Pathophysiology of Body Fluids and Fluid Therapy
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Transcript of 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 )
Vitamin D dependent rickets type 2 ( MIM 277420 )
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
Vitamin D dependent rickets type 1 ( MIM 264700 )
Vitamin D dependent rickets type 2 ( MIM 277440 )
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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