Chapter 11: Function and

Measurement of Electrolytes

Mihret Alemayehu (Assi.Prof)

 Chapter Learning Objectives
• Upon completion of this chapter the
student should be able to:
– Describe the function of electrolytes
– Explain electrolyte and water balance,
electrolytes and acid balance in normal
conditions and conditions of imbalance.
– Explain measurement of electrolytes like
sodium, potassium, chloride, bicarbonate,
calcium, phosphorus and magnesium
 Chapter Learning Objectives
• Upon completion of this chapter the
student should be able to
• Explain serum iron and iron binding
capacity
• Describe the physiologic function,
regulation and assay of blood gases
 Outline
• Function of electrolytes
• Elctrolytes and water balance
• Condition of fluid imbalance
• Conditions of electrolyte imbalance
• Electrolytes and acid-base balance
• Disturbances of acid – base balance
 Outline
• Measurement of electrolytes like sodium,
potassium, chloride, calcium,
phosphorous and magnesium, and serum
iron and iron binding capacity
• Physiological function, regulation and
assay principles of blood gases
 Learning Objectives
Upon completion of the lecture and exercise the
student will be able to:
• Define electrolytes and related terms.
• Discuss the intracellualr and extracellular
distribution of electrolytes
• Explain the typical relationship (balance) of
water and electrolytes
 Learning Objectives
• Upon completion of this lecture the student will
be able to:
• Discuss typical Na, K, Cl, CO2/HCO3 levels in
body fluids based on pathophysiological
responses.

• Describe the principle of analysis of Na, K, Cl

and total CO2 (HCO3-), in terms of electronic
components, reagents and endpoint detection.
 Learning Objectives
Upon completion of this lecture and exercise the
student will be able to:

• Describe specimen collection and handling requirements

for electrolyte analysis.

• Explain the expected reference ranges of Na, K, Cl,

CO2/HCO3 based on normal physiologic responses.

• Discuss interpretation of electrolyte results

 Outline of Electrolytes and
Blood Gases Lecture
• Introduction
• Source
• Clinical Significance
• Methods of Analysis
• Specimen
• Interpretation
• Quality Control
• Sources of Error
• Documentation and Reporting
• Summary
 Introduction to Electrolytes
• Definition: charged particles or ions when
in solution . Cations are positive ions.
Anions are negative ions.
Major Electrolytes:
• Main cations: Sodium (Na +), Potassium
(K+), Magnesium (Mg++), Calcium (Ca++).
• Main anions: Chloride (Cl-), Bicarbonate
(HCO3-), Phosphates (HPO4--, H2PO4 -),
Sulphate (SO4--), Organic acids, Proteins.
 The Function of Electrolytes
• Participate in:
– enzyme activation
– coagulation and complement cascades
– contribute to plasma osmolality
– participates in cardiac rhythm
– neuromuscular excitation
– oxidation-reduction reactions
• Other
 Distribution of Electrolytes
• Intracellular versus Extracellular
distributions vary
– Na+, Ca++ and Cl- extracellular
– K+, Mg++ and CO3- intracellular
• Effect of hemolysis
 Water and Electrolyte Balance
• Intracellular Fluid (ICF)
– More protein, K +, Mg2+, phosphates, HCO3-
• Extracellular Fluid (ECF)
– Less protein
– More Na+, Cl-

• Interstitual Fluid
• Intravascular Fluid (plasma)
 Water Balance

• Total water intake = total water out-

put
• Osmotic Pressure (Na + water)
• Hormonal Influences
– Aldosterone
– Anti-diuretic Hormone (ADH)
 Condition of Fluid Imbalance
• Loss of Water
– Dehydration
– Lack of ADH

• Loss of Water and Electrolytes

– GI loss
– Excessive sweating
– Burns
– Excess urine excretion
 Oedema
• Abnormally large amount of interstitial fluid
accumulates in tissue space
• Causes
– Low plasma protein levels
– Block lymphatic vessels
– Sodium retention combined with increased
capillary blood pressure
 Electrolytes and Acid Base
Balance
Major electrolyte involved is HCO3-

(carbonic anhydrase)

• H2CO3-------------- H2O + CO2 HCO3-

and H+
• The resulting bicarbonate is reabsorbed to
help maintain acid base balance in blood
plasma.
Overview of Acid-Base Balance

In order to maintain acid base balance and provide a neutral blood

pH of 7.4, there is approximately 20 times more salt, bicarbonate,
than weak acid, carbonic acid.
Both components contribute to acid base balance.
The kidney primarily controls bicarbonate ion levels while the
respiratory system controls carbonic acid through carbon dioxide
gas regulation.
 Electrolytes and Acid Base
Balance
• Bicarbonate buffer system: most significant.
• Renal control: HCO3- and H+
• Respiratory control: H2CO3
• Normal ratio for bicarbonate ion (mmol/L):
carbonic acid = 20:1

7.40 = 6.1 + log (HCO3-/ H2CO3)

• 6.1 is the pKa and 7.40 is the normal blood pH.
 Electrolytes and Acid Base
Balance
• Additional buffering of urinary H+:

• Renal tubular secretion and reabsorption

of H+, k+, Na + and HCO3-

• A buffer: mixture of chemicals that are

able to resist changes in pH
 Renal Control of Electrolytes
• Renal Control of Acid Base Balance
• Distal convoluted tubules perform 2 main
functions. They are:
1) secrete H+ and NH4+
2) secrete Na+, HCO3- & H2PO4-
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic Acidosis
– Indicated by decreased blood pH and
decreased bicarbonate/ total CO2
– Causes of Metabolic Acidosis are: diarrhea,
diabetic ketoacidosis and renal failure

– Compensation: Respiratory system attempts to

normal blood pH by eliminating more carbon
dioxide and decreasing blood pCO2 levels
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic acidosis with increased
anion gap
o Metabolic conditions such as diabetic
ketoacidosis, renal failure or other renal
diseases, lactic acidosis.

• Metabolic acidosis with normal anion

gap
• diarrhea
Disturbances of Electrolyte and
Acid Base Balance
• Metabolic Alkalosis
– Indicated by increased blood pH and increased
bicarbonate/ total CO2
– Causes of Metabolic alkalosis: excess treatment
with bicarbonate salts, prolonged vomitting and
renal causes of K depletion.

– Compensation: Respiratory system attempts to

normal blood pH by retaining carbon dioxide and
blood pCO2 levels
 Disturbance of Acid Base
Balance
• Respiratory Acidosis
– Indicated by decreased blood pH and
increased dissolved carbon dioxide/ pCO2
– Causes of respiratory acidosis are:
• Respiratory illnesses that cause hypoventilation
and hypercapnia
– Emphysems
– Chronic Bronchitis
• Medications that depress respiration
– Renal compensation causes increased blood
bicarbonate
 Disturbance of Acid Base
Balance
• Respiratory alkalosis
– Indicated by increased blood pH and
decreased dissolved carbon dioxide/ pCO2
– Causes: of respiratory alkalosis are:
• Hyperventilation from various reasons

• Compensation with renal control of bicarbonate

with will decrease blood bicarbonate levels to
attempt to normalize pH
 Sodium
• Major role in maintaining osmotic
pressure.
• Maintained by: kidneys

• Influence of the hormone: aldosterone

 Clinical Significance
Hypernatremia
• Caused by renal and non-renal disorders.
• Common non-renal causes:
– Dehydration
– Burns
– Excessive Sweating
• Renal:
– Nephrogenic diabetes insipidus
• Serum osmolality & urinary sodium levels
differentiate renal loss of water versus non-renal
causes.
 Clinical Significance
Hyponatremia
Renal:
• Salt losing nephritis

• Chronic renal failure can cause water overload:

• Nephrotic syndrome can cause fluid imbalances and

edema with resulting hyponatremia. Urine Na levels are
normal or decreased in hyponatremia due to edema.

• Non-renal causes of hyponatremia include psychogenic

water overload, cellular shift changes from acidosis and
edema secondary to cirrhosis or CHF
 Potassium
• Maintains cardiac rhythm and contributes
to neuromuscular conduction.
• Imbalances, hyperkalemia or hypokalemia,
will result in:
– Cardiac arrhythmia and weakness
 Clinical Significance
Hyperkalemia
• What causes hyperkalemia?
– Renal failure
– Diuretics
– Hypoaldosteronism
– Hypocortisolism
– Diabetic ketoacidosis
– Hemolytic or Leukemia
 Clinical Significance
Hypokalemia
• What causes it?
– Renal tubular acidosis
– Hyperaldosteronisms
– Hypercortisolism
– Vomiting or GI loss
• Note: cellular shift in insulin overdose and
alkalosis can also cause hypokalemia
 Electrolytes Analysis
• Ion selective Electrodes
• Flame Emission Photometry

• Measurement of Minor Electrolytes:

– Colorimetry
– Atomic Absorption Spectroscopy
 Electrolyte Analysis
• Only free unbound ion is measured by ion selective
electrode; significant for:
– Ca
– Mg
• Ion selective electrodes are covered by a unique
material that is more selective for one ion than other
ions.
• When the ion comes in contact with the electrode,
there is:  potential
• Lipemia interferes with indirect method
 Method of Na Analysis
• Ion Selective Electrode (ISE)
• made of a lithium aluminum silicate or
other composite silicon dioxide glass
compound
• selective for Na+
– Not selective K+ or H+
 Method of K Analysis
• The ISE for K typically contains a selective
membrane containing valinomycin
• binds well with K+
• does not bind well
with Na+ or H+
 Method of Na and K+ Analysis
Flame emission photometry
• Sample is mixed with internal standard.
• Solution is aspirated into a flame.
• Ions are excited with the addition of the thermal
energy and emit radiant energy.
• Photodetector detects the unique emitted
wavelengths of light specific to the Na+ and K+
• Concentration of Na+ or K+ in mmol/L is
determined.
 Interpretation of Serum Na and
K Levels
• Reference intervals for Various body fluids:
– Na: Serum or plasma 135-145mmol/L, not age
dependent
– Na: CSF , 136-150mmol/L
– Na: Urine, 40-220mmol/day
– K: Plasma : 3.3-4.9 mmol/l
– K: Urine:, 25-125mmol/day varies with dietary
intake
 Specimens for Na and K
• Venous Serum
• Heparinized plasma
• Effect of Hemolysis
– No error for Na but causes false elevation of K
• Avoid lipemic sera
• Separate serum or plasma quickly from cells
• CSF for Na but not K
• Urine sample with out preservative
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Sources of Error for Na and K
Analysis
• Hemolysis
• Failure to quickly separate plasma/serum
from cells
• Anticoagulants other than heparin
• Prolonged use of tourniquet
• Lipemia
• Errors of analysis
– Not calibrated
Source of Error with ISE Method
for Electrolytes
• ISE system which dilutes the sample with
diluent prior to analysis with the electrode
is termed indirect.
• Interference by hyperlipidemia or
hyperproteinemia
 Chloride
• Contributes to the acid-base balance by
the isohydric shift
• The shift is the buffering of H+ with HCO3-
and others intracellularly with movement
to extracellular fluid spaces.
• Chloride shift is:
– Movement of Cl
– Balances HCO3-
 Clinical Significance
Hyperchloremia
• Dehydration
• Hyperaldosteronism
 Clinical Significance
Hypochloremia
• Excessive urination
• Excessive sweating
• Hypoaldosteronism
 Method of Cl Analysis
• Ion Selective Electrode (ISE):unique liquid
membrane or solid state indicator made of
chloride salts which measures or senses
the activity of Cl ions and converts the
activity measurements to mmol/l.
• selective for Cl-
– Not selective other anions
 Method of Cl Analysis
Coulometry:
• Cl- titrated with Ag+ - insoluble AgCl.
• The time of titration is proportional to Cl
activity in the sample.
• This method is commonly used for sweat
chloride analysis.
• Historical method for serum Cl analysis
 Methods for Cl Analysis

Spectrophotometric methods
Hg(SCN)2 + 2Cl-  HgCl2 +2SCN-
3SCN- + Fe3+  Fe(SCN)3
• The final chromagen reddish complex of
ferricthiocyanate is measured
photometrically at 480 nm
 Specimen for Cl Analysis
• Serum or heparinized plasma
– Mild hemolysis is accepted
• Urine
• CSF
• Sweat
 Interpretation of Cl Results
• Cl Reference Ranges:
Serum in mmol/L
adult 98-107
infant 98-113
Urine in mmol /24 hr
adult 110-250
infant 2-10
child 15-40
CSF in mmol/L
adult 118-132
infant 110-130
Sweat 5-35 mmol/L
 Sources of Error in Cl Analysis
Specimen errors are associated with:
• Anticoagulants other than heparin

Analysis errors:
• In ISE Br- ions may interfere in Cl- electrodes
– Protein coating on the electrode
• In photometric method, poor calibration or in
accurate instrument operation
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Discussion Point
• Explain why chloride levels are
sometimes analyzed in sweat?
 Bicarbonate
• CO2 + H2O-> H2CO3-> H+ + HCO3-
• tCO2 includes many components:

• Dissolved CO2 and pCO2 make up a small

% of CO2 forms

• Major metabolic component to balance pH

 Clinical Significance of
Bicarbonate Ion Levels
• Excess Blood bicarbonate
– Metabolic alkalosis
– Compensation for respiratory acidosis
• Decreased Blood bicarbonate
– Metabolic acidosis
– Compensation for respiratory alkalosis
 Method Bicarbonate Analysis
• tCO2 gas electrode converts HCO3- to gas
• CO2 gas diffuses through a silicone membrane
• CO2 reacts with a bicarbonate/ carbonic acid
buffer
• Amount of H+ production is proportional to the
concentration of tCO2 in the plasma

• CO2 + H2O-> H2CO3-  HCO3- + H +

Bicarbonate/ total CO2
Method of Bicarbonate Analysis
Photometric method:
• HCO3 + urea --(urea amidolyase) NH4+
+ NADPH –(glutamate dehydrogenase)
NADP+ + H+
• Decrease in Abs is measured at 340 nm
 Specimens for Bicarbonate
• Serum
– Arterial
– Venous
• Heparinized whole blood
– Arterial
Interpretation of Bicarbonate
Levels
Reference Ranges:
Specimen HCO3- Unit
Serum, Venous 22-29 mmol/L
Serum, Arterial 21-28 mmol/L
Whole blood,
Arterial 22-26 mmol/L
 Quality Control
• A normal & abnormal quality control sample
should be analyzed along with patient samples,
using Westgard or other quality control rules for
acceptance or rejection of the analytical run.
– Assayed known samples
– Commercially manufactured (Humastar)

• Validate patient results

• Detects analytical errors.
 Sources of Error for Bicarbonate
Analysis
• Specimen errors due to:
– Wrong anticoagulant
– Failing to keep the specimen stoppered
– Not fresh
– Hemolysis
• Analytic errors due to:
– Protein contamination of membrane in ISE
– Poorly calibrated analyzers
• Reporting errors due to:
– Using wrong reference ranges with type of specimen
– (whole blood versus plasma)
 Reporting and Documentation
• To avoid post-analytic errors,
• Report the patient result with :
• right name and result
• Include reference ranges
• Timely manner

• QC and patient results should be

documented in logbook and retained in lab
 Anion Gap
• Electrolytes exist in a balance to provide
electrolyte neutrality.
• Sum of anions, including chloride, bicarbonate
and ionized proteins =sum of all cations such as
potassium ,calcium and sodium .

• The major electrolytes account for most ions

with about 15 mmol/L from unmeasured anions.
Clinical Significance Anion Gap
• In many types of metabolic acidosis, anion
gap is increased (> 20 ) due to deficit of
bicarbonate ions and presence of organic
acids, such as acetoacetic acid, lactate,
salicylate, formate or glycolate.
• Circumstances that cause increase in
sodium relative to deficiency of anions
such as bicarbonate will also increase
anion gap.
Clinical Significance Anion Gap
• Decreased anion gap may be due to
situations that decrease Na relative to
excess of Cl and HCO3-
• A decreased anion gap may be found with
an occasional patient sample
• More commonly, decreased anion gap is
an indication of technical problems.
 Calculation of Anion Gap
• Anion gap is a calculation of the difference
between anions and cations in blood.
• represents chemical anions other than
those used in the formulas, chloride and
bicarbonate, that might be present in
blood.
• used to estimate acid-base and electrolyte
disturbances.
 Calculation of Anion Gap
• The most commonly used formula is
• (Na + K) -(Cl +CO2) with reference range
of: 10-20 mmol/L

• The formula (Na ) -(Cl+CO2) can be used

but is generally being replaced by the
formula that includes potassium.
 Interpretation of Results
Electrolyte Analysis
• In order to classify electrolyte
abnormalities, compare results to the
reference ranges and consider critically
high or low levels.
• Critical values indicate life-threatening
situation due to the electrolyte
abnormality. They are typically
established at each institution.
 Electrolyte Analysis
• Critical Na K Cl HCO3-
Values for mmol/ mmol/ mmo/ mmol/
Electrolytes L L
L L
>160 >6.2 > 120 > 40

< 120 < 2.8 < 80 <10

 Interpretation of Serum
Electrolyte Levels
Test Unit Ref. Range

Na mmol/L 135-145

K mmol/L 3.3-4.9

Cl mmol/L 98-108

HCO3- mmol/L 22-28

Anion Gap none 10-20

 Summary
• Discuss patient sample collection and
handling processes in terms of impact on
electrolyte analysis.
– Hemolysis
– Other problems with specimen collection or
handling
 Summary
• Describe the principle of analysis of these
in terms of electronic components,
reagents and endpoint detection
– Na
–K
– Cl
– tCO2 (HCO3-),
 Summary
• Provide appropriate criteria for interpreting
clinical electrolyte results
– Acute renal failure
– Primary renal tubular acidosis
– Hyper- and hyponatremia
– Hyper- and hypokalemia
– Metabolic acidosis with increased anion gap
– Metabolic acidosis with normal anion gap
– Metabolic alkalosis
 Summary
• Determine the appropriate course of action
needed to resolve problems, which occur
during electrolyte testing.
– e.g. hemolysis
– Lipemia
– Analytical interferences
– Post analytical factors
 References
• Burtis, Carl A., and Ashwood, Edward R.. Tietz:
Fundamentals of Clinical Chemistry. Philadelphia, 2001
• Arneson, W and J Brickell: Clinical Chemistry: A
Laboratory Perspective 1st ed. 2007 FA Davis