guyton & hall fisio : capitulo 25 los compartmentos liquidos del cuerpo

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U N I T V Textbook of Medical Physiology, 11th Edition GUYTON & HALL Copyright © 2006 by Elsevier, Inc. 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.

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Page 1: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

U N I T V

Textbook of Medical Physiology, 11th Edition

GUYTON & HALL

Copyright © 2006 by Elsevier, Inc.

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.

Page 2: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-1;Guyton and Hall

Regulación del Líquido CorporalRegulación del Líquido Corporal

Page 3: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-1;Guyton and Hall

Regulación del Líquido CorporalRegulación del Líquido Corporal

Page 4: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-1;Guyton and Hall

Regulación del Líquido CorporalRegulación del Líquido Corporal

Page 5: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Balance Líquido (ml/dia) – Adulto de 70 kg

EntradasLíquidos ingeridos 2100A partir del metabolismo 200

2300

Normal

Salidas Insensibles - piel 350Insensibles - pulmones 350Sudor 100Heces 100Urina 1400

2300

Dieta Alta en Sal

4100 2004300

350 350 100 10034004300

Page 6: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

El Concepto de Balance

El balance es necesario, en el mantenimiento a largo plazo de la vida.

Perdidas liquidas = Ingesta liquidaPerdidas 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.

Page 7: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 26-1;Guyton and Hall

Effect of increasing sodium intake 10-fold on urinary sodium excretion and extracellular fluid volume

Effect of increasing sodium intake 10-fold on urinary sodium excretion and extracellular fluid volume

Page 8: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Fluid Balance (ml/day) – 70 kg Adult

IntakeFluids ingested 2100 ?From metabolism 200 200

2300 ?Output

Insensible - skin 350 350 Insensible - lungs 350 650Sweat 100 5000 Feces 100 100Urine 1400 500

2300 6600

Normal Heavy Exercise

Page 9: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-1;Guyton and Hall

Body Fluid DistributionBody Fluid Distribution

70 kg adult

Page 10: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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 age decreases TBW %

Increasing obesity decreases TBW %

Page 11: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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 age decreases TBW %

Increasing obesity decreases TBW %

Page 12: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Indicator Dilution Principle

Volume (B) = Indicator Mass (B) Concentration (B)

Valid if:• Indicator disperses only in compartment measured

= QC

• Indicator disperses evenly in compartment

• Indicator not metabolized or excreted

Page 13: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Measuring Body Fluid Compartments

Total Body water:• D2O, 3H2O, antipyrine (C11H12N2O)

Intracellular fluid = total body water - extracellular fluid

Extracellular fluid volume:• 22Na, inulin, thiosulfate

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.

Page 14: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Control of Body Fluid Distribution

Distribution across capillaries: determined by hydrostatic and

colloid osmotic forces

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

Page 15: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Osmotic Pressure ()

= CRTC = 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

Page 16: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Principles of Osmotic Equilibria

• H2O moves across cell membranes easilyi.e. ECFosm = ICFosm

40

300

200

100

0

0 10 20 30

OsmolaritymOsm/

L

Normal State

VOLUME (L)

ICF ECF

28 L 14 L

7980 mOsm 3920 mOsm

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

• Hydrostatic pressure differences have onlya small effect on fluid movement across cell membrane

Page 17: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-5; Guyton and Hall

Isotonic(no change)

Hypertonic(cell

shrinks)

Hypotonic(cell

swells)

Effects of solutions on Cell Volume

Page 18: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Isosmotic - has same osmolarity as body fluids

Hyperosmotic - higher osmolarity than body fluids

Hyposmotic- lower osmolarity than body fluids

Page 19: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

• What is the osmolarity of a

5 % glucose solution?

• Is the solution hyperosmotic, hypo-osmotic, or isosmotic?

Question

Page 20: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Osmolarity of a 5 % Glucose Solution

MW glucose = 180 gm/mol5 % = 5 gm/100 ml = 50 gm/L

Isosmotic

50 gm x 1 mol = .278 mol =L 180 gm L

278 mOsmL

Page 21: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

• What is the osmolarity of a 3.0% NaCl solution?

• Is the solution hypertonic, hypotonic, or isotonic?

Question

Page 22: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Osmolarity of a 3% NaCl Solution

MW NaCl = 58.53 % = 3 gm/100ml = 30 gm/L30 gm x 1 mol = .513 mol = 513 mmol

L L LFor NaCl, 1 mmol = 2 mOsm513 mmol x 2 mOsm = 1026 mOsm

LL mmol

Hypertonic

58.5 gm

Page 23: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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?

Page 24: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

40

300

200

100

0

0 10 20 30

OS

MO

LA

RIT

Ym

Osm

/L

Normal State

VOLUME (L)

ECFICF A.

B.C.

Effect of adding 2 L of 0.9 % NaCl ?

Copyright © 2006 by Elsevier, Inc.

Page 25: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

What are the Changes in the following variables after giving 2.0 liters of

water i.v.?

Extracellular Fluid Volume?Extracellular Fluid Osmolarity?Intracellular Fluid Volume?Intracellular Fluid Osmolarity?

Page 26: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

40

300

200

100

0

0 10 20 30

OS

MO

LA

RIT

Ym

Osm

/LNormal State

VOLUME (L)

ECFICF A.

B.C.

Effect of adding 2 L of water ?

Copyright © 2006 by Elsevier, Inc.

Page 27: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

What are the Changes in the following variables after giving 2.0 liters of

3.0% NaCl i.v.?

Extracellular Fluid Volume?Extracellular Fluid Osmolarity?Intracellular Fluid Volume?Intracellular Fluid Osmolarity?

Page 28: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

40

300

200

100

0

0 10 20 30

OS

MO

LA

RIT

Ym

Osm

/LNormal State

VOLUME (L)

ECFICF A.

B.C.

Effect of adding 2 L of 3 % NaCl ?

Copyright © 2006 by Elsevier, Inc.

Page 29: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

What are the Changes in the following variables after giving 2.0

liters of 3.0% NaCl i.v.?

Extracellular Fluid Volume?Extracellular Fluid Osmolarity?Intracellular Fluid Volume?Intracellular Fluid Osmolarity?

> 2.0 Liters

Page 30: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

300

200

100

0Osm

olar

ity

mO

sm/L

Normal State A. Add Isotonic NaCl

B. Add Hypertonic NaCl

C.Add Water (or hypotonicFluids)

0 10 20 30 40

Volume (L)

Copyright © 2006 by Elsevier, Inc.

Page 31: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Which of the diagrams below representssimple dehydration caused by water loss?

300

200

100

0Osm

olar

ity

mO

sm/L

0 10 20 30 40Volume (L)

A. B.

C. D.

Copyright © 2006 by Elsevier, Inc.

Page 32: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

• Calculation of intracellular and extracellular fluid volumes and osmolarities after fluid

administration.

Osmotic Equilibrium Problems

Page 33: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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?

Page 34: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Step 1. Initial conditions

Volume Conc. Total(L) mOsm/L mOsm

Extracell. Fluid (.2 x 70) = 280

Intracell. Fluid (.4 x 70) = 280

Total Fluid = 280

Assume: extracell vol. = 20 % BW; intracell. vol. = 40 % BW

3920

7840

11,760

14

28

42

Effect of Infusing 2.0 liters of 3% NaCl to a 70 kg Person

Page 35: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Osmolarity of a 3% NaCl Solution

MW NaCl = 58.53% = 3 gm/100ml = 30 gm/L

513 mmol x 2 mOsm = 1026 mOsmLL mmol

30 gm x 1 mol = .513 mol = 513 mmolL L L58.5 gm

For NaCl, 1 mmol = 2 mOsm

2.0 L x 1026 mOsm/L = 2052 mOsm

Page 36: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Extracell. fluid 14+2= ? 3920+2052=

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

Total Fluid 42+2= ? 11,760+2052= no equilibrium

Effect of Infusing 2.0 liters of 3% NaCl to a 70 kg Person

Step 2. Instantaneous Effect Volume Conc. Total (L) mOsm/L mOsm

16

44

5972

13,812

Page 37: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Extracell. fluid 3920+2052=

Intracell. fluid 7840 + 0 = 7840

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

Effect of Infusing 2.0 liters of 3% NaCl to a 70 kg Person

Step 2. After osmotic equilibrium Volume Conc. Total (L) mOsm/L mOsm

5972

13,812

19

25

314

314

314

Net effect: Extracell. Volume by 5.0 L Intracell volume by 3.0 L

Page 38: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Abnormalities of ExtracellularFluid Na+ Concentration

(Osmolarity)

Page 39: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hyponatremia : Na+ conc.

Hypernatremia : Na+ conc.

Abnormalities of ExtracellularFluid Na+ Concentration

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

• water loss • Na+ excess

• water excess• Na+ loss

Page 40: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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).

Page 41: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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.

Page 42: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hypernatremia

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

What lab measurements would help in diagnosis?

With Increased Extracellular Fluid Volume( NaCl excess: hyperosmotic overhydration)

• Hematocrit, plasma proteins• Urine volume

Page 43: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hypernatremia

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

• Large volume of dilute urine - diabetes insipidus

• Increased hematocrit, plasma proteins

• Small volume of concentrated urine - dehydration, excess sweating

- lack of ADH (“central” diabetes insipidus)- “nephrogenic” diabetes insipidus

Page 44: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hypernatremia

With Increased Extracellular Fluid Volume( NaCl excess: hyperosmotic overhydration)

• Primary aldosteronism• Cushing’s syndrome

Usually the Hypernatremia is mild in these examples,but the person may have very low plasma K +

(hypokalemia).

• Decreased hematocrit, plasma proteins

Page 45: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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 kgPlasma Na+ = 162 mmol/LPlasma K+ = 4.7 mmol/LBlood pressure = 102/65 mmHgHeart rate = 92 beats/minHematocrit = 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 – Clinical Case

Page 46: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hypernatremia****aqui preguntas del examen parcial****

A. With Increased Extracellular Fluid Volume( NaCl excess: hyperosmotic overhydration)

• Primary aldosteronism• Cushing’s syndrome

B. With Decreased Extracellular Fluid Volume(water loss: hyperosmotic dehydration)

• Large volume of dilute urine - diabetes insipidus- lack of ADH (“central” diabetes insipidus)- “nephrogenic” diabetes insipidus

• Small volume of concentrated urine - dehydration, excess sweating

Page 47: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hyponatremia

With Decreased Extracellular Fluid Volume ( NaCl Loss: hypo-osmotic dehydration)

• diarrhea, vomiting• Addison’s disease (decreased aldosterone)• overuse of diuretics• sodium wasting renal diseases

Increased hematocrit, plasma proteins

Page 48: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Hyponatremia

With Increased Extracellular Fluid Volume(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

Page 49: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Intracellular Edema

• Hyponatremia

• Depression of tissue metabolic systems(e.g. hypothyroidism)

• Inadequate tissue nutrition(e.g. ischemia)

• Inflammation of tissues (increased cell membrane permeability)

Page 50: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Determinants of Capillary Filtration

Page 51: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Determinants of Capillary Filtration

Page 52: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Causes of Extracellular Edema (increased interstitial fluid volume)

• Increased Capillary Filtration

• Failure of lymphatics to Return Interstitial Fluid to Circulation

Extracellular Edema

Page 53: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Determinants of Capillary Filtration

CapillaryPressure (Pc)

Plasma ColloidOsmotic Pressure ( c)

InterstitialFluid Pressure (Pisf)

Interstitial ColloidOsmotic Pressure (isf)

Kf

FILT = Kf (Pc - Pisf - c + isf)

Page 54: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Determinants of Capillary Filtration

Page 55: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Determinants of Capillary Filtration

Page 56: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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

Page 57: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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?

Page 58: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Figure 25-1; Guyton and Hall

X Lymphatic Failure = Edema

Lymphatic Failure and Edema

Page 59: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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

Page 60: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

- 8 - 4 0 + 4

12

24

36

48

60

0

Inte

rstit

ial F

luid

Vol

ume

(lite

rs)

Interstitial Fluid Pressure (mmHg)

FreeFluid

GelFluid

Low compliance

HighCompliance

Copyright © 2006 by Elsevier, Inc.

Page 61: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Low Tissue Compliance and Negative Intersititial Fluid Hydrostatic Pressure

InterstitialVolume

Interstitial FluidHydrostatic Pressure

Capillary Filtration

Page 62: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Increased Lymph Flow

InterstitialVolume

Interstitial FluidHydrostatic Pressure

Lymph Flow

Page 63: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Lymph Flow( x normal)

20

10

1

- 6 - 4 - 2 0 2 4Interstitial Fluid Pressure ( mmHg)

Effect of Interstitial Fluid Pressure on Lymph Flow

Page 64: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

2

4

6

8

0

0 20 40 60 80 100 120 140 160 180

Plasma Protein Concentration

Rate of Non-Visceral Lymph Flow (ml/hr)

Int

erst

itia

l Flu

idP

rote

in c

once

ntra

tion

(

gm/1

00 m

l)

Washdown of Interstitial Proteins

Page 65: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

“Washdown” of Interstitial Fluid Proteins

InterstitialVolume

Interstitial FluidOncotic Pressure

Capillary Filtration

Interstitial FluidHydrostatic Pressure

Lymph Flow

Protein Removal From Tissues

Page 66: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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

Page 67: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Conditions Causing Edema

1. High capillary hydrostatic pressure• Excess fluid retention by kidneys- acute or chronic kidney failure- glomerulonephritis- mineralocorticoid excess

Page 68: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

Conditions Causing Edema

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

Page 69: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

2. Decreased plasma proteins (low oncotic pressure)

• Loss of proteins- burns, wounds- nephrosis- gastroenteropathy

• Failure to produce proteins- malnutrition (“kwashiorkor”)- cirrhosis- analbuminemia

Conditions Causing Edema

Page 70: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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

pregnancy

Conditions Causing Edema

Page 71: Guyton & Hall Fisio : Capitulo 25 Los Compartmentos Liquidos del Cuerpo

Copyright © 2006 by Elsevier, Inc.

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

Conditions Causing Edema