水电解质代谢和酸碱平衡失调-E070914-2010(5)医学.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,1,和谐社会,2,旱灾,3,水灾,4,Case 1,：,王某，女，,23,岁。以“呕吐、腹泻,36,小时”入院,患者于,36,小时前，吃剩饭后即感上腹不适，继则腹痛、呕吐频繁，呕吐出大量食物和胃液，并腹泻十余次，为大量黄色稀水便。逐渐出现口渴、尿少、恶心、厌食、软弱无力。半小时前便后起立时，突然晕倒在厕所，救醒后速送医院求治。,入院查体：体温,37.8,脉搏,120,次,/,分,.,呼吸深快,(28,次,/,分,),血压,90/70mmHg,，体重,50Kg,，神志淡漠，面色苍白，皮肤弹性差，眼眶凹陷。肢端湿泠，腹部轻度深压痛。,化验：血常规：,RBC550,万,/mm,3,，,Hb12g%,，,WBC15000/mm,3,，,N80%,；尿常规：比重,1.030,强酸性；粪常规：黄色稀水便，,WBC(,),；血清,Na,+,138 mEg/L,、,K+3.5 mEg/L,、,CO2CP 30VOL%,，,BUN39mg/ml,。,Diagnosis,:?,Prescription,:?,5,Case 2,赵,，男性，,60,岁，体重,65Kg,“,胆囊切除，胆总管探查术后第一天,”,术后从胃管内共抽出液体,600 ml,。,T,管引流出胆汁,400 ml,。,烟卷引流出渗液约,240 ml,体温持续在,38.2,Prescription of fluid replacement:?,6,Body Fluid&Its Compartments,Composition,:Water,Electrolytes,Volume,:50%,（,female,）,60%,（,male,）,80%,（,infant,）,of body weight,FACTOR,：,sex,、,age,、,lean&fat,Distribution,(figure 1):,Extracellular Fluid,（,20%,）,Plasma 5%,、,Interstitial Fluid 15%,Intracellular Fluid,（,35%,40%,）,Skeletal muscle 35%,Electrolyte,：,ECF,：,Na,/CI,、,HCO3,、,protein,ICF,：,K,、,Mg,/P,3,、,protein,The effective osmotic pressure in the two compartments are considered equal,about 290-310mOsm,L.,以上的稳定持机体新陈代谢正常进行的保证,8,Function of Electrolytes,Maintaining the Osmotic Pressure and the balance of water,：,K,/HPO4,；,Na,/CI,Maintaining Acid-base Balance,：,Buffer system in body fluids.,Maintaining the excitability of nerve and muscle,：,Na,K,the excitability,Ca,Mg,H,+,K,is the activator of many enzymes in human body,：,K,take part in the biosynthesis of glycogen and protein.,9,水的摄入与排出,Water gain and loss,每天代谢产生固体废物,35,40g,，每,g,至少需尿,15ml,将它排出。因此，每天尿量不应少于,500ml,（,1.030,）,.,但每天尿量,1500ml,（,1.012,）时肾脏负担最轻。,A normal adult need at least 1500ml water everyday,but 2500ml is more reasonable.,H2O Gain,（,ml,）,H2O Loss,Oral fluids 1000,1500,Urine 1000,1500,Solid foods 700,Stool 150,endogeny 300,Insensible,Skin 500,Lungs 350,Total 2000,2500,Total 2000,2500,10,Electrolyte Content of Body Fluid,1,正常人血浆,or,血清中的电解质浓度,positive ion,mEg/L negative ion mEg/L,Na,142 CI,103,K,5 HCO3,27,Ca,HPO,4,-2,2,SO,4,-2,1,Mg,organic acid,5,Protein 16,Total 154 Total 154,11,Electrolyte Content of Body Fluid,2,各种消化液每日分泌量（,ml,）及其电解质浓（,mEg/L,）,Digestive juice,Volume of secretion(ml/day),H,+,(mEq/l),Na,+,(mEq/l),K,+,(mEq/l),Cl,-,(mEq/l),HCO,3,-,(mEq/l),saliva,1500,9,25,10,1218,Gastric juice,2000,090,40100,1045,50140,05,Bile juice,700,135145,5,80110,35,Pancreatic juice,800,135185,5,5070,90,Small intestinal juice,3000,105135,520,100120,2030,Total Volume 8000,Only 150ml fluid excrete through dejecta in normal state.,During vomiting and diarrhea,the body fluid will change.Loss of any digestive juice will lead to specific sequent.,12,Metabolize of Electrolytes,Electrolytes is ingested from food,come into every tissue through blood,and excreted from kidney mostly.,The urine of adult contains:,natrium(NaCI 6,9g)and kalium(2,3g).,The excretion of Na,+,and K,+,from kidney,Na,+,:the more ingested,the more excreted,vice versa.,no ingested,no excreted.,K,+,:,the more ingested,the more excreted,vice versa.,no ingested,still excerted.,13,Adjust of Body Fluid Balance,1,可以分为,:,出入量的调节；细胞内外的调节；血管内外的调节。,晶体渗透压,血浆胶渗压,毛细管通透性,毛细管静水压,饮水,and,排尿,主要通过肾脏，其调节功能受神经、内分泌反应影响,首先：,Hypothalamus,neurohypophysis,ADH system,osmotic pressure,然后：,Rein,angiotensin,aldosterone system,volume,但当血容量时，机体优先保持和恢复血容量，,使重要生命器官的灌流得以保证，维护生命。,14,Adjust of Body Fluid Balance,2,下丘脑、垂体后叶、,抗利尿激素,S,体内水份丧失，细胞外液渗透压,（灵敏度,2%,）,口渴、饮水增加,下丘脑、垂体后叶分泌,ADH,远曲肾小管、集合管,上皮细胞吸收水 、尿量,保留水份于体内,细胞外液渗透压,细胞外液渗透压,15,细胞外液（,血容量,）,BP,肾素醛固酮,S,交感神经兴奋,压力感受器,（肾小球入球小动脉）,肾小球滤过率,经远曲肾小管的,Na,+,钠感受器,（远曲肾小管致密斑）,肾小球旁细胞分泌肾素,血管紧张素原,血管紧张素,血管紧张素,肾上腺皮质球状带,醛固酮合成分泌,血浆中,远曲肾小管再吸收,Na,CI,H,2,O,（排泌,K,、,H,）,细胞外液,循环血量,BP,Adjust of Body Fluid Balance,3,16,神经,-,内分泌对细胞外液的调节,细胞外液变化,渗透压,容量,下丘脑,肾素,口喝,血管紧张素,饮水,保水（尿量）,血管紧张素,醛固酮,保,Na,（尿,Na,）,渗透压,容量,细胞外液恢复,Adjust of Body Fluid Balance,4,17,Body Fluid Abnormalities,Total Body Water Loss,Dehydration=salt deficient+water deficient,In surgical patients,water and salt deficits more often occur together.,Dehydration,can be classified into three categories:,hypertonic,hypotonic,isotonic,.,18,高渗性脱水,.,1,Hypertonic dehydration,Definition,:,water deficient,sodium,deficient,P,Na,+,150mEq/L (hypertonia),Cause,:,Intake deficient-,-,unable to regulate intake,fountain discontinuity,Overabundant loss,profuse,sweating from ardent fever,excessive diuresis,It,s also called primary water deficits.,Pathophysiology,:,ECF volume deficit accompanied by hypernatremia,ADH,，,aldostenrone,19,高渗性脱水,.,2,Hypertonic dehydration,Laboratory Investigation,:WBC,、,Concentrated blood,increased urine specific gravity(spgr1.035).Plasma protein,Potassium,Natrium,Chlorine,BUN,and Osmotic pressure are all increased.,Extent,Weight%,Clinical finding,Light,2,Thirsty,Moderate,34,Severe thirsty,Ligula xeransis,Flexibility of skin decerase,Sunken eyes,Apathy,Xeransis in axilla and inguen,Oliguria,increased urine specific gravity,Severe,Above 56,Severe thirsty+obvious symptom of central nervous system,Mania,Hallucination,Phrenitis,Hyperpyrexia,Eclampsia,coma,Decreased BP,Shock,20,2.,低渗性脱水,.,1,Hypotonic dehydration,Definition,:,water deficient,sodium,deficient,P,Na,+,135mEq/L (hypotonia),Cause:,Chronic body fluid loss or,body fluid loss are replaced with only with noly 5%dextrose in water or a hypotonic sodium solution.,It,s also called Chronic water deficits.,Pathophysiology:,ECF volume deficit and hyponatremia,Circulation failure presents in the early stage.,ADH decreases in early stage and increases in terminal stage,Increased aldostenrone,21,2.,低渗性脱水,.,2,Hypotonic dehydration,Laboratory Investigation,:Concentrated blood,increased MCV,MCHC,Oliguria,non-increased urine specific gravity,Severely decreased Natrium and Chlorine in urine.Increased plasma protein and BUN,Decreased plasma Natrium and Chlorine,Decreased Osmotic pressure.,Extent,NaCl/kg BW,PNa(meq/L),Clinical finding,Light,0.5g,130135,Tired,Apathy,Faint,extreme,anaesthesia,Without thirsty,decreased urine Na,normal urine volume,Moderate,0.60.8g,120130,The above symptom aggravate,Anorexia,Nausea,Vomiting,Sleepiness,Collapsed,veins and pulse,Unsteady or decreased,BP,illegible eyesight,Orthostatic faint,Oliguria,without chloride in urine,Severe,Above 0.8g,below 120,CNS symptom:Dottiness,Jerk,Decreased tendon reflexes,Anesthsia of distal extremities,shock.,22,3.,等渗性脱水,.,1,Isotonic dehydration,Definition,:The loss of fluid is water and electrolytes in approximately the same proportion as that in thich they exist in normal ECF.,Plasma Na+is normal.(isotonia),Cause,:Acute losses of gastrointestinal fluids due to vomiting,diarrhea.Ponderosus ascite drainage,Early stage of large area empyrosis(exudation).,Its also called acute water deficits.,Pathophysiology,:,Decreased ECF,Severe volume depletion,Increased aldostenrone,23,Clinical finding,:,Hydropenia syndrome,:,Thirsty,Oliguria,With the sodium deficit,:,Anorexia,nausea,adynamia,.,Above 4%of weight:,Symptom of severe volume depletion.,Absent peripheral pulses,Cold extremities,unsteady or decreased BP.,Above 6%of weight:,peripheral circulatory failure,Shock,It is often accompanied with metabolic acidosis.When the gastric juice lost severely,it will be accompanied with metabolic alkalosis.,Laboratory Investigation,:,Concentrated blood,Normal MCV,MCHC,Increased urine specific gravity,Decreased Natrium and Chlorine in urine.Increased plasma protein and BUN,Normal plasma Natrium,Chlorine,and Osmotic pressure,3.,等渗性脱水,.,2,Isotonic dehydration,24,The treatment of the primary diease.,Restoring volume and the deficient electrolytes.,The contents of fluid replacement contain:,the volume of physiological requirements,Preexisting deficits,and ongoing losses.,The replacement of existing deficits of volume:,the extent and category of dehydration decide the volume and the type of solution(G/N,),respectively.,Hypertonic dehydration,-5-10%Glucose Solution.,Hypotonic dehydration,-normal saline or 35,saline(Hypertonic),Isotonic dehydration,-5%GNS,Take orally as far as possible,supply from veins when the patient cannot take orally.,2.,脱水的处理原则,The therapic principle of dehydration,25,Electrolyte Disorders,Hypokalemia,26,Transportation between extra-and intracellular:,Physiologic factor,:,Na,K,ATP,enzyme,Digitaloid drugs,，,Catecholamine,Insulin,Blood glucose concentration,Blood Potassium concentration,Heavy exercise.,Pathologic factor,:Plasma pH(inorganic acid),Hypertonia,histoclasia,excessive growth.,Regulation of body,：,Intake and excreted of Potassium,：,Kidney,：,aldosterone(act at collecting tubule to promote the secretion of Potassium),glucocorticosteroid(keep natrium and excrete Potassium),Adjust of Serum Potassium,27,Definition,:,Serum Potassium3.5mmol/L.,体内缺钾,300mmol,以上时，血清钾才下降。,Cause,:,钾摄入量不足,：,禁食、厌食、拒食时间较久,钾损失过多,：,大量出汗、呕吐、腹泻、胃肠减压、肠,瘘；利尿药、肾小管酸中毒、棉酚中毒,Conn,综合征,et.al.,体内分布异常,：,糖元、蛋白合成，碱中毒，低钾性周期,性麻痹，儿茶酚胺制剂，细胞生长过速，钾进入细胞内,Hypokalemia,1,28,Clinical finding,：,钾的丢失主要来自细胞内，,C,内含钾很丰富，故机体丢钾,350mmol,以下时，无临床表现；,临床表现的严重与否、取决于钾丢失的多少及丢失的速度。,临床表现包括以下,6,个方面：,循环系统；,神经肌肉系统；,CN,系统；,泌尿系统；,消化系统；肌纤维溶解；,酸碱平衡失调。,Hypokalemia,2,29,Circulation system,cardiac damage,：,坏死、细胞侵润、瘢痕心衰,arhythmia,：,期前收缩、阵发性心动过速、室扑,或室颤、猝死,Susceptible to digitalis intoxication,：,ECG,：,K,3.0,，,U,波出现、,TU,融合,K,2.5,，,ST,段下移、,T,波倒置,U,波出现，体内缺钾,400mmol,以上,hypopiesia,：,植物,N,功能紊乱、血管扩张引起,Hypokalemia,3,临床表现,：,30,neuromuscular system,骨骼肌：,肌无力,(K,3.0,),、肌痛、肌麻痹、,软瘫,(K,2.5,),平滑肌：,腹胀、便秘、麻痹性肠梗阻、尿潴留,K,是许多酶的激活剂,与三羧循环,.,乙酰胆碱合成有关,central nervous system,神志淡漠、目光呆滞、疲乏；,烦躁不安、情绪激动、精神不振；,嗜睡、定向力障碍、昏迷,(K,2.0,),与糖代谢障碍、能量生成及乙酰胆碱生成减少有关,Hypokalemia,4,临床表现,：,31,urinary system,多尿、夜尿增多、甚至肾衰煩渴、多饮,缺钾可引起肾小管上皮细胞损害；,体内缺钾,200mmol,时肾小管浓缩功能,digestive system,食欲不振、恶心、呕吐、腹胀、便秘,muscle fibrolysis,K,2.5,，,肌红蛋白尿、甚至急性肾衰,Hypokalemia,5,临床表现,：,32,Hypokalemia,6,临床表现,：,cid-base disturbance,metabolic alkalosis,paradoxical aciduria,低钾时，,C,内,K,与,C,外,H,交换，,C,内,H,C,内酸中毒；,C,外,H,C,外液碱中毒。,肾保,Cl,-,，尿,Cl,-,，,Na,重吸收时不能与,Cl,-,而与,HCO,3,-,HCO,3,-,重吸收,低钾时，代谢性碱中毒,肾小管上皮细胞内,K,，,K,与肾小管管腔中的,Na,交换，,H,与,Na,交换，,尿呈酸性，肾排,H,33,Diagnosis,：,主要依靠病史表现,血清,3.5 mEg/L,EKG,特征改变确诊,注意,:,酸中毒、脱水时，重症才出现,Therapy,：,积极治疗原发病，必要时补充钾盐。,注意：,尽量口服，不能口服者,V,补给（常用,10,KCl,）；,尿少不补,K,；浓度不宜过高（,0.3%,）；,速度不宜过快,(80d/,分,),；总量不宜过多,(6g,左右,),最好加入,NS,，加入,GS,有可能使血钾更低；,丢正糖尿病酮症酸中毒时，应特别注意低钾可能。,Hypokalemia,7,34,Acid-base Balance,35,The ph(the negative logarithm of the hydrogen ion concentration PH=7.357.45)of the body fluids is normally maintained within narrow limits despite the rather large load of acid produced endogenously as a by-product of body metabolism.,包括四个方面,:,A.,buffer system,（,作用快,仅能应付急需,）,HCO,3,27mmol/L 20,=(PH7.4),H,2,CO,3,1.351 mmol/L 1,B.CO,2,excreted via the lungs,（体内挥发性酸,H,2,CO,3,）,调节血液中的呼吸性成分，即,H,2,CO,3,（,PCO,3,）,1.Maintain of,Acid-base Balance,1,36,1.Maintain of,Acid-base Balance,2,C.,Kidney,排出固定酸和过多的碱性物质,维持血中,HCO,3,浓度的稳定,机理：,H,Na,+,交换；,HCO,3,重吸收；,正常尿液,PH,值,6,，最低,4.4,肾有强排酸功能,D.,Buffering effect of cell,细胞内每进入,1,个,H,2,个,Na,3,个,K,替换出,碱中毒：,H,出细胞内,K,入细胞内,低血钾,酸中毒：,H,入细胞内,K,出细胞内,高血钾,37,2.,Disturbances of Acid-base Balance,Metabolic acidosis,（,CO2CP,，,PH,）,Metabolic alkalosis,（,CO,2,CP,，,PH,）,Respiratory acidosis,（,PCO,2,、,CO,2,CP,、,PH,）,Respiratory alkalosis,（,PCO,2,、,CO,2,CP,、,PH,）,HCO,3,H,2,CO,3,增多,减少,增多,减少,38,Metabolic acidosis,1,Retention of fixed acids or loss of base bicarbonate.,The causes of metabolic acidosis can be divided into two manageable groups by determining the anion gap,：,高,AG,代酸,-,常见于尿毒症、糖尿病酮症酸中毒、乳酸中毒,正常,AG,代酸,常见于,HCO,-,3,丢失过多及应用含有,Cl,-,的药物,Anion gap,AG,:Amount of the unmeasured anions(i.e.sulfate and phosphate plus lactate and other organic anions).,正常值：,10,15mmol/L.,AG=,（,Na,+,+K,+,）,-(HCO,-,3,+Cl,-,),均以,mEq/L,为单位,145/155 134/155,（,95%,）（,85%,）,=,未测定阴离子,-,未测定阳离子,因,K,+,很低，所以,AG=Na,+,-(HCO,-,3,+Cl,-,),39,Metabolic acidosis,2,Cause,：,Excessive losses of bicarbonate,见于消化道瘘、呕吐、腹泻,Retention of acids,腹膜炎、休克、高热、长期未进食者,Excretion of H+and resorption of HCO3-decrease,肾衰,40,Metabolic acidosis,3,Clinical finding,：,轻者：,常被原发病所遮盖,重者：,疲乏、眩晕、嗜睡、迟钝、烦躁不安,呼吸深快、带酮味,（烂苹果味）面部潮红、,心率、,BP,、神态不清,-,昏迷,常伴严重脱水、休克、尿少、尿酸性反应。,Diagnosis,：,病史临床表现血气分析,41,Metabolic acidosis,4,Therapy,：,严重者，才需,V,补碱性药物,5%Na HCO,3,ml,=,（,50-CO,2,CP,）,Kg0.5,(,作用快、效确切最常用,),11.2,乳酸钠,ml,=,（,50-CO,2,CP,）,Kg0.3,(,休克、肝功不良禁用,),3.6%THAM ml,=,（,50-CO,2,CP,）,Kg1,(,细胞内外均能起作用,但副作用多,一般不用,),公式计算量易偏多，实际中常先输入计算量,1/2,2/3,也可先按提示,10vol%,的,CO,2,CP,补给，再据测得的,CO,2,CP,值调整。,45 vol%,以上、尿碱性、即停补。尿量、注意补钾。,42,Principles of Fluid&Electrolyte Therapy,Fluid&Electrolyte,Abnormalities,Prevent,Disease,43,Prevent,1.,The volume of physiological requirements(2000,2500ml):,5-10%GS 1500 ml,等渗盐,500,1000 ml,10%KCI 30 ml,2.,Recruit the sensible losses in time,体温每增加,1,，每公斤体重需 增补液体,3,5 ml,汗湿,-,衬衣、裤,-,增补,1000 ml,气管切开,-,增补,1000 ml/,日,3.,Perioperative fluid replacement,小手术,不需,大手术,术日清晨开始,急症手术、有紊乱者术前尽可能部分纠正，术后继续,术后胃肠功能未恢复补生理需要量,有胃肠减压者,酌情,术后,1-2,日不补,K,，,3,日后仍不能进食、补钾,3-4g/,日,44,Therapy,1,1,Calculation of fluid replacement,Physiological requirements,：,2000,2500ml,，其中,NS 500 ml,Preexisting deficits,：,On-going losses,：,胃肠道继续丢失；内在性失液；发热出汗,酌情于当天,or,次日补给,丢失什么,补什么,45,Therapy,2,已丧失量的估计方法,缺水的日数：,脱水,1,日丧失体重的,2%,体重的减轻数：,临床表现：,血清,Na,浓度：,高渗：降,1 mmol/L,的,Na,需补男,4 ml,、女,3 ml/Kg,体重,低渗：缺,Na,量,mmol/L=,体重,Kg0.6(140,Na,),1L N,a,CI=154mol.,NS,量,(L)=,缺,Na,量,154,46,Therapy,3,根据临床表现估计,Preexisting deficits,程度,高渗脱水,缺水占,体重,需补液量,ml/Kg,体重,低渗缺水缺,NaCI,量,（,g/Kg,体重）,补,NS,量,ml/Kg,体重,轻度,2,4%,20,0.5,25,中度,4%,6%,20,40,0.75,20,40,重度,7,%,40,60,1.0,40,60,47,Therapy,4,常用溶液的电解质含量,(mEg/L),Solution,Na,CI,K,Ca,Mg,HCO,3,lactate,Plasma,142,103,5,5,2,27,5,Balanced saline,154,154,5,saline,850,850,Ringers solution,147,157,4,6,Sodium Lactate,170,170,Lactated Ringers,130,102,4,4,27,63,5%NaHCO3,595,595,10%KCI,1340,1340,intradex,153,153,48,Therapy,5,注意事项,1.management for primary disease,2.Identify the extent and type of dehydration,3.Take notice of the function of patients heart,lung,kidney,especially for aged people.,4.The disturbance of water,electrolytes,acid-base balance may occur at the same time.,5.Closely monitor the change of pathogenetic condition.,6.Making laboratory investigation oriented to time to guide the treatment.,7,总的程序：,先浓后淡，先快后慢，先晶体后胶体，见尿补钾，灵活掌握。,应据病人情况和化验、合理安排补液，随时调整量、速度、性质。,对于各种公式计量，只能做参考。从临床实践中进一步提高。,49,Case 1:,1,王某，女，,23,岁。以,“,呕吐、腹泻,36,小时,”,入院,患者于,36,小时前，吃剩饭后即感上腹不适，继则腹痛、呕吐频繁，呕吐出大量食物和胃液，并腹泻十余次，为大量黄色稀水便。逐渐出现口渴、尿少、恶心、厌食、软弱无力。半小时前便后起立时，突然晕倒在厕所，救醒后速送医院求治。,入院查体：体温,37.8,脉搏,120,次,/,分,.,呼吸深快,(28,次,/,分,),血压,90/70mmHg,，体重,50Kg,，神志淡漠，面色苍白，皮肤弹性差，眼眶凹陷。肢端湿泠，腹部轻度深压痛。,化验：血常规：,RBC550,万,/mm,3,，,Hb12g%,，,WBC15000/mm,3,，,N80%,；尿常规：比重,1.030,强酸性；粪常规：黄色稀水便，,WBC(,),；血清,Na,+,138 mEg/L,、,K+3.5 mEg/L,、,CO2CP 30VOL%,，,BUN39mg/ml,。,诊断,：？,处方,：？,50,Case 1:,2,Diagnosis,：,Isotonic dehydration,（,midrange,）；,metabolic acidosis,补液计算：,已丧失量的计算：失液量,=,体重,5%=505%=2500 ml,即已丧失量,=2500 ml,第一天只补,1/2,即只补,1250 ml,生理需要量：,2000 ml,（,NS 500 ml,）,故补液总量,=,=3250 ml,纠正酸中毒,:5%,碳酸氢钠量,=,（,50,30,）,500.5=500 ml,先输,1/2=250 ml,51,Case 1:,3,physician order,:,NS 500 ml,平衡盐,1000 ml,5,10%GS1500 ml,5%NaHCO,3,250 ml,iv drop,尿量增至,40 ml/h,以,上，液体中加入,10%,KCL40ml,酌情补充继续丢失量,严密观察,:BP,、,P,、,R,、尿量、尿比重、,神志,52,Case 2:,1,赵,，男性，,60,岁，体重,65 Kg,“,胆囊切除，胆总管探查术后第一天,”,术后从胃管内共抽出液体,600 ml,。,T,管引流出胆汁,400 ml,。,烟卷引流出渗液约,