Ineffective intraarterial volume

5

Category : Acid-Base & Lytes, Attending Rounds

Readers know that I love teaching acid base and electrolytes. For years I (and many other educators) have difficulty explaining why edematous states can lead to hyponatremia. We always have talked about ineffective intravascular volume, although when you measure the intravascular volume it measures as increased. Thus, we had a difficult concept to communicate and understand.

This week I read I wonderful piece by Dr. Schrier which allows me to understand the concept and teach it. Decreased Effective Blood Volume in Edematous Disorders: What Does This Mean?

Here is the short story.  These edematous disorders represent an interesting paradox.  Generally 85% of the intravascular volume is venous and 15% arterial.  In these edematous states, the proportion of venous filling increases and the arterial filling decreases, with a net increase in total intravascular volume.  Thus, we should rephrase the concept to decreased intra-arterial volume.

This makes sense.  If intra-arterial volume is decreased we should have increased ADH as well as renin-angiotensin-aldosterone.

This article makes more clear an interesting physiologic mystery.  I hope my revelation helps at least 1 reader!

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Comments (5)

Thanks db! I recently had an edmeatous patient and this post helped remind me of this fact that a medicine professor taught me long ago. thanks for refreshing my neurons!

Very interesting indeed! I’ve wondered about this as occasionally as a health and vitality coach I come across someone who tells me they drink no water and yet have edema, and “feel like they are drowning” when they lie down. I couldn’t understand how someone who must lose water each day in urine, breathing, sweat etc., could possibly feel this way. I tend to recommend drinking a lot of water, but in this case, I didn’t want to because I didn’t understand why this was happening.

Is it the decreased intra-arterial volume that causes the increased ADH and renin-angiotensin-aldersterone, or is it the other way around? Increased ADH etc. causes decreased intra-arterial volume? If not, what causes the decreased intra-arterial volume in the first place? I’m finding in many many health conditions the ultimate cause is related to an improper cortisol rhythm. Is it possible that an elevated cortisol to DHEA ratio would increase water and salt retention? If this is the case, a chronic stressor, either physiological or psychological, would be the ultimate cause of the problem I would think.

What is done about this problem in your world? Does gentle exercise help the venous return? I’m no doctor, but my goal is to understand as completely as possible how the body works.

Thanks for shedding some light on this.

Okay, I’ve got another idea.

Would eating a low-starchy carb, no sugar diet resolve the issue? We know that when people do so, initially they lose mostly water weight (and therefore sodium).

Carbohydrate consumption causes insulin secretion, which causes the kidneys to hold onto sodium, so therefore water must also be retained to keep the appropriate electrolyte balance in the blood. This causes an increase in blood pressure.

So, eat a low starchy carb diet, the kidneys release the sodium, and the body releases the water, which would decrease blood pressure probably just as well as diuretics would. Not sure what that does to increase intra-arterial volume though.

The reasons for ineffective intra-arterial volume are all disease states. Diet will have have no impact. These are vascular responses to heart failure or cirrhosis or pregnancy.

Another (albeit similar) way to think about it that I was just taught: Fluid gets “trapped” by a pathological process in a “compartment” (interstitium, venous circulation, bullae) that doesn’t freely communicate with other fluid compartments. Starling forces keep that fluid in there, and more fluid/salts are added with the kidney’s adjustment for what it senses as decreased EABV, and the process becomes cyclic. (I hope I got all that right!)

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