pathophysiology of body fluids and fluid therapy

7/28/2019 Pathophysiology of Body Fluids and Fluid Therapy

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Pathophysiology of Body

Fluids and Fluid Therapy


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Total Body Water, Intracellular fluid and

extracellular fluid as a percentage of body weigth

and a function of age


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Compartments of total body water, expressed as

a percentage of body weight, in an older child or

adult


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The Concentration of the major cations and

anions in the intracellular space and the plasma,

expressed in mEq/L.


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Causes of Hypernatremia

Excessive Sodium

Improperly mixed Formula

Excess sodium bicarbonate

Ingestion of seawater or sodium chlorideintentional salt poisoning (child abuse of Munchhausen syndrome byproxy)

Intravenous hypertonic saline

Hyperaldosteronism


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Water Deficit

Nephrogenic Diabetes Insipidus

Acquired

X-Linked (MIM 304800)

Autosomal Recessive (MIM 222000)

Central Diabetes Insipidus

AcquiredAutosomal Dominant (MIM 125700)

Increased Insensible Losses

Premature Infants

Radiant Warners

Phototherapy

Inadequate IntakeIneffective breast-feeding

Child negfect of abuse

Adipsia (Lack of thirst)


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Water And Sodium Deficits

Gastrointestinal Losses

Diarrhea

Emesis/Nasogastric suction

Osmotic Cathartics (e.g.lactulose)

Cutaneous Losses

BurnsExcessive sweating

Renal Losses

Osmotic Diuretic (e.g.mannitol)

Diabetes Melitus

Chronic kidney disease (e.g.dysplasia and obstructive uropathy )Polyuric phase of acute tubular necrosis

Post obstructive diuresis


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Mechanism of brain edema during

correction of hypernatremia


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Pseudohyponatremia

Hyperosmolality

HyperglycemiaMannitol


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Hypovolemic Hyponatremia

Extrarenal Lo ssesGastrointestinal (Emesis,Diarrhea )

Skin ( Sweating or Burn )

Third space Losses

Renal Loss esThiazide or loop diuretic

Osmotic diuresis

Post obstructive diuresis

Polyuric phase of ATN

Juvenile nephronophthisis ( MIM 256100/602088/266900/604387)

Autosomal recessive polycistic kidney kidney disease (MIM 263200 )

Tubulointerstitial nephritis

Obstructive uropathy

Cerebralsalt wasting

Proximal (Type II) RTA (MIM 604278 )Lack of aldosterone effect (high serum potassium)

Absent aldosterone(e.g.21-hydroxylase deficiency [MIM 201910] )

Pseudohypoaldosteronism type I (MIM 264530 and 177735 )

Urinary Tract obstruction and/or urinary tract infection


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Euvolemic hyponatremia

Syndrome of inappropriate antidiuretic hormone

Desmopressin acetate

Glucocorticoid deficiency

Hypothyroidism

Water Intoxication

Istrogenic (i.e.excess hypotonic intravenous fluids )Swimming lesson

Tap water enema

child abuse

Psychogenic polydipsia

Diluted formulaBeer potomania


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Hypervolemic hyponatremia

Congestive heart failure

Cirrhosis

Nephrotic Syndrome Renal Failure

Capillary leakdue to sepsis

Hypoalbuminemia due to gastrointestinaldisease


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CAUSES of HYPERKALEMIA

Spur ious Laboratory ValueHemolysis

Tissue Ischemia during blood drawing

Thrombocytosis

Leukocytosis

Increased In takeIntravenous or oral

Blood transfusions


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Transcel lular Shif ts

Acidemia

RhabdomyolysisTumor lysis syndrome

Tissue necrosis

Hemolysis/hematomas/GI bleeding

Succinylcholine

Digitalis IntoxicationFluoride Intoxication

Beta-adrenergic blockers

Exercise

Hyperosmolality

Insulin deficiencyMalignant hyperthermia (MIM 145600)

Hyperkalemic periodic paralysis (MIM 170500)


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Decreased Excretion Renal Failu re Primary Ad renal disease

Acquired Addison disease

21-hydroxylase deficiency (MIM 201910)3-hydroxysteroid dehydrogenase deficiency (MIM 201810)

Lipoid kongenital adrenal hyperplasia (MIM 201710 )

Adrenal hypoplasia congenita (MIM 300200)

Aldosterone syntase deficiency (MIM 203400)

Adrenoleukodystrophy (MIM 300100)

Hyporeninemic hypo aldos teronismUrinary tract obstruction

Sickle cell disease (MIM 603903)

Kidney Transplant

Lupus Nephritis

Renal Tub ular DiseasePseudohypoaldosteronism type I (MIM 264350 and 177735)

Pseudohypoaldosterone type II (MIM 145260 )

Urinary tract obstruction

Sickie cell disease

Kideney Transplant


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Medications

Angiotensin converting enzyme inhibitors

Angiotensin II blockers

Potassium sparing diuretics

Cyclosporin

Nonsteroidal anti inflammatories

Trimethoprim


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Causes of Hypokalemia

Spur iousHigh white blood cell count

Transcellular ShiftsAlkalemia

Insulin

Adrenergic agonistDrugs/toxins (theophyline barium, toluene)

Hypokalemic periodic paralysis (MIM*170400)

Decreased Intake

Extrarenal Loss esDiarrheaLaxative abuse

Sweating


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Renal Losses

With Metabolic Acidosis

Distal renal tubular acidosis (RTA) (MIM 179800/602722)

Proximal RTA (MIM 6042781)

Ureterosigmoidostomy

Diabetic Ketoacidosis

Without specific acid based disturbancedTubular toxins amphotericin, cisplatin, aminoglycosides

Interstitial Nephritis

Diuretic phase of acute tubular necrosis

Postobstructive diuresis

Hypomagnesemia

High urine anions (e.g. penicillin or penicillin derivative)


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With metabolic Alkalosis

Low urine chlorideEmesis nasogastricsuction

Chloride losing diarrhea (MIM 214700)

Cystic fibrosis (MIM 219700)

Low chloride formula

Posthypercapnia

Previous loop or thiazide diuretic use

High urine chloride and normal blood pressure

Gitelman syndrome (MIM 263800)

Bartter syndrome (MIM 602023)

Loop and Thiazide diuretic


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High urine chloride and high blood presurre

Adrenal adenoma or hyperplasia

Glucocorticoid remedial aldosteronism (MIM 103900)

Renovascular DiseaseRenin secreting tumor

17 hydroxylase deficiency ( MIM 202110)

11 hydroxylase deficiency (MIM 202010)

Cushing Syndrome

11 hydroxysteroid dehydrogenase deficiency (MIM 218030)Licorice ingestion

Liddle syndrome (MIM 177200)


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Causes of Hypocalcemia

Specific Causes In The NeonateEarly neonatal hypocalcemia

Late neonatal hypocalcemia

Maternal hypercalcemia

Hypoparathyroidism

DiGeorge syndrome (MIM* 188400)X Linked hypoparathyroidsm (MIM 307700)

Parathyroid hormone (PTH) gene mutations (MIM 168450)

Calcium sensing receptor mutation (MIM 601199)

Autosomal recessive hypoparathyroidsm with dysmorphic features (MIM 241410)

HDR (or Barakat ) syndrome ( MIM 146255 )

Autoimmuno polyglandular syndrome type I (MIM 240300)

Kearns sayre syndrome (MIM 530000 )

HemochromatosisWilson disease ( MIM 277900 )

Postsurgical hypoparathyroidism

Radioactive iodine ablation of the thyroid gland

Hypomagnesemia


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Lack of Response to PTHPseudohypoparathyroidism type IA ( MIM 103580 )

Pseudohypoparathyroidism type IB ( MIM 603233 )

Pseudohypoparathyroidism type II

Hypomagnesemia

Vitamin D Deficiency

Poor IntakeLack of Sunligth

Malabsorption

Increase Metabolism (e.g.,anticonvulsants)

Failure to form 25 hydroxyvitamin D in the Liver

Vitamin D dependent rickets type 1 ( MIM 264700 )


Renal Insufficiency


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Redistribution of Plasma CalciumHyperphosphatemia

Rhabdomyolysis

Tumor Lysis syndrome

Blood TransfusionsHungry bone Syndrome

Acute Pancreatitis

Osteopetrosis, Infantile ( MIM 259700 )

Inadequate calcium IntakeCalcium Poor diet or total parenteral nutrition

Dietary calcium chelator

Malabsorption

UnknownSeptic Shock

Critical illness


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Causes Of Hypercalcemia Excess Parathyro id Hormone

Primary Hyperparathyroidsm

Sporadic Adenoma

Familial Isolated Hyperparathyroidism ( MIM *145000 )

Multiple Endocrine Neoplasia type I ( MIM 131100 )

Multiple Endocrine Neoplasia type II ( MIM 171400 )

Hyperparathyroidism Jaw Tumor Syndrome ( MIM 145001 )

Calcium - Sensing receptor mutation ( MIM 239200 )

Transient Secondary Neonatal Hyperparathyroidism

Tertiary Hyperparathyroidism

Excess Vitamin DHypervitaminosis D

Subcutaneous fat NecrosisSarcoidosis

Granulomatous disease (e.g.,tuberculosis and Fungal Infections )

Lymphomas


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Excess Calcium Intake

Calcium Supplements

Latrogenic (e.g., total parenteral nutrition )

Excess Renal Reabso rpt ion of Calc iumFamilial Benign hypocalciuric hypercalcemia ( MIM 145980 )

Thiazide Diuretic

Release From Bone

Thyrotoxicosis

Hypervitaminosis AMalignancy Associated

Ectopic parathyroid hormone ( PTH )

PTH related peptide

Bone Metatasis

Other Factors

ImmobilizationRenal Osteodystrophy

Low turnover disease

Aluminum Deposition


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MiscellaneousWilliams Syndrome ( MIM 194050 )

Hypophosphatemia

PheochromocytomaAdrenal Insufficiency

Recovery Phase of rhabdomyolisis

Jansen metaphyseal chondrodysplasia ( MIM 156400 )

Hypophosphatasia ( MIM 241500 )


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Clinical Manifestations of Hypercalcemia

Gastrointestinal

Nausea and VomitingPoor Feeding

Failure to Thrive

Constipation

Abdominal Pain

Pancreatitis

Peptic ulcer

Cardiac

Hypertension

Decreased QT Interval

Arrhythmias


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Central Nervous SystemLethargy

Hypotonia

Psychiatric disturbancesComa

Kidney

Polyuria and Dehydration

Hypernatremia

Renal Failure

Nephrolithiasis


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Causes of HypomagnesemiaGastrointestinal Disorders

Diarrhea

Nasogastric Suction or emesis

Inflammatory bowel disease

Celiac disease

Intestinal hymphangiectasia

Small bowel resection or bypass

Pancreatitis

Protein calorie malnutrition

Primary Intestinal hypomagnesemia with secondary hypocalcemia (

MIM * 602014 )


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Renal DisordersMedications: amphotericin, cisplatin, cyclosporin, loop diuretics, mannitol,

pentamidine, aminoglycosides, thiazide diuretic

Diabetes

Acute tubular necrosis ( recovery phase )

Postobstruvtive nephropathy

Chronic kidney diseases: Interstitial nephritis, glomerulonephritis, postrenaltransplant

Hypercalcemia

Intravenous fluids

Primary aldosteronism

Genetic diseases

Gitelman Syndrome ( MIM 263800 )

Bartter Syndrome ( MIM 602023 )

Familial hypomagnesemia with hypercalciura and

Nephrocalcinosis ( MIM 603959 )

Autosomal recessive renal magnesium wasting ( MIM 248250 )Autosomal dominant renal magnesium wasting ( MIM 154020 )

Autosomal dominant hypoparathyroidism ( MIM 601198/601199 )

mitochondrial disorders


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Miscellaneous Causes

Poor Intake

Hungry Bone Syndrome

Insulin Administration

Pancreatitis

Intrauterine growth retardation

Infants of Diabetic mothersExchange Tranfusion


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Causes of Hypophosphatemia

Transcellular ShiftsGlucose Infusion

Insulin

Refeeding

Total Parenteral Nutrition

Respiratory Alkalosis

Tumor growthBone marrow transplantation

Hungry bone syndrome

Decreased Intake

NutrionalPremature Infants

Low Phosphorous formula

Antacids and other phosphate binder


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Renal LossesHyperparathyroidism

Parathyroid hormone related peptide

X Linked hypophosphatemic rickets ( MIM*307800 )

Tumor Induced osteomalacia

Autosomal dominant hypophosphatemic rickets (MIM 193100 )

Fanconi syndrome

Dent disease ( MIM 300009 )

Hypophosphatemic rickets with hypercalciura ( MIM 241530 )

Volume expansion and intravenous fluids

Metabolic acidosis

Diuretic

GlycosuriaGlucocorticoids

Kidney Tranplantation


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Mult i factor ial

Vitamin D deficiency



Alcoholism

Sepsis

Dialysis


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Causes of Hyperphosphatemia

Transcellular ShiftsTumor Lysis Syndrome

Rhabdomyolysis

Acute hemolysis

Diabetic Ketoacidosis and lactic acidosis

Increase Intake

Enemas and laxatives

Cows Milk in infants

Treatment of hypophosphatemiaVitamin D intoxication


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Decreased Excretion

Renal Failure

Hypoparathyroidism

Acromegaly

Hyperthyroidism

Tumoral calcinosis with hyperphosphatemia ( MIM*211900 )


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pathophysiology of body fluids and fluid therapy

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