Guyton & Hall Fisio: Capitulo 25 Los Compartmentos Liquidos Del Cuerpo

UNIT V
Textbook of Medical Physiology, 11th Edition
Capitulo 25:
Los Compartimientos Líquidos del Cuerpo:
Liquido Extracelular y Liquido Intracelular; Liquido Intersticial y Edema
Diapositivas por John E. Hall, Ph.D.
Traducción por Rene R. García – Szabó, M.D., Ph.D.
GUYTON & HALL

Copyright © 2006 by Elsevier, Inc.
Regulación del Líquido Corporal
Figure 25-1;
Guyton and Hall
Figure 25-1;
Guyton and Hall
Figure 25-1;
Guyton and Hall
Balance Líquido (ml/dia) – Adulto de
70 kg
Entradas Normal Dieta Alta en Sal

Líquidos ingeridos 2100 4100
A partir del metabolismo 200 200
2300 4300
Salidas
Insensibles - piel 350 350
Insensibles - pulmones 350 350
Sudor 100 100
Heces 100 100
Urina 1400 3400
2300 4300
El Concepto de Balance
El balance es necesario, en el mantenimiento a largo

plazo de la vida.
Perdidas liquidas = Ingesta liquida

Perdidas electrolíticas = Ingesta electrolítica
La ingesta liquida: es regulada por el mecanismo de la sed,
hábitos
La ingesta electrolítica: es regida por habitos dieteticos.
Las salidas liquidas: son reguladas principalmente por los
riñones.
Las salidas electrolíticas: re son reguladas principalmente
por los riñones.
Effect of increasing sodium intake 10-fold on
urinary sodium excretion and extracellular
fluid volume
Figure 26-1;
Guyton and Hall
Fluid Balance (ml/day) – 70 kg
Adult
Normal Heavy
Intake Exercise
Fluids ingested 2100 ?
From metabolism 200 200
2300 ?
Output
Insensible - skin 350 350
Insensible - lungs 350 650
Sweat 100 5000
Feces 100 100
Urine 1400 500
2300 6600
Body Fluid Distribution
70 kg adult
Figure 25-1;
Guyton and Hall
Total Body Water in Relation to Body
Weight:
Effects of Gender, Body Build and Age
Body Build TBW (%) TBW (%) TBW (%)

Adult Male Adult Female Infant
Normal 60 50 70
Lean 70 60 80
Obese 50 42 60
Increasing obesity decreases TBW %

Increasing age decreases TBW %
Total Body Water in Relation to Body
Weight:
Effects of Gender, Body Build and
Age****aqui grupo #3****
Body Build TBW (%) TBW (%) TBW (%)
Adult Male Adult Female Infant
Normal 60 50 70
Lean 70 60 80
Obese 50 42 60
Increasing obesity decreases TBW %

Increasing age decreases TBW %
Indicator Dilution Principle
Volume (B) = Indicator Mass (B) = Q

Concentration (B) C
Valid if:
• Indicator disperses only in compartment measured
• Indicator disperses evenly in compartment
• Indicator not metabolized or excreted

Measuring Body Fluid
Compartments
Total Body water:
• D2O, 3H2O, antipyrine (C11H12N2O)
Extracellular fluid volume:

• 22Na, inulin, thiosulfate
Intracellular fluid =
total body water - extracellular fluid
Plasma volume:
• 125I-albumin, 51Cr-red blood cells
blood volume = plasma volume /(1 -HCT)
plasma volume = blood volume x (1 -HCT)
Interstitial fluid vol. =
Extracell fluid vol. - plasma vol.
Control of Body Fluid
Distribution
Distribution across cell membranes:

determined by osmotic forces
(mainly from electrolytes)
Distribution across capillaries:

determined by hydrostatic and
colloid osmotic forces

Osmotic Pressure ()
 = CRT
C = concentration (osm/L)
R = gas constant (62.3 if = mmHg)
T = Kelvino = 273o + Co
= 310o (normal body temp.)
 = 19,300 mmHg / Osm
If C = mOsm/L,
= C x 19.3 mmHg

Principles of Osmotic Equilibria
300 Normal State
ICF ECF
Osmolarity 200
7980 mOsm 3920 mOsm
mOsm/ 100
L 28 L 14 L
0
0 10 20 30 40 VOLUME (L)
• H2O moves across cell membranes easily

i.e. ECFosm = ICFosm
• Many solutes (e.g. NaCl) are relatively impermeant

to cell membranes
• Hydrostatic pressure differences have only
a small effect on fluid movement across cell membrane
Effects of solutions on
Cell Volume
Isotonic
(no change)
Hypotonic Hypertonic
(cell (cell
swells) shrinks)
Figure 25-5; Guyton and Hall

Isosmotic - has same osmolarity as body fluids
Hyperosmotic - higher osmolarity than body fluids
Hyposmotic- lower osmolarity than body fluids

Question
• What is the osmolarity of a

5 % glucose solution?
• Is the solution hyperosmotic,

hypo-osmotic, or isosmotic?

Osmolarity of a 5 % Glucose
Solution
MW glucose = 180 gm/mol

5 % = 5 gm/100 ml = 50 gm/L
50 gm x 1 mol = .278 mol = 278 mOsm
L 180 gm L L
Isosmotic

Question
• What is the osmolarity of a 3.0%

NaCl solution?
• Is the solution hypertonic, hypotonic,

or isotonic?

Osmolarity of a 3% NaCl
Solution
MW NaCl = 58.5
3 % = 3 gm/100ml = 30 gm/L
30 gm x 1 mol = .513 mol = 513 mmol
L 58.5 gm L L
For NaCl, 1 mmol = 2 mOsm
513 mmol x 2 mOsm = 1026 mOsm
L mmol L
Hypertonic

What are the changes in the following
variables after giving 2.0 liters of 0.9%
NaCl (Isotonic) i.v.****aqui grupo No.
1***
Extracellular Fluid Volume?

Extracellular Fluid Osmolarity?
Intracellular Fluid Volume?
Intracellular Fluid Osmolarity?
Effect of adding 2 L of 0.9 % NaCl ?
Normal State ICF ECF
A.
OSMOLARITY
300
mOsm/L
200
100
0
0 10 20 30 40
VOLUME (L)
C. B.

What are the Changes in the following
variables after giving 2.0 liters of
water i.v.?

Effect of adding 2 L of water ?
A.
OSMOLARITY
300
mOsm/L
200
100
0
0 10 20 30 40
VOLUME (L)
C. B.

What are the Changes in the following
variables after giving 2.0 liters of
3.0% NaCl i.v.?

Effect of adding 2 L of 3 % NaCl ?
A.
OSMOLARITY
300
mOsm/L
200
100
0
0 10 20 30 40
VOLUME (L)
C. B.

What are the Changes in the
following variables after giving 2.0
liters of 3.0% NaCl i.v.?
Extracellular Fluid Volume? > 2.0 Liters

Normal State A. Add Isotonic
NaCl
300
Osmolarity
mOsm/L
200
100
0
0 10 20 30 40
Volume (L)
C.Add Water (or hypotonic B. Add Hypertonic
NaCl
Fluids)

Which of the diagrams below represents
simple dehydration caused by water loss?
A. B.
300
Osmolarity
mOsm/L
200
100
0
0 10 20 30 40
Volume (L)
C. D.

Osmotic Equilibrium Problems
• Calculation of intracellular and extracellular

fluid volumes and osmolarities after fluid
administration.

Effect of Infusing 2.0 liters of
3% NaCl to a 70 kg Person
Assume:
1) no excretion of water or solutes,
2) osmotic equilibrium,
3) ECF =20% body wt, ICF =40 % body wt.
• What is the extracellular osmolarity?
• What are the intra- and extracellular fluid volumes?

Assume: extracell vol. = 20 % BW; intracell. vol. = 40 % BW
Step 1. Initial conditions
Volume Conc. Total
(L) mOsm/L mOsm
Extracell. Fluid (.2 x 70) = 14 280 3920
Intracell. Fluid (.4 x 70) = 28 280 7840
Total Fluid = 42 280 11,760

Osmolarity of a 3% NaCl
Solution
MW NaCl = 58.5
3% = 3 gm/100ml = 30 gm/L
30 gm x 1 mol = .513 mol = 513 mmol
L 58.5 gm L L
For NaCl, 1 mmol = 2 mOsm
513 mmol x 2 mOsm = 1026 mOsm
L mmol L
2.0 L x 1026 mOsm/L = 2052 mOsm
Step 2. Instantaneous Effect

Volume Conc. Total
(L) mOsm/L mOsm
Extracell. fluid 14+2= 16 ? 3920+2052= 5972
Intracell. fluid 28 +0= 28 280 7840 + 0 = 7840
Total Fluid 42+2= 44 ? 11,760+2052=

no equilibrium 13,812

Step 2. After osmotic equilibrium

Volume Conc. Total
(L) mOsm/L mOsm
Extracell. fluid 19 314 3920+2052= 5972
Intracell. fluid 25 314 7840 + 0 = 7840
Total Fluid 42+2= 44 314 11,760+2052= 13,812

Net effect: Extracell. Volume by 5.0 L
Intracell volume by 3.0 L
Abnormalities of Extracellular
Fluid Na+ Concentration
(Osmolarity)

Abnormalities of Extracellular
Fluid Na+ Concentration
Hypernatremia : Na+ conc.

• water loss
• Na+ excess
Hyponatremia : Na+ conc.
• water excess
• Na+ loss
Normal plasma [Na+] = 140-145 mmol / L

Consequences of Hyponatremia
and Hypernatremia
• Water moves in and out of cells

 cells swell or shrink
• This has profound effects on the brain.
- Neurologic function is altered
- Rapid shrinking can tear vessels and cause hemorrhage

- Rapid swelling can cause herniation
Because the skull is rigid, the brain cannot
increase its volume by more than 10% without
being forced down the neck (herniation).

Defense of Cell Volume
• Extracellular hypertonicity increases expression of genes
encoding proteins that increase intracellular osmoles.
- Membrane transporters (Na+-H+- exchanger)
- Enzymes (e.g. aldose reductase that synthesize
intracellular solutes (e.g. sorbital)
• Clinical significance: Rapid changes in extracellular fluid

tonicity alter cell volume and cause neurologic
complications, while slow changes have much less
effect on cell volume and much less clinical effect.

Hypernatremia
With Decreased Extracellular Fluid Volume

(water loss: hyperosmotic dehydration)
With Increased Extracellular Fluid Volume

( NaCl excess: hyperosmotic overhydration)
What lab measurements would help in

diagnosis?
• Hematocrit, plasma proteins
• Urine volume
Hypernatremia

• Increased hematocrit, plasma proteins
• Small volume of concentrated urine
- dehydration, excess sweating
• Large volume of dilute urine - diabetes insipidus
- lack of ADH (“central” diabetes insipidus)
- “nephrogenic” diabetes insipidus
Hypernatremia

• Decreased hematocrit, plasma proteins
• Primary aldosteronism
• Cushing’s syndrome
Usually the Hypernatremia is mild in these examples,
but the person may have very low plasma K +
(hypokalemia).
Hypernatremia – Clinical Case
A 52 year old male comes to you office complaining of frequent
headaches and large volumes of urine. His medical history indicates
that he is being treated with lithium for manic-depressive disorder.
your laboratory tests give the following results:
Body weight = 70 kg
Plasma Na+ = 162 mmol/L
Plasma K+ = 4.7 mmol/L
Blood pressure = 102/65 mmHg
Heart rate = 92 beats/min
Hematocrit = 0.50
Plasma protein = 8.40
• What are some potential causes of his hypernatremia?
• What additional tests would help in making a differential diagnosis?
Hypernatremia****aqui
preguntas del examen parcial****
A. With Increased Extracellular Fluid Volume
• Primary aldosteronism
• Cushing’s syndrome
B. With Decreased Extracellular Fluid Volume

• Small volume of concentrated urine

- dehydration, excess sweating
• Large volume of dilute urine - diabetes insipidus
- lack of ADH (“central” diabetes insipidus)
- “nephrogenic” diabetes insipidus
Hyponatremia

( NaCl Loss: hypo-osmotic dehydration)
• diarrhea, vomiting
• Addison’s disease (decreased aldosterone)
• overuse of diuretics
• sodium wasting renal diseases
Increased hematocrit, plasma proteins

Hyponatremia

(water excess: hypo-osmotic overhydration)
• Inappropriate ADH syndrome

• Bronchogenic tumors
• Fibrosing tuberculosis lung lesions
• Circulatory failure (e.g., congestive heart
failure)
Decreased hematocrit, plasma proteins
Intracellular Edema
• Hyponatremia
• Depression of tissue metabolic systems
(e.g. hypothyroidism)
• Inadequate tissue nutrition
(e.g. ischemia)
• Inflammation of tissues (increased cell
membrane permeability)

Determinants of Capillary
Filtration

Filtration

Extracellular Edema
Causes of Extracellular Edema

(increased interstitial fluid volume)
• Increased Capillary Filtration
• Failure of lymphatics to Return

Interstitial Fluid to Circulation

Filtration
Capillary Plasma Colloid

Pressure (Pc) Osmotic Pressure ( c)
Kf
Interstitial Interstitial Colloid

Fluid Pressure Osmotic Pressure
(Pisf) (isf)
FILT = Kf (Pc - Pisf - c + isf)

Filtration

Filtration

Causes of Increased Capillary
Filtration
FILT = Kf (Pc - Pisf - c + isf)
Increased Kf: toxins, ischemic damage, infections, etc.
Increased Pc:
• increased arterial pressure, excess fluid retention,
• decreased arteriolar resistance
• increased venous resistance, increased venous pressure
Decreased c:
• nephrotic syndrome
• cirrhosis
• malnutrition
Normal Filtration
FILT = Kf x Net Filt Pressure

= 6.6 x ( 17.3 - (-3) - 28 +8)
= 6.6 x ( + 0.3)
= 1.89 ml/min
FILT = 2722 ml/day

Where does all of this fluid (and protein in it) go?
Lymphatic Failure and Edema
Lymphatic
X Failure = Edema
Figure 25-1;
Guyton and Hall
Safety Factors Against Edema
• Low compliance of interstitium when = 3 mmHg

interstitial fluid pressure is negative
• Increased lymph flow = 7 mmHg
• “ Washdown” of interstitial protein = 7 mmHg

at high lymph flow rates
Total Safety factor = 17 mmHg

60
High
48 Compliance
Interstitial Fluid
Volume (liters)
36
Free
Fluid
24 Low compliance
12 Gel
Fluid
0
-8 -4 0 +4
Interstitial Fluid Pressure
(mmHg)
Low Tissue Compliance and Negative
Intersititial Fluid Hydrostatic Pressure
Interstitial Interstitial Fluid

Volume Hydrostatic Pressure
Capillary Filtration

Increased Lymph Flow

Lymph Flow

Effect of Interstitial Fluid
Pressure on Lymph Flow
20
Lymph Flow
( x normal) 10
1
-6 -4 -2 0 2 4
Interstitial Fluid Pressure ( mmHg)
Washdown of Interstitial
Proteins
8 Plasma Protein Concentration
6
Protein concentration
Interstitial Fluid
(gm/100 ml)
0
0 20 40 60 80 100 120 140 160 18
0
Rate of Non-Visceral Lymph Flow (ml/hr)
“Washdown” of Interstitial
Fluid Proteins

Capillary Filtration Lymph Flow
Interstitial Fluid Protein Removal

Oncotic Pressure From Tissues

Saftey Factors Against Edema
• Low compliance of interstitium when = 3 mmHg

interstitial fluid pressure is negative
• Increased lymph flow = 7 mmHg
• “ Washdown of interstitial protein = 7 mmHg

at high lymph flow rates
Total Safety factor = 17 mmHg

Conditions Causing Edema
1. High capillary hydrostatic pressure

• Excess fluid retention by kidneys
- acute or chronic kidney failure
- glomerulonephritis
- mineralocorticoid excess

1. High capillary hydrostatic pressure

• Decreased arteriolar resistance
- vasodilator drugs
- autonomic insufficiency
• Increased venous pressure
- congestive heart failure
- high output heart failure (e.g. anemia)
- venous obstruction
- venous valve failure
- cirrhosis
2. Decreased plasma proteins

(low oncotic pressure)
• Loss of proteins
- burns, wounds
- nephrosis
- gastroenteropathy
• Failure to produce proteins
- malnutrition (“kwashiorkor”)
- cirrhosis
- analbuminemia
3. Increased capillary permeability

• Immune reactions (histamine)
• Toxins
• Burns
• Prolonged ischemia
• Vitamin deficiency (e.g. vitamin C)
• Pre-eclampsia and eclampsia in
pregnancy

4. Blockage of lymphatics
• Cancer
• Surgery
• Infections (e.g. filaria nematodes)

Guyton & Hall Fisio: Capitulo 25 Los Compartmentos Liquidos Del Cuerpo

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Guyton & Hall Fisio: Capitulo 25 Los Compartmentos Liquidos Del Cuerpo

Hochgeladen von

Copyright:

Verfügbare Formate

UNIT V

Textbook of Medical Physiology, 11th Edition

GUYTON & HALL

Entradas Normal Dieta Alta en Sal

El balance es necesario, en el mantenimiento a largo

Perdidas liquidas = Ingesta liquida

Body Build TBW (%) TBW (%) TBW (%)

Increasing obesity decreases TBW %

Increasing obesity decreases TBW %

Volume (B) = Indicator Mass (B) = Q

Copyright © 2006 by Elsevier, Inc.

Extracellular fluid volume:

Distribution across cell membranes:

Distribution across capillaries:

Copyright © 2006 by Elsevier, Inc.

Copyright © 2006 by Elsevier, Inc.

• H2O moves across cell membranes easily

• Many solutes (e.g. NaCl) are relatively impermeant

Figure 25-5; Guyton and Hall

Hyperosmotic - higher osmolarity than body fluids

Hyposmotic- lower osmolarity than body fluids

Copyright © 2006 by Elsevier, Inc.

• What is the osmolarity of a

• Is the solution hyperosmotic,

Copyright © 2006 by Elsevier, Inc.

MW glucose = 180 gm/mol

Copyright © 2006 by Elsevier, Inc.

• What is the osmolarity of a 3.0%

• Is the solution hypertonic, hypotonic,

Copyright © 2006 by Elsevier, Inc.

Copyright © 2006 by Elsevier, Inc.

Extracellular Fluid Volume?

Copyright © 2006 by Elsevier, Inc.

Extracellular Fluid Volume?

Copyright © 2006 by Elsevier, Inc.

Extracellular Fluid Volume?

Copyright © 2006 by Elsevier, Inc.

Extracellular Fluid Volume? > 2.0 Liters

Copyright © 2006 by Elsevier, Inc.

Copyright © 2006 by Elsevier, Inc.

• Calculation of intracellular and extracellular

Copyright © 2006 by Elsevier, Inc.

• What is the extracellular osmolarity?

• What are the intra- and extracellular fluid volumes?

Copyright © 2006 by Elsevier, Inc.

Extracell. Fluid (.2 x 70) = 14 280 3920

Intracell. Fluid (.4 x 70) = 28 280 7840

Total Fluid = 42 280 11,760

Step 2. Instantaneous Effect

Intracell. fluid 28 +0= 28 280 7840 + 0 = 7840

Total Fluid 42+2= 44 ? 11,760+2052=

Copyright © 2006 by Elsevier, Inc.

Step 2. After osmotic equilibrium

Extracell. fluid 19 314 3920+2052= 5972

Intracell. fluid 25 314 7840 + 0 = 7840

Total Fluid 42+2= 44 314 11,760+2052= 13,812

Copyright © 2006 by Elsevier, Inc.

Hypernatremia : Na+ conc.

Normal plasma [Na+] = 140-145 mmol / L

• Water moves in and out of cells

- Rapid shrinking can tear vessels and cause hemorrhage

Copyright © 2006 by Elsevier, Inc.

• Clinical significance: Rapid changes in extracellular fluid