WATER AND ELECTROLYTESDISTURBANCES BODY WATER: sodium (Na +) DOMINAN, chloride (Cl–), oxygen (O2), hydrogen (H+), bicarbonate (HCO3–), calcium (Ca2+), potassium (K+), sulfate (SO42–), and phosphate (PO43–) KIDNEY HOMEOSTATIS • volume, • Electrolyte concentration, • acid-base balance of body fluids; • detoxify and eliminate wastes; • regulate blood pressure regulating fluid volume. skin and lungs • The also play a role in fluid and electrolyte balance. Sweating results in loss of sodium and water • every breath contains water vapor. Mineral functions • Source of life • Basic component • enzyme and hormone functions • cells, tissues, bones, blood and body fluids component • Help every life aspects: hormone and energy production, dygestion, nerve transmition and muscle contraction • Adjust pH, metabolism, cholesterol and blood glucose. • Vitamins and enzyme activators FLUIDS COMPARTMENS INTRA CELLULER EXTRA CELLULER PLASMA INTERSTITIAL IN PATHOLOGIC CONDITIONS: THIRD ROUND organs: INTRAPERITONEAL THORAX OTHERS FLUID EXCHANGE BETWEEN BLOOD PLASMA AND INTERSTITIAL FLUID • OBJECTIVE: FLUID, ELEKTROLYTES AND PROTEIN CONCENTRATION BALANCE • TWO PAIRS FORCES INFLUENCE: – THE FORCE THAT MOVE LUID FROM BLOOD VESSELS TO THE INTERSTITIAL – PLASMA HYDROSTATIC PRESSURE – TISSUE OSMOTIC PRESSURE – THE FORCE THAT MOVE FLUID INTO BLOOD VESSELS – PLASMA PROTEIN ONCOTIC PRESSURE – INTERSTITIAL FLUID HIDROSTATIC PRESSURE pH of body fluid pH = 7.0 pH = 7.35 pH = 7.35 pH = 7.45 Sistem Buffer • sistem carbonic acid—bicarbonate (the most important, work in lung) • haemoglobine–oxyhaemoglobine system (work in red blood cells) haemoglobine bind to free H+, the blood flow through lung and the H+ combined with CO2. • Protein Buffer (in ECF and ICF) • Phosphat system (especially in ICF) BUFFERING 1. Bicarbonate: HCl + NaHCO3 H2O + NaCl NaOH + H2CO3 NaHCO3 + H2O 2. Hb Protein Proteinate- + H+ N+ + Proteinate Na-Proteinate (extracell) K+ + Proteinate K-Proteinate (intracell) BUFFERING 3. phosphate Na2HPO4 +HCl NaCl + NaH2PO4 Keseimbangan Asam-Basa • ·<6.8 Dangerous to life • ·<7.2 seriously damage of cell functions • ·<7.35 acidosis • ·7.35 to 7.45 normal • ·>7.45 alkalosis • ·>7.55 seriously damage of cell functions • ·>7.8 Dangerous to life pH influence on enzyme actions ANION GAP CONSEPT • Total kations (Na+, K+, Ca++, Mg++ etc.) ar always comparable with total anion (Cl-, HCO3-, PO4-, SO4=, proteinate= etc.) • Routine measured: Na+, K+, Cl- and HCO3-) • Anion concentration always < kation • This difference called “anion gape” ANION GAP • Anion gap = [Na+ + K+]-[Cl- + HCO3-] • Ex: for normal electrolytes levels • Anion gap = [140+4] – [100 + 28] • = 16 mEq/L • K+ is seldom measured in clinical practice anion gap = [Na+] – [Cl- + HCO3-] = 12 4 mEq/L • What happent to anion gape in too acid or too basic conditions? • pH = pK + log HCO3- pCO2 ↓PH = pK + log ↓ HCO3- pCO2 Anion gap >> Pathophysiologic Consept of Acid- Base • Acidemia: • Acidosis (MA dan RA) • alkalemia, • Alkalosis (MA dan RA) • Compensation Acidemia • PH arteri <7.35, More H+ ion in blood • ECF content >, H+ Ion into ICF. To get extracellular elektricity of neutral intracel pH the number of equivalent K+ leave the cell relatif hyperkalemia. Acidosis • > konsentrasi ion H+ sistemik. • Bila paru gagal mengeliminasi CO2 atau bila produk asam-asam volatile (asam karbonat) atau nonvolatile (asam laktat) hasil metabolisme terakumulasi, konsentrasi ion H+ naik. • Acidosis dapat juga terjadi pada diare berat hilang anion basa bikarbonat atau • ginjal gagal mensekresikan H+ atau mereabsorbsi bikarbonat Alkalosis • H+ level < in the body • Causes: – Lost of CO 2 during hyperventilation, – Lost of nonvolatile acids during vomit, or – more basic intake hidrogen ion consentration > Alkalemia • Arterial blood pH > 7.45, relatively more base in blood. • More H+ in ICF insist the to flow into ECF. For ICF electrical homeostatis (neutralisation) K+ moves from ECF into ICF, relative hypokalemia. COMPENSATION • LUNG AND KIDNEY, AND CHEMICAL BUFFER OF INTRACELLULAR AND INTRACELLULAR COMPARTMENTS WORK TOGETHER TO MAINTAIN PLASMA PH AT THE RANGE OF 7.35 to 7.45 ACID/BASE BALANCE ACID/BASE DISTURBANCES AND COMPENSATION Metabolic acidosis/ alkalosis Respiratory alkalosis Ketoasidosis Patofisiologi • Pengaturan konsentrasi elektrolit intraseluler dan extraseluler tergantung pada: – Keseimbangan intake elektrolit dan output nya di urin, feses, dan keringat – transport cairan dan elektrolit antara cairan ekstraseluler dan intraseluler 1. Pengertian imbalance ECF • Gangguan Volume : – air berlebih (Overhydration)ECF – air kurang (Dehydration) • Hipervolemia : kelebihan air dan elektrolit • Hipovolemia : kekurangan air dan elektrolit 2. PENYEBAB OVERHYDRATION? • Kelebihan Na • Kelebihan infus, terutama yang hipertonis • Gangguan pengaturan homeostatik air dan Na: – Chronic renal failure – Congestive heart failure • Kelebihan terapi corticosteroid • Sindroma kekurngan ADH (SIADH) 3. PENYEBAB DEHYDRATION? • Kekurangan intake air dan elektrolit: – Gangguan mekanisme haus – Tak mampu menelan cairan • Kehilangan cairan melalui sekresi atau ekskresi: – Terapi diuretik kuat – Diabetes insipidus – Kehilangan cairan dari saluran GI – Keringat berlebihan Tanda dan Gejala? 1. OVERHIDRASI: • Peningkatan berat badan tiba-tiba • Edema perifer • Nafas pendek dan paru-paru berbunyi • Perubahan perilaku : bingung, lemah • Pembuluh vena melebar • Pulsa meningkat (>) • BP meningkat • Pengosongan vena lambat TANDA DEHIDRASI • Berat badan turun tiba-tiba • Turgor kulit menurun • Kekeringan membran mukosa – Kulit kasar – lidah kering • Perubahan perilaku: agitasi(terangsang), capek, lemah • Vena leher datar pada posisi tidur • Pulsa lemah • Hipotensi Orthostatic • Pengisian vena perifer lambat Ketidak seimbangan Elektrolit • Setiap mineral berpengaruh pada mineral lain dalam tubuh • Bila satu mineral tidak seimbang mempengaruhi keseimbangan mineral-mineral lain melalui serangkaian reaksi berantai Misalnya: Bila anda makan 1 tablet Fe 1. Na ↑. Karena perangksangan kelenjar adrenal 2. Magnesium ↓. Karena Na menurunkan Mg 3. Calcium ↓. Karena bila Mg↓, Ca juga ↓ untuk mempertahankan rasio calcium/ magnesium 4. K ↑. Calcium dan potassium pindah ke arah berlawanan Bila calcium ↓, potassium ↑. Ex. If you take Iron tablet 5. Nitrogen ↓. Karena oksiidasi cepat, kannibalisasi proteins. (proteolisis) 6. Cu ↓. Karena peningkatan laju pernafasan Cu diperlukan dan digunakan. Bila ratio zinc thd Cu > Cu availability akan sangat <. At < 1.0, zona cancer 7. Zinc ↓. Bila Cu <, zinc juga < (Memperthankan ratio Karena Zn diperlukan untuk fungsi kel adrenal, Fungsi adrenal terganggu. rasa lelah 8. Mn ↑. Karena Zn biasanya bergerak berlawanan dengan Mn.. A. SODIUM (Na+) 1. normal: • Serum Na 135-145 MEq/L • Serum Na+ Menentukan osmolalitas darah 2. Ketidakseimbangan • Hypernatremia B – Serum Na+ > 145 mEq/L – Serum osmolality > 295 mOsm/kg • Hyponatremia – Serum Na <135 mEq/L Functions • Maintenance of Membrane Potential • Nutrient Absorption and Transport • Maintenance of Blood Volume and Blood Pressure Pengaturan oleh Ginjal • Perubahan GFR atau hemodinamik ginjal • Aldosteron • Atrial natriuretic peptide (ANP) PENYEBAB HYPERNATREMIA? • Kehilangan air: • Diabetes insipidus • Gangguan pemekatan Ginjal • diarrhea • Menurun intake air meningkat intakeNa+ : • Ketidakmampuan merespon mechanism haus • Susah menelan cairan • Makanan hipertonis kurang minum • Kelebihan penggunaan larutan NaCl atau NaHCO3 hipertonis • Hiperfungsi Adrenal Hyperaldosteronism PENYEBAB HIPONATREMIA • Peningkatan ambilan air • Enema air • Perangantsangan anti diuretic hormone (ADH) • Psychogenic polydipsia • Kehilangan Na+: • Penggunaan diuretil loop gol thiazide • Kehilangan Na karena penyakit ginjal • Penggantian air tapi bukan elektrolit pad kasus terbakar, muntah atau diare • Adrenal insufficiency signs and symptoms Hypernatremia • Perubahan perilaku : – cemas – stupor, coma • Haus berlebihan • Lemah otot • Membran mukosa kering dan lengket sign and symptoms Hyponatremia • Perubahan perilaku: – Cemas – Convulsions dan coma • Lemah otot • Mual dan cramp perut • Hypotension Postural B. Potassium (K+) 1. normal: • Serum K+ 3.5 - 5.0 mEq/l • K+ is primarily intracellular (98%) 2. imbalance: • Hyperkalemia Serum K+ > 5.0 mEq/L • Hypokalemia Serum K+ < 3.5 mEq/L Functions • Maintenance of Membrane Potential • Cofactor for Enzymes (K/Na ATPase, pyruvate kinase) Causes hyperkalemia • Increased K+ intake: • Rapid IV administration of K+ • Administration of aged blood • Increased oral intake causes hyperkalemia only if accompanied by decreased K+ excretion • Excessive use of salt substitutes (K+ClB) • Decreased renal excretion of K+: • Acute and chronic renal failure • Kerusakan sel (terbakar dll) K+ keluar dari sel • Asidosis (H+ banyak dalam sel K+ keluar) Causes hyperkalemia • Decreased production of Aldosterone • Adrenal insufficiency (Addison=s disease) • Excessive use of K+ conserving diuretics: Spironolactone (Aldactone) and Amiloride (Moduretic) • Movement of K+ into ECF: • Tissue injury (burns, major surgery, or crush injury) • Acidosis B decreased pH with excess H+ in ECF (compensation causes K+ to shift from cells to ECF) • Insulin deficiency Causes hypokalemia • Decreased K+ intake: • Anorexia nervosa • Gastrointestinal K+ loss: • Vomiting, gastric suction • Diarrhea, laxative abuse, recent ileostomy • Large sweat loss without K+ replacement • Increased renal excretion of K+: Hypokalemia (cont) • Use of K+ losing diuretics without K+ replacement Ex.: Furosemide (Lasix), Bumetanide (Bumex), and HCTZ • Hyperaldosteronism • Entry of K+ into cells: – Alkalosis : increased pH with decreased H+ in ECF (compensation causes K+ to shift from ECF to cells) signs and symptoms hyperkalemia Mental confusion • GI hyperactivity (abdominal cramping and diarrhea) • Cardiotoxicity • EKG changes (K+ > 6 mEq/L: • Cardiac arrhythmias bradycardia and heart block • Cardiac arrest Sign and symptoms hypokalemia • Muscle weakness/paralysis, flaccid muscles (lack tone) • Decreased bowel motility (intestinal ileus, nausea and vomiting) • Polyuria • EKG changes (serum K+ < 3 mEq/L): • Cardiac arrhythmias • Respiratory failure K+ <1.5 mEq/L C. Calcium (Ca++) 1. normal? • Serum Ca++ 8.5-11 mg/dL • Serum Ca++ and serum phosphate vary inversely 2. imbalance? • Hypercalcemia Serum Ca++ > 11 mg/dL • Hypocalcemia Serum Ca++ < 8.5 mg/dL Physiological functions: • blood to clot, • bones hold up. • nerves fire, • for your brain to function, • for your muscles to contract. • heart beating • Calcium maintains the organization of tissues • Cofactor for Enzymes and Proteins • secretion of hormones (insuline) causes hypercalcemia? • Ca++ release from bone: • Hyperparathyroidism • Metastatic carcinoma • Multiple myeloma • Thyrotoxicosis • Prolonged immobilization • Increase GI absorption of Ca++ • Excessive ingestion of Vitamin D Causes hypocalcemia: • Decreased intake or decreased GI absorption of Ca++: • Vitamin D deficiency • Chronic insufficient dietary intake of Ca++ • Acute pancreatitis • Overuse of antacids • Malabsorption Syndromes • Decrease in physiologically available Ca++: • Hypoparathyroidism • Overuse of phosphate-containing laxatives and enemas (Ex.: Fleet Phospho-soda) • Increased urinary excretion of Ca++: • Chronic renal failure signs and symptoms? hypercalcemmia • Nausea and vomiting • Constipation • Muscle weakness/flaccidity • Depressed deep tendon reflexes • Confusion, lethargy, CNS depression (coma) • Polyuria • Pathological fractures (chronic) • Renal calculi • EKG changes: Shortened QT interval, Cardiac arrest • brittle arteries Sign and symptoms hypocalcemia • Muscle cramps • Confusion, anxiety • Tetany • Neuromuscular irritability: • Positive Chvostek= s sign muscle spasm at cheek and corner of mouth in response to tap over facial nerve in front of ear. • Positive Trousseau= s sign carpal spasms after occlusion of blood flow to hand with BP cuff for three minutes. • Hyperactive deep tendon reflexes • Convulsions • EKG changes: Prolonged QT interval • Cardiac arrest D. Magnesium (Mg++) 1. normal? • Serum Mg++ 1.5-2.5 mEq/L • Mg++ is absorbed primarily through the small intestine 2. imbalance: • Hypermagnesemia B Serum Mg++ >2.5 mEq/L • Hypomagnesemia B Serum Mg++ < 1.5 mEq/L Functions: • structure and the function of the human body • Cell Signaling (involved in more than 300 essential metabolic reactions ) • Energy Production • Synthesis of Essential Molecules • Ion Transport Across Cell Membranes • Cell Migration causes hypermagnesemia • Excessive intake or absorption of Mg++: • Overuse of antacids containing Mg++ (Maalox, Gelusil, Riopan) • Overuse of laxatives containing Mg++ (Milk of Magnesia) • Impaired Mg++ excretion:Advanced renal failure • Adrenal insufficiency (Addison=s disease) causes hypomagnesemia • Decreased Mg++ intake or absorption:Chronic diarrhea • Chronic malnutrition • Malabsorption syndrome B Steatorrhea • Small bowel resectionChronic alcoholism • Prolonged IV administration without Mg++ supplementation • Gastrointestinal Mg++ loss:Prolonged diarrhea or nasogastric suction • Intestinal fistulas • Increased urinary excretion of Mg++:Prolonged excessive diuretic therapy signs and symptoms hypermagnesemia • Hypoactive deep tendon reflexes • Drowsiness, lethargy • Mild hypotension • Nausea and vomiting • Respiratory depression (serum Mg++ > 15 mEq/L) dan paralisis otot • Cardiac arrhythmias (bradycardia, heart block) • Cardiac arrest (serum Mg++ > 25 mEq/L) signs & symptoms hypomagnesemia • Hyperactive deep tendon reflexes • Coarse tremors • Tetany • Positive Chvostek’s (FACE MUSCLE MOVING) and Trousseau’s sign (MUSCLE CRAMP) • Intense confusion • Cardiac arrhythmias • Convulsions • Coma • ALL DUE TO NERVE – MUSCLE ALTERATION conclutions 1. Mineral and fluid and pH imbalance will couse alteration of other systems functions 2. Imbalance: over><less 3. Alterations and symptoms are depend on minerals / acid- base imbalance 4. Imbalance of one mineral affects all minerals by massive chain reactions of mineral imbalance 5. Acid/base imbalance will be compensated (respiratory or kidney) 6. Be carefull of taking any food supplement containing minerals!