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Hailey - CRRAB II > Muster Week 1 > Flashcards

Muster Week 1 Flashcards

1
Q

body fluid compartments

A
  1. intracellular
  2. intravascular
  3. interstitial
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2
Q

TBW

A

60% water M
50% water F

55,500 mM (millimoles)

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3
Q

“stuff”

A

Na, K, Cl, urea, HCO3-, WOA, albumin, glucose, Mg, Ph

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4
Q

osmolality

A

total free solute (mM)/Kg of solvent

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5
Q

osmolarity

A

total free solute (mM)/L of solvent

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6
Q

milliosmoles

A

units of osmolarity or millimoles of total free solute

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7
Q

primary solutes in plasma (intravascular)

A 
Na+ (140mM)*
K+ (5mM)*
glucose (5mM/90mg)
Ca++ (4mM)
PO4- (6mM)*
anions (20mM)*
Cl- (105mM)
HCO3- (25mM)
urea (6mM)

in mM/L

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8
Q

primary solutes in interstitum

A

Na+ (140mM)*
K+ (5mM)*
PO4- (6mM)*
anions 0*

in mM/L

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9
Q

primary solutes intracellular

A 
Na+ (~3mM)**
K+ (140mM)**
PO4- (10mM)**
Cl- (10mM)
anions (45mM)**
protein- IMPERMEABLE

THIS ONE IS DIFFERENT

in mM/L

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10
Q

charge of albumin

A

A-

(-)(-)(-)(-)(-)!!!
RESPONSIBLE FOR ANION GAP
anion gap = albumin
[Na+ -(Cl- + HCO3-)] = 8-12

*should get a gap/difference in charges (+/-) by concentration because haven’t accounted for albumin (-) = anion gap

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11
Q

anion gap

A 
think albumin
(-) anion gap = albumin = 8-12
  • if off, have some other ion put into the blood stream (other +/- stuff or acids/bases) because albumin balances with Ca, FA, H, drugs, etc.
    ex: sickness, diabetic ketoacidosis, etc.
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12
Q

osmolality/L of plasma

A

~300mM/L

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13
Q

interstitial fluid is plasma without ______

A

ALBUMIN.

so no negative charges….creates concentration/electrochemical gradient

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14
Q

capillary wall characteristics

A

FENESTRATED
semi-permeable membrane
constantly under pressure (blood pressure)
impermeable to albumin

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15
Q

in general, under NORMAL circumstances, the capillary pressure (Pc) is…

A

opposed EQUAL AND OPPOSITE by the oncotic capillary pressure (Pic)

kf [(Pc + Pii) - (Pi + Pic)] in mmHg = filtration equation/NET STATE OF FLOW
kf[(25 + 0) - (0 + 25)] = 0
stuff moves but the capillaries don’t leak!

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16
Q

Net state of flow equation

A

kf (force favoring filtration) - (forces favoring reabsorption) = net state of flow

kf [(Pc + Pii) - (Pi + Pic)] in mmHg

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17
Q

forces favoring filtration

A

pressure within capillary (Pc)

oncotic pressure within interstitial space (Pii)

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18
Q

forces favoring reabsorption

A

oncotic pressure within capillary (Pic)

pressure within interstitial space (Pi)

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19
Q

protein osmotic pressure names (Pic)

A

= oncotic pressure
colloid pressure
osmotic pressure

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20
Q

oncotic pressure

A
  • created by the ~1mM plasma albumin within a permeable capillary that is impermeable to A-
  • draws fluid into capillary space
  • measured in mmHg but is just another way to measure [Alb-]
  • force of draw is ratio of oncotic pressure:hydrostatic pressure; albumin:blood pressure
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21
Q

force of draw into capillary space

A

oncotic pressure:hydrostatic pressure;

albumin:blood pressure

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22
Q

osmolality of intracellular

A

~300mM/L

same

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23
Q

Differences between intracellular and plasma…

A

MORE K+

LESS Na+

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24
Q

How is this change (between intracell and intersti/plasma) maintained?

A

How?! —> ATPase

Something has to keep the gradient otherwise cells burst and die (because cell membrane controlled, not fenestrated)

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25
Q

Why is digitalis (digoxin) so dangerous?

A

Because it inhibits Na+/K+ ATPase…disrupts membrane concentration gradient…CELLS BURST AND DIE –> MAJOR DAMAGE –> FATAL

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26
Q

isosmotic

A
  • any solution that has ~300mOsms
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27
Q

isotonic

A
  • any solution that will NOT change the volume of a cell

- need 300mOsom of impermeable solutes

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28
Q

isoncotic

A
  • any solution with 1mM of plasma albumin or ~4.5g/100mL
    OR
  • any solution with protein osmotic pressure of ~25mmHg
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29
Q

Fluids are _____.

A

drugs

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30
Q

Losing blood problem… hypotensive and tachycardic

A

intravascular problem

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31
Q

SOB problem… hypotensive and bradycardic, pitting edema, elevated creatinine

A

interstitial problem

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32
Q

Types of fluid

A

Normal saline (0.9%)
1/2 NS (0.45%)
D5

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33
Q

NS

A

osmolality: 308mM/L
Na+: 154 mM/L
Cl-: 154mM/L

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34
Q

1/2 NS

A

osmolality: 150mM/L
Na+: 75mM/L
Cl-: 75mM/L

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35
Q

D5

A

osmolality: 300mM/L
Na+: 0
Cl-: 0
glucose: 280mM/L

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36
Q

TBW = Vd

A

changes when patients are critically ill (like in sepsis)

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37
Q

intracellular fraction TBW

A

2/3

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38
Q

extracellular fraction TBW

A

1/3

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39
Q

interstitial (extracellular) fraction TBW

A

3/4

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40
Q

plasma (extracellular) fraction TBW

A

1/4

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41
Q

average patient weight

A

70kg

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42
Q

So…TBW, intracell, etc. breakdown per L (using weight)

A 
TBW: 42L
intracellular water: 28L
extracellular: 14L
interstitial (extracellular): 11L
plasma (extracellular): 3L
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43
Q

Amount TBW in plasma and importance of it

A

plasma: 3L (7.5% of TBW)

* that’s not much, which is why if have arterial bleed, can die within 10 minutes!!!

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44
Q

If you drink water, where does it distribute?

A

It will distribute proportionately according to the volume of the compartments, to ALL, nothing stopping it.

1L: 3/42 to plasma, 11/42 to interstitial, 28/42 to intracellular
= 333mL to extracellular, 666mL to intracellular

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45
Q

What allows water to distribute to all body fluid compartments?

A
  • fenestrations of capillaries

- aquaporins of cell membranes

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46
Q

If you infuse 1L NS, where does it distribute?

A

It will distribute to interstitial and plasma (extracellularly).

1L: 3/14 to plasma, 11/14 to interstitial = 214mL to plasma, 786mL to interstitium

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47
Q

Situations calling for NS

A
  • DKA
  • sepsis: haven’t lost fluid, but inflamed/dilated vessels so DECREASED BP (give fluids to fill up that extra cellular space and increase BP)
  • secretory diarrhea: losing Na, Cl, and water (replace)
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48
Q

Give 1L 1/2 NS, where will it distribute?

A

1/2 amount want to give, distribute JUST LIKE NS JUST HALF THE AMOUNT
1/2 amount want to give, distrusted JUST LIKE WATER

49
Q

Situations calling for 1/2 NS

A
  • sweat losses (athletes losing 1/2 NS)
  • elderly (same)
  • hospitalization (febrile)
50
Q

Give 1L D5W (5% dextrose = 5g/100mL water), where will it distribute?

A

Distributes JUST LIKE WATER
- glucose gets completely removed and water follows

IF CANT DRINK WATER, GIVE 5DW

51
Q

Situations calling for D5

A

DI (nephron entice or central)

Severe hypoglycemia

52
Q

What does it mean to order a serum [Na+]?

A

Does NOT necessarily reflect volume status.

53
Q

Volume depletion definition

A

EXTRACELLULAR volume loss from any cause (most often loss of NaCl and water).

54
Q

Dehydration definition:

A

Presence of HYPERNATREMIA (increased serum [Na+]) due to pure water loss.

55
Q

Serum [Na+] does not equal

A

Volume

56
Q

Give NS… Effect on serum [Na]

A
  • no change in serum [Na+]

- only goes to EXTRACELLULAR so increase VOLUME of same osmolality

57
Q

Give water… Effect on serum [Na+]

A
  • decreased serum [Na+] (decreasing osmolality by adding more solvent)
  • small increase in volume (extra and intra cellularly)
58
Q

Give pure salt…lots of it… Effect of [Na+]

A
  • increase [Na+]
  • increased osmolality EXTRACELLULARLY –> water floods out of cells into EXTRACELLULAR –> BAD
    = why hypernatremia is bad…what if this is happening in brain (then water rushed back in and cells burst and die–> gonzo bad)
59
Q

Functions of kidney

A 
HOMEOSTASIS
Filtration
Maintain BP
Na+ homeostasis (volume)
Water homeostasis 
K+ homeostasis
Bone mineral, vitamin D, PO4-, Ca++
Acid/base homeostasis
RBC production and regulation of EPO
gluconeogenesis (also an endocrine organ)
60
Q

Kidney in most basic sense:

A

Fluid in –> filtered –> fluid excreted in urine OR fluid returned to blood

61
Q

If kidney cannot filter…

A

Cannot excrete…cannot maintain homeostasis

Ex: if cannot filter K+ –> cannot excrete K+ –> hyperkalemic –> DIE

62
Q

How many glomeruli in kidney

A

1 million glomeruli per kidney

63
Q

Fluid IN to kidney:

A
  1. Blood
  2. 20% first pass CO (1000mL/min) of blood flow…!
  3. 60% of this is plasma (40% of blood is hematocrit/RBCs) = RPF, renal plasma flow
64
Q

Why isn’t renal vein blue?

A

High P O2, kidney is highly oxygenated organ –> it senses small changes in P O2 –> can crank up EPO production –> more RBC –> add more O2 by more RBCs

65
Q

How many capillaries per glomeruli

A

20

66
Q

How many mesangial cells per glomeruli

A

2-3

67
Q

Physical structure of glomerulus restricts what can be filtered by:

A
  1. size
  2. charge

Ex: albumin doesn’t get through here (unless damage GBM)

68
Q

Components of glomerulus filtration barrier

A
  1. capillary endothelium: FENESTRATED
    anything but cells and protein can pass here
  2. basement membrane: ANIONIC
  3. podocytes: cells exterior to GMB form NEGATIVELY CHARGED SLITS

*damage to any one of these three will result in filtration of things don’t want filtered

69
Q

How does DM damage filtration barrier?

A

Damages capillaries and mesangial cells –> albumin in urine

70
Q

How does vasculitis damage filtration barrier?

A

Damages capillaries –> leak RBCs into urine

71
Q

How does Anti-GBM NPGD damage filtration barrier?

A

Anti-basement membrane disease causes fat, think, ribbon like deposits on top or into BM –> interrupts BM –> “stuff” falls through

72
Q

How does Minimal Change diesase or Membraneous Change disease damage filtration barrier?

A

Podocytes damaged –> HUGE amounts of albumin in urine

73
Q

What is typical size of plasma components (in daltons; mass proportional to size)?

A 
Na: 23
K: 39
Cr: 113
urea: 60
albumin: 66,000Da
74
Q

What sizes are freely filtered?

A
75
Q

What size would be completely excluded in normal state?

A

> 70,000 Da

76
Q

Charge of GMB

A

anionic (-)(-)(-)

so NEGATIVELY CHARGED BIG STUFF HAS HARD TIME GETTING THROUGH

= easy for Na+, K+ (small and cationic)

77
Q

Definition of GFR:

A

the movement of FLUID and SOLUTE across from the capillary lumen INTO Bowman’s space across ALL (2 million) glomeruli in both kidneys

78
Q

Calculation of GFR

A

kf (constant) [(Pgc + Pibs) - (Pbs + Pigc)]

Remember: gc = glomerular capillary
bs = bowman’s space
Pi = oncotic pressure = albumin

79
Q

What does low/reduced GFR mean?

A

Means kidney’s ability to filter blood is not how it should be, it is sub-par = can’t get stuff from capillaries to bowman’s space (nephron/urine) effectively

80
Q

Kf constant is

A

the glomerular filtration coeffiecient or degree of “openness” of capillary pores
- about 10% open

81
Q

GFR = net _______ pressure

A

GFR = net ULTRAFILTRATION pressure

= that is what the kidney does! Filter!

82
Q

Pgc

A

60mmHg

higher than other capillaries in body

83
Q

Pbs

A

15mmHg

have tons of fluid trying to get into small proximal tubule from bowman’s space

84
Q

Pi gc

A

29mmHg

little higher than other spaces

85
Q

Pi bs

A

0

no albumin filters through GBM

86
Q

Net ULTRAfiltration pressure of glomerulus?

A

16mmHg

= HUGE pressure gradient across each glomeruli!

87
Q

Normal GFR

A

180L/day or 125mL/min

putting 180L/day into urinary tubular space every day, pee out 2L/day, reabsorb 178L/day WOW

88
Q

If any factors contributing to net filtration P are damaged…

A

will change the net GFR

89
Q

Angiotensin II has great effect on which glomerular arteriole?

A

EFFERENT

90
Q

Where do prostaglandins work and what do they do (to glomerulus/arterioles)

A

PGs on AFFERENT arteriole DILATE

91
Q

Normal RPF

A

600mL/min

92
Q

Can change/control (P/Pi) (gc/bs)???

A

Can control/change the Pgc (pressure inside glomerular capillary)
REMEMBER PGC FAVORS FILTRATION

Cannot change Pi gc (can’t change albumin in 5 minutes), Pbs (can’t change size of bs), Pi bs (is 0)

REMEMBER: (Pgc + Pibs) favoring filtration - (Pbs + Pigc) favoring reabsoprtion = net filtration pressure

93
Q

Kink in afferent arteriole…effect on Pgc and GFR

A

Pgc decreases
(in front of kink is high pressure, just after is low pressure)
GFR decreases

94
Q

Dilated afferent arteriole…effect on Pgc and GFR

A

Pgc increases
(more flow into glomerulus)
GFR increases
(increased P and no change in reabsorption = increase GFR)

95
Q

Constricted efferent arteriole…effect on Pgc and GFR

A

Pgc increases
(in front of kink is high pressure, just after is low pressure)
GFR stays same (hopefully)
(if compensatory mechanisms kick in, will stay the same)

96
Q

What would constrict the efferent arteriole?

A

angiotensin II

usually compensatory to low pressure

97
Q

Dilated efferent arteriole…effect on Pgc and GFR

A

Pgc decreases
(pressure across glomerulus decreases)
GFR decreases

98
Q

Constricted SNS response on both afferent and efferent artieroles…effect on Pgc and GFR

A

Pgc NO CHANGE
(NO renal plasma flow)
= NO RPF = NO GFR

(in septic shock, SNS kicks in, kidney is shut down like this, shunts blood to brain)

99
Q

Remember…Pgc favors ______.

A

FILTRATION

100
Q

Filtration fraction

A

20%

percent RPF (Na, K, H20, Cr, urea) is being filtered into bs every minute

101
Q

Filtered load

A

[X serum] * GFR

how much “stuff” in actual amounts is filtered

102
Q

Filtered load of sodium

A

[X serum] * GFR
140mM/L x 180L/day = 25,000mM Na+ filtered PER DAY

–> but not all is peed out, so REMEMBER REABSORPTION

103
Q

Filtered load of glucose

A

[X serum] * GRF
5mM/L x 180L/day = 900mM glucose filtered PER DAY

—> but none of it is in urine, so REMEMBER REABSORPTION

104
Q

Excretion rate

A

urine flow rate * [solute in urine]

filter certain amount –> excrete certain amount

105
Q

Excretion rate of Na+

A

200mM/day = 4.5g salt/day

if pee 2.5L/day

106
Q

Excretion rate should be…

A

whatever is required to excrete to keep you in HOMETOSTASIS/BALANCE

107
Q

In some cases, the filtered load equals the excretion rate (no reabsorption)…

A

Solute is completely filtered…not reabsorbed, secreted, destroyed or produced…

Ex: Creatinine, inulin, iohexol, iothalamate

108
Q

GFR = (of unique solute where filtration rate = excretion rate)

A

GFR = excretion rate of unique solute / plasma concentration of unique solute

GFR = URF [Xu] / [Xp]

109
Q

If GFR is 180L/day…the kidney is CLEARING 180L/day of plasma
So…of all creatinine CLEARED per day, excreting all creatinine from that 180L
Therefore clearance = _____

A

GFR

under ideal circumstances

110
Q

If you know the plasma concentration of a “special” solute…you can measure the urinary concentration and know urine volume to calculate _______

A

GFR

what you filter comes out in urine

111
Q

Creatinine clearance 24 hour urine measure requires

A

steady state

*order urine creatinine (to determine if was collected appropriately)

112
Q

CrCl should be (in theory) equal to _____?

A

GFR

113
Q

Female CrCl normal

A

about 20mg/kg/day

114
Q

Male Cr Cl normal

A

about 25mg/kg/day

115
Q

Estimation of Cr Cl

A

Cockcroft-Gault

116
Q

Cockcroft-Gault equation

A

(140 - age)(weight in kg)(0.82 if female) / serum [Cr]mg/dL * 72

117
Q

Estimation of GFR

A

MDRD: modification of diet in renal disease study

118
Q

MDRD equation

A

GFR (in mL/mim) = (186.3)(serum Cr)(age)(0.742 if female)(1.21 if black)

119
Q

Limitations of estimation of Cr Cl and GFR of Cr…

A
  • Neither of these are valid in normal or near normal renal function.
  • Creatinine is SECRETED depending on renal function, is ramped up in early phases of GFR decline
  • if renal function falls by 1/2…would see a doubling of creatinine (but not true in early phases of renal loss due to secretion)
  • Creatinine can have variable production based upon age, illness, etc.
  • When finally see Cr doubled, it has exceeded its secretion rate, BAD HAS BEEN HAPPENING FOR A WHILE

Hailey - CRRAB II (6 decks)

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