Body fluid

The maintenance of a relatively constant volume and a stable composition of the body fluids are essential for homeostasis.
[Most important problems in clinical medicine arise because of abnormalities in the control systems that maintain this constancy of the body fluids] .

During steady-state conditions intake and output must be balanced, despite the continuous exchange of fluid and solutes with the external environment as well as within the different compartments of the body

Intake 2.3 L/day :

-Ingested water 2.1 L/d water, food -Synthesis 200 oxydation

Output 2.3 L/day :

- Insensible loss 700 evaporation, diffusion - Sweat 100 , hot more - Feces 100 ml/d - Urine 1.4 , 0.5-20L

Table 14-3, p. 451

Table 14-2, p. 447

Body fluid compartments 60% of body weight

Intravascular Extravascular a. Plasma a. Extracellular 20% b. Interstitial c. Transcellular : in synovial, peritoneal, pericardial , CSF.
b. Intracellular 40%

Body fluid compartments

Percentage of fluids determines by age. Gender, and degree of obesity. ICF : 28 L, around 40% of body weight.

ECF : 14 L around 20% of body weight. Interstitial is 75%, plasma is 25%.

 contains both ICF (RBCs) & ECF (plasma) considered as a separate compartment because its contained in the circulatory system. 7% of body weight: 5 L, 60% plasma, 40% blood cells.

hematocrit :(packed red cell volume) the fraction of blood composed of RBCs (in men: 0.4 , in women: 0.36). in anemic patients the hematocrit is lower. patients with polycythemia have higher hematocrit

Table 14-1, p. 445

Plasma

Interstitial fluid

Intracellular fluid (skeletal muscle)

Plasma membrane

Capillary wall

Fig. 14-2, p. 446

Composition of ECF
Donnan effect: Plasma proteins negatively charged, so attract more cations in plasma, and repel negatively charged out. 2% cations more iside. ICF: small quantities of sodium, chloride, almost no calcium, but large amount of potassium, phosphate, sulfate ions, and large amount of proteins (4 times more than plasma)

Measurement of fluid volumes

Indicator-diluting-principle: indicator: - evenly distributed in targeted compartment. - not metabolized, or excreted. - not toxic -easy to use. Analyze concentration of indicator: - chemically - photo electrically -radioactivity. Injected mass = mass after dispersion Vi . Ci =Vf . Cf

Measurement of fluid volumes :

- Indicator-dilution principle Vi Ci = Vf Cf a. Total body water: tritium H2O, deuterium H2O, Antipyrine b. ECF : Labeled Na , Cl, thiosolfate , iothalmate, and inuline c. ICF = TBW - ECF (calculated) d. Plasma : I - serum albumin, Evans blue dye e. Interstitial = ECF - plasma (calculated) f. Blood vol. = plasma vol. 1 - Hct g. RBC: chromium

Regulation of fluid exchange

b/w intra-and extracellular fluid

Regulation of fluid exchange

Distribution b/w plasma & interstitial is determined by balance of hydrostatic & colloid forces across capillary. Distribution b/w IC and ECF is determined by osmotic effect of the smaller solutes acting across cell membrane.

Regulation of fluid exchange

Relation b/w moles and osmoles: water concentration in a solution depends on the # of solute particles in solution, so a concentration term is needed to describe the total concentration of solute particles, regardless of their exact composition. Total # of particles in solution is measured in osmoles.

Regulation of fluid exchange

Osmotic pressure: Precise amount of pressure required to prevent the osmosis. The higher the osmotic pressure of a solution, the lower the water concentration and the higher the solute concentration of the solution.

Relation between moles and osmoles

1 osmole = 1 mole of solute particles (6.02 x10). 1 mole glucose = 1 osm. 1 mole NaCl = 2 osm. 1 mole Na2SO3 = 3 osm.

Osmotic pressure : pressure that prevents the osmosis . The higher the osmotic pressure of a solution, the lower its [H2O] but the higher its [solute]. According to Vant hoffs law: = CRT = 19300 mm Hg for 1 osmole/liter at body temp.
(osmotic pr.) C(solute con. In osmole/liter) R (ideal gas const.) T(absolute temp.)

Osmolarity of body fluids

In ECF more than 80-90% related to sodium chloride concentration. In ICF 50% related to potassium concentration. ECF & ICF osmolarity almost 300 mOsm/L. Plasma has one mOsm/L more because of plasma proteins effect.

Osmolarity of body fluids

If particles exert interionic & intermolecular attraction, that causing slight decrease of osmotic activity. If particles repel each other, that causes a slight increase in osmotic activity. Plasma = 282 mOsm/L ECF & ICF = 281 mOsm/L

-Frequent problem in the treatment of seriously ill patients is the difficulty of maintaining adequate fluids in one or both of the intra- and extracellular compartments.

- Osmotic effect of electrolytes (NaCl) determines the distribution of fluids b/w intra- and extracell. comp.

(because the membrane is permeable for H2O but not for Na and Cl)

- Osmolality and osmolarity in human fluids are equal.

 osmotic pr. = osmolarity(mOsm/L) X 19.3 mmHg the calculated value is not 100% correct due to intraionic and intermolecular interactions between the particles and it has to be multiplied by the osmotic coefficient of the particles to reach the true value. the osmolarity of the body fluids is around 300 mOsm/L, the plasma being 1mOsm/L higher because of the osmotic effect of plasma proteins

Osmotic equilibrium
Small changes in concentration of impermeant solutes in the ECF can cause tremendous changes in cell volume .

Isotonic Isosmotic

Hypertonic Hyperosmotic

Hypotic Hypoosmotic

Osmotic Equilibrium

Isotonic, hypotonic and hypertonic solutions depend on how cells behave in the solution, whether they swell or shrink or do not change their volume. Iso-smotic, hyper-osmotic, and hypoosmotic : determine the level of osmolarity regardless of weather solute can penetrate cell membrane.

Osmotic equilibrium
Transfer of fluid across membrane occurs rapidly, so osmolariteis b/w IC & ECF are corrected w/in seconds, or at the most, minutes. After drinking water we need only 30 min. to reach equilibrium everywhere in the body.

Osmotic equal. principles :

1. Osmolarity of ECF and ICF remain almost exactly equal, except for a few minute after a change in one compartment. 2. Cell membrane almost impermeable to many solutes so # of osmoles is constant unless solutes are aded to or lost from the ECF.

1. Calculation of H2O deficit in dehydration - 70 Kg pt. dehydrated unconscious. Plasma osm. 320 mOsm. - How much water needed to restore plasma osmolarity to 280 mOsm/L .

First step: assuming ECF 20% of body wt. ICF 40% ____ ECF Vol. 14 L Osmoles 4480 ICF 28 L 896 Total 42 L 13440

(because osm. = 320)

Second step: determine the volume needed to reduce osmol. to 280 mOsm/L. Knowing that # of mosmoles is constant then volume = # mosmoles osmolarity
ECF ICF Total

Vol. Osm. # osm.

16 280 4480

32 280 8960

48 L 280 13440

Third step : Calculate the fluid volume needed.

48 L - 42 L = 6 L water

Volume & osmolarity in abnormal states

-Ingestion of water - Dehydration -I.V infusion -Loss of fluids: From GI : diarrhea, vomiting. Sweating : during hot weather, or heavy exercise. From kidneys: diabetes insipidus, and neprogenic.

What is the effect of infusing 2 liters of a hypertonic 3.0 per cent sodium chloride into the ECF compartment of a 70Kg patient whose initial plasma osmolarity is 280mOsm/L?

Table 14-4, p. 453

Glucose and other solutions administered for nutritive purposes

given to patients who can not otherwise take adequate amounts of nutrition. the osmotic ally active substances concentrations are adjusted nearly to isotonicity, or they are given slowly enough in order not to disturb the osmotic eq. of the body. after they are metabolized what is left is only water that is excreted by the kidneys in the form of very dilute urine.

2- Hyponatremia:

(a). Water excess in ECF : (hypoosmotic overhydration)

- Excess secretion of ADH

(b). Loss of NaCl ( hypoosmotic dehydration)

-Excessive sweating, diarrhea, vomiting - Overuse of diuretics - Addisons disease hypoaldosterone de dcreases Na reabsorption in kidneys

3. Hypernatremia:
a. Loss of water from ECF hyperosmotic dehydration. -No ADH (diabetes insipidus, nephrogenic diabetes insipidus) - Heavy sweating. b. Excessive NaCl addedhyperosmotic overhydration. Hyperaldosterone.

Starling capillary circulation

-Balance of hydrostatic and colloid

osmotic forces across the capillary membrane determines the distribution of ECF b/w plasma and interstitial fluids.

Capillary

Endothelial cell

Pores

Fig. 10-16a, p. 292

Starling capillary circulation - 3 mmHg - 3 mmHg 8 mmHg 1 8 mmHg ____________________________ 1 30 mmHg 1 28 mmHg 1 10 mmHg ______________________________ Mean capillary pr. Negative interstitial pr. Osmotic interstitial pr. Plasma colloid pr. 17.3 mmHg 03.0 mmHg 08.0 mmHg 28.0 mmHg ____ 0.3 mmHg

Net filtration

Initial lymphatic vessel

Interstitial fluid 11 mm Hg (ultrafiltration) 9 mm Hg (reabsorption)

From arteriole

To venule

Blood capillary

(See next slide)

Fig. 10-18 (middle), p. 294

Capillary pressure (mm Hg)

Transition point Fluid movement Inward pressure ( pP + PIF) Outward pressure (PC + pIF)

Beginning

Capillary length

End

= Ultrafiltration

= Reabsorption
Fig. 10-19, p. 295

Edema A- Intracellular: causes 1. depression of the metabolic system of the tissues. 2. Lack of adequate nutrition to the cell. 3. Ischemia, inflammation.

Na-K pump stopped - Na lacks inside H2O follows.

B- Extracellular: Two major causes

(1). Abnormal leakage of fluid from the plasma to the interstitial spaces across the capillaries.
(2). Failure of the lymphatic to return fluid from the interstitial back into the blood.

Filtration = Kf x (Pc -Pif - c + if )

Causes of extracellular edema

1.Increased capillary pressure : A. Excessive kidney retention of salt and water 1. Acute or chronic kidney failure 2. Mineral corticoid excess B. High venous pressure :

1. Heart failure 2. venous obstruction 3. Failure of venous pumps: - muscle paralysis - Immobilized part - Venous valve failure
C. Decreased arteriolar resistance: 1. Heat 2. Insufficiency of symp. S. 3. vasodilators

edema caused by heart failure: the heart fails to pump blood from the veins to the arteries which causes: venous pr. capillary pr. capillary filtration. arterial pr. excretion of salts blood volume capillary hydrostatic pr. . blood flow to the kidneys aldosterone salt & water retention.

2. Decreased plasma proteins: A. Nephrotic syndrome: increase protein leakage. B. Protein loss : Wounds , burns C. Failure to produce proteins: - Liver disease, cirrhosis - Malnutrition

edema caused by decreased plasma proteins: Can be caused by: 1- plasma proteins leakage, and this can be noted in nephrotic syndrome 2- failure to produce normal amounts of proteins such as in liver cirrhosis cirrhosis also causes edema by compressing the abdominal portal venous drainage before entering the general circulation capillary hydrostatic pr. In the GI area transudation of fluid and proteins to the abdominal cavity this is known as ascites

edema caused by decreased kidney excretion: Diseased kidney fails to excrete water and salts accumulation of water and salts in the blood and the interstitial space this causes: 1- extracellular edema 2- hypertension

3.Increased capillary permeability:

A. Immune rxnshistamine release B. Bacterial infiction. C. Toxins D. Vitamin C deficiency E. Burns F. Prolong ischemia

4.Blockage of lymph Return: A. Cancer B.Infections (filari) C.Surgery D. Congenital abnormality of lymphatic vessels

C-Safety factors that prevent edema: 1.Low tissue compliance of the interstitium when pres. is (-). 3mmHg

2.Ability of lymphatic flow to increase 1050 times. 7mmHg

3.Washout proteins from interstitium. 7mmHG

Interstitial low compliance

Large change in pressure will cause small change in volume. This is only when interstitial space has negative pressure. Compliance increases markedly, once interstitial pressure rises above zero. Protoglycan creates gel form of fluid prevents flowing no free fluid spaces. When + pressure pitting edema.

Lymphatic flow

Lymphatic vessels able to increase their flow ten to fifty folds. This increase will be significant when the interstitial pressure is zero and above.

Fluid pressure on the outside of the vessel pushes the endothelial cells free edge inward, permitting entrance of interstitial fluid (now lymph).

Overlapping endothelial cell

Interstitial fluid Lymph Fluid pressure on the inside of the vessel forces the overlapping edges together so that lymph cannot escape.

Fig. 10-20b, p. 296

Edema in potential spaces

These type of edema called Effusion Accumulation of fluids in transcellular spaces. Ascites: collection of fluids in the abdominal cavity, huge 20 liters. All transcellular spaces have negative pressure: - pleural=7-8mm Hg - synovial=3-5mm Hg - pericardial=5-6mm Hg.