets
replenisher, irrigation solution
Available as enteric coated tablets
 Bacteriostatic Sodium Chloride
containing 300mg or 1g
Injection
 Ringer’s Injection
Contains 0.9% NaCl. Category: sterile
Contains 0.03% KCl (147mEq/l Na,
vehicle
4mEq/l K, 4.5mEq/l Ca, 155.5mEq/l Cl)
 Sodium Chloride Solution
Category: fluid and electrolyte
Contains 0.9% NaCl, Category: isotonic
replenisher
vehicle
Usual dose: intravenous infusion, 1L
 Dextrose and Sodium Chloride
 Lactated Potassium Saline Injection
Injection
Contains 0.026% KCl (121mEq/l Na,
Category: Fluid, nutrient and Electrolyte
35mEq/l K, 103mEq/l Cl, 53mEql
replenisher
lactate)
 Fructose and Sodium Chloride
Category: fluid and electrolyte
Injection
replenisher
Contains: 10% fructose and 0.9% NaCl
Category: Fluid, nutrient and Electrolyte Potassium Gluconate
replenisher
- Occurs as a white to yellowish white,
 Ringer’s Injection
crystalline powder or as granules
Contains: 0.86% NaCl
- Freely soluble in water, practically insoluble
Category: Fluid and electrolyte
in dehydrated alcohol, ether, benzene,
replenisher
chloroform
 - Less irritating and easier to use to mask Calcium Gluconate
potassium’s saline taste
- Occurs as white crystalline, odorless,
- Category: electrolyte replenisher
tasteless granules or powder which is stable
- Usual dose: the equivalent of 10mEq of
in air
potassium, 4x daily
- Sparingly soluble in water, freely soluble in
Available forms: boiling water, insoluble in alcohol
- It is the treatment of choice for
 Potassium Gluconate Elixir – hypocalcemia because. It is nonirritating
available as an elixir containing 4.68% when given orally and intravenously
of potassium gluconate in each 15ml, - Usual dose: oral 1g three or more times a
equivalent to 20mEq of potassium day
 Potassium Gluconate Tablets – IV 1g one or more times a day
available as sugar-coated tablets
containing 1.17g of potassium gluconate Available forms:
equivalent to 5mEq of potassium
- Calcium gluconate Injection (97mg Calcium
Calcium replacement: Gluconate/ml)
- Calcium gluconate Tablets (500mg and 1g
 Calcium chloride tablets)
 Calcium gluconate
 Calcium lactate PARENTERAL MAGNESIUM ADMINISTRATION
 Dibasic calcium phosphate Magnesium Sulfate
 Tribasic calcium phosphate
- Used as a central nervous system
Calcium Chloride depressant in the treatment of eclampsia
(convulsion and coma)
- Occurs as white, hard, odorless fragments
- Used during hypomagnesemia
or granules
- Overtreatment with magnesium sulfate can
- Freely soluble in water, alcohol, boiling
cause respiratory paralysis and cardiac
alcohol and very soluble in boiling water
depression
- It is irritating to the veins and should be
- Category: anticonvulsant and cathartic
injected slowly
- Usual dose: IV 4gm in 10% solution
- It is contraindicated in hypocalcemia
associated with renal insufficiency Physiological acid base balance
- Used as a calcium source in many
commercially available electrolyte - Acids are continuously being produced
replacement and maintenance solutions during metabolism. Since most metabolic
reaction occurs only within very narrow pH
Available forms: range, body utilizes several buffer systems
- Two of the major buffer systems in the body
 Ringer’s Injection
are bicarbonate/carbonic acid found in
Contains: 0.0033% CaCl2.H2O
plasma and kidneys and
(147mEq/l Na, 4mEq/l K, 4.5mEq/l Ca,
phosphate/dihydrogen phosphate found in
155.5mEq/l Cl).
the cells and kidney
Category: fluid and electrolyte
- Also, hemoglobin buffer system which is the
replenisher
most effective single system buffering
 Lactated Ringer’s Injection
carbonic acid produced during metabolic
Contains 0.02% CaCl2.H2O (130mEq/l
processes
Na, 4 mEq/l K, 2.7mEq/l Ca, 109.7mEq/l
- Carbon dioxide is continuously produced in
Cl, 27mEq/l lactate).
the cells. It diffuses from the cells into the
Category: systemic alkalizer, fluid and
plasma where a small portion is dissolved,
electrolyte replenisher
and another small portion reacts with the
water to form carbonic acid
 - The increased carbonic acid is buffered by -
plasma protein - Lactate, acetate and citrate are normal
- Most CO2 enters the erythrocytes where it components of metabolism and will be
either rapidly forms carbonic acid by the degraded to carbon dioxide and water. The
action of carbonic anhydrase or combines carbon dioxide by the action of carbonic
with hemoglobin anhydrase will form bicarbonate and reduce
the bicarbonate deficit.
- The tendency to lower the pH of the
- Metabolic alkalosis has been treated with
electrolyte due to increased concentration of
ammonium salts e.gNH4Cl and it retards
carbonic acid is compensated by Na-H exchange in the kidneys.
hemoglobin
- Bicarbonate anion then diffuses out of the Sodium Bicarbonate
erythrocyte and chloride anion diffuses in - Occurs as a white, crystalline powder which
- This has been named chloride shift is stable in dry air but slowly decomposes in
- The bicarbonate in plasma along with the moist air
plasma carbonic acid, now acts as an - Solutions are alkaline to litmus
efficient buffer system - When heated, the salt loses water and
- Then in the lung, there is a reversal of carbon dioxide and is converted into the
above process due to large amounts of normal carbonate
oxygen present 2 NaHCO3 ——> Na2CO3+ H2CO3
<——
- Oxygen combines with the
H2CO3——> H2O + CO2
deoxyhaemoglobin, releasing protons - The above decomposition takes place when
- These combine with the bicarbonate, the dry salt or a solution is heated
forming carbonic acid, which then Importance:
dissociates to carbon dioxide and water 1. The normal acid-base balance of the plasma is
- The carbon dioxide is exhaled by the lungs maintained by three mechanisms working together
- The buffers of the body fluids and red blood
Acid excretion through kidneys cells
The steps for acid excretion in the kidneys occur as - Pulmonary excretion of excess carbon
follows: dioxide
- Renal excretion of either excess acid or
1. Sodium salts of mineral and organic acids base
are removed from the plasma by glomerular - The bicarbonate/carbonic acid system is the
filtration most important plasma buffer. This buffer
system involves an equilibrium between
2. sodium is preferentially removed from the sodium bicarbonate and carbonic acid.
renal filtrate or tubular fluid and in the tubule - At a given pH, the ratio of the
cells, reacts with carbonic acid formed by concentrations of the two substances is
the carbonic anhydrase catalyzed reaction constant.
of carbon dioxide and water. This is
sometimes called the Na+ -H+ exchange - The priniciple is as follows:
3. The sodium bicarbonate returns to the
plasma and the proton enter the tubular  If an excess of acid is liberated in the
fluid, forming acids of the anions that body, it is neutralized by some of the
originally were sodium salts. sodium bicarbonate.
 The excess carbonic acid decomposes
Electrolytes used in acid-base therapy into water and carbon dioxide and this
carbon dioxide is excreted by the lungs
- Metabolic acidosis is treated with sodium
until the normal bicarbonate/ carbonic
salts of bicarbonate, lactate, acetate and
acid ratio is achieved.
occasionally citrate H++ NaHCO3--------> Na++H2CO3
- Administration of bicarbonate increases the sH2CO3--------> H2O + CO2
H C O−¿¿
3 / H2CO3 ratio when there is
bicarbonate citrate
 If an excess alkali occurs in the body, it Fluid Maintenance therapy:
combines with carbonic acid to form
bicarbonate and so more carbonic acid - Maintenance therapy with intravenous fluids
is formed from carbon dioxide and water is intended to supply normal requirements
to restore the balance. for water and electrolytes to patients who
Importance: cannot take them orally.
- All maintenance solutions should contain
2. Sodium bicarbonate is used in medicine atleast 5% dextrose. This minimizes the
principally for its acid neutralizing properties. It is buildup of metabolites such as urea,
used to: phosphate and ketone bodies associated
 To combat gastric hyperacidity with starvation.
 To combat systemic acidosis - In addition to dextrose, the general
 For miscellaneous uses electrolyte composition of maintenance
solution is 25-30 mEq/l Na, 15-20 mEq/l K,
Available forms: sodium Bicarbonate Injection 22mEq/l Cl, 20-23mEq/l HCO3 (or
Sodium Bicarbonate Tablets equivalent amounts of lactate or acetate), 3
mEq/l Mg and 3 mEq/l P.
Sodium Citrate - Replacement therapy is needed when there
- Occurs as colorless crystals or as a white, is heavy loss of water and electrolytes due
crystalline powder to prolonged fever, severe vomiting and
- used as an anticoagulant for whole blood by diarrhea.
chelating serum calcium, thereby removing - There are usually two types of solutions
one of the components of blood clotting used in replacement therapy:
- Used as buffering agents  A solution for rapid initial
- Used in chronic acidosis replacement and a solution for
Usual dose: 1-2gm every 2-4hrs as required subsequent replacement
Available forms:
Rapid initial replacement
 Anticoagulant Citrate Dextrose Solution - The electrolyte concentration in solutions for
 Anticoagulant Citrate Phosphate rapid initial replacement are as follows:
Dextrose Solution  130-150 mEq/l Na,
Ammonium Chloride  4-12mEq/l K,
- Occurs as colorless crystals or as a white,  98-109mEq/l Cl
fine or coarse crystalline powder  28-55mEq/l HCO3 (or equivalent
- Has a cool saline taste amounts of lactate or acetate or
- Freely soluble in water and in glycerin, gluconate),
sparingly soluble in alcohol  3 mEq/l Mg and
- The ammonium cation falls into certain  3-5 mEq/l Ca.
pharmacological categories: Subsequent replacement
 To treat Acidosis - The electrolyte concentration in solutions in
subsequent replacement are as follows:
 Diuretic effect
 40-121mEq/l Na,
 Expectorant effect
 16-35mEq/l K,
Electrolyte combination therapy
 30-103mEq/l Cl,
- In short-term therapy, such as following a
surgery, infusion ofa standard glucose and  16-53mEq/l HCO3 (or equivalent
saline solution may be adequate. amounts of lactate or acetate),
- However, when deficits are severe,  3-6 mEq/l Mg
solutions containing additional electrolytes  0-5 mEq/l Ca and
are usually required.  0-13 mEq/l P
Commercial electrolyte infusion solutions can Official combination electrolyte infusions
be divided into two groups:
Ringer’s injection
1. Fluid maintenance
Each liter contains 8.6 g of sodium chloride,
2. Electrolyte replacement 0.3 g of potassium chloride,
0.33 g of calcium chloride.
This is equivalent to 147 mEq/l Na,
4 mEq/l K,
4.5 mEq/l Ca,
155.5 mEq/l Cl.
Usual dose: Intravenous infusion, 1 liter.
Lactated Ringer’s Injection
Each 100ml contains 600 mg of sodium chloride,
310 mg of sodium lactate,
30 mg of potassium chloride
20mg of calcium chloride.
This is equivalent to 130 mEq/l Na,
4 mEq/l K,
2.7 mEq/l Ca,
109.7 mEq/l Cl
27 mEq/l lactate.z
Usual dose : Intravenous infusion, 1 liter.