1、Fluid-Electrolyte-Acid-base Management General surgery department The first affiliated hospital to Soochow Universityoverviewcompositionsofbodyfluidregulationsoffluidbalanceacid-basebalanceimportanceoffluidbalanceContentsofdiscuss fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base man
2、agement catalogcatalogadjustoffluidmetabolismdemonstratechartsbasicprinciplesoftreatmentsNormalbodyfluid,osmoticpressureandelectrolytearethebasisofbodymetabolismandorganfunctions.Trauma,operationandmanyclinicaldisordersleadtofluid,electrolyteandacid-baseimbalance,managementoftheseproblemsisaveryimpo
3、rtantmatterinthesurgicaltherapy.-1fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management overviewoverviewMain components of the body fluid arewaterandelectrolytes.Body fluid is divided into intracellularfluidandextracellularfluid.Musclecontainsmuchwater.(75-80)Fatcontainslesswa
4、ter.(10-30)fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidAbout 60 of weight of adult male isbodyfluid;about 55 of weightof adult female isbodyfluid;about 80 of weight of infant is bodyfluid;after 14 years old,childre
5、n are near tomanhood.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidMostintracellularfluidisinskeletalmuscle;intracellularfluidaccount40%ofbodyweightformale,forfemaleis35%.Extracellularfluidaccount20%ofbodyweightforbo
6、thofmaleandfemale.Extracellularfluidisfurtherdividedintoplasmaandinterstitialfluid;plasmaoccupy5%ofbodyweight;Interstitialfluidoccupy15%ofbodyweight.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidMostofinterstitialflu
7、idcanexchangewithplasmaorintracellularfluidquickly,andgettobalance,whichisveryimportantinfluidandelectrolytemanagement,calledfunctionalextracellularfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidOtherinterstitia
8、lfluidcanonlyexchangeandgettobalanceslowly,theyhavedifferentfunctions,buttheyarelessimportantinthemaintainofbodyfluidbalance,callednonfunctionalextracelluarfluid.Connectivetissuefluidandpenetrablefluidofcell,e.g.cerebrospinalfluid,synovialfluidanddigestivejuice,andsoon,areallcallednonfunctionalextra
9、celluarfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidThechangesofsomenonfunctionalextracelluarfluidcanleadtoimbalanceofbodyfluid,electrolyteandacid-baseobviously.Themostfamiliarexampleisagreatdeallossofdigestiv
10、ejuice,itcanleadtomarkedchangeofbodyfluidvolumeandelements.-2Nonfunctionalextracelluarfluidoccupies1%-2%ofbodyweight,andabout10%ofinterstitialfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidThemostimportantcation
11、inextracelluarfluidisNa+,andthemainanionareCl-,HCO3-andprotein.ThemaincationinintracelluarfluidareK+andMg2+,themainanionareHPO42-andprotein.Theosmolalityofextracelluarfluidandintracelluarfluidareequal,theosmolalityofplasmais290-310mmolL.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-ba
12、se management composition compositions of body fluids of body fluidThestabilityofbodyfluidandosmoticpressureisadjustedbynerve-incretionsystem.Thenormalosmoticpressureofbodyfluidisresumedandmaintainedbythalamo-posthypophysis-antidiureticsystem.Thevolumeofbloodisresumedandmaintainedbyrenin-aldosterone
13、system.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustextracellularextracellularosmoticosmoticpressurepressure thalamo-thalamo-posthypophysis-antidiuretic-antidiureticsystemsystemantidiure
14、tichormoneisverysensitivetothechangesofextracellularosmoticpressure,evenoverstep2extra-extra-cellularcellularosmoticosmoticpressurepressurefalltofalltonormalnormalwaterlosethirst,drinkmorewaterresorburinereducewaterisreserved keephomeostasis fluid-electrolyte-acid-base managementfluid-electrolyte-ac
15、id-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjuststimulatestimulate reninrenin adrenaladrenalaldosteronealdosterone withincreasedresorptionofwithincreasedresorptionofnatrium,morewaterisresorbnatrium,morewaterisresorbextra-extra-cellularcellularosmo
16、ticosmoticpressurepressurefalltofalltonormalnormalbloodvolumebloodpressureNa+resorbK+drainageH+drainagekeephomeostasis fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustBothofthetwosystemsall
17、actonBothofthetwosystemsallactonkidneytoadjusttheabsorptionandkidneytoadjusttheabsorptionanddrainageofelectrolyteaswateranddrainageofelectrolyteaswaterandnatriumandsoon,togetthebodyfluidnatriumandsoon,togetthebodyfluidbalanceandinternalenvironmentbalanceandinternalenvironmentstability.stability.Theb
18、loodvolumeismoreimportantThebloodvolumeismoreimportantthanosmoticpressureforbody.thanosmoticpressureforbody.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustSoasthebloodvolumereducedgreatlya
19、ndinthesametimetheplasmaosmoticpressurereduced,theaccelerationforantidiuretichormonebyformerplayamuchmoreimportantrolethanthedepressionforthehormonebylatter.-3Thepurposeisatfirsttokeepandresumebloodvolume,ensuretheenoughbloodforvitals,maintainthesafeofpatientslife.fluid-electrolyte-acid-base managem
20、entfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustThenormalphysiologicalandmetabolismfunctionneednormalbodyfluidwithproperhydrogen.UsuallythebodyfluidmaintainacertainconcentrationofH+,alsomaintainacertainpH(arterialplasmaspHbe
21、tween7.400.05).Butintheprocessofmetabolism,bodypersistentlyproduceacidandalkalisubstance,inthisway,theconcentrationofH+alsochangesregularly.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceInordertokeepthefluct
22、uationofconcentrationofH+inasmallrange,thebodyadjusttheacidandalklaibybuffersystem,breathingwithlungandexcretionwithkidney.ThemostimportantbuffersysteminbloodisHCO3-/H2CO3.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-b
23、ase balanceThenormalmeanvalueofHCO3-is24mmolL,H2CO3is1.2mmolL,theratioofHCO3-/H2CO3=241.2=20:1.nomatterhowhigherorlowertheHCO3-andH2CO3are,theratioofHCO3-/H2CO3stillkeepsin20:1,pHofplasmaisremaining7.40.-4e.g.H+HCO3-=H2CO3=H2OCO2 fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base mana
24、gement management of acid-base balancemanagement of acid-base balanceBreathoflungadjusttheacid-basebalancebydischargingCO2fromlung,thiscanreducePaCO2inblood,inthesametime,alsoadjustH2CO3inblood.Ifrespiratoryisinsufficiency,itwillleadacid-basedisorder,anditwillalsodepressitscompensatorycapacityofacid
25、-basebalance.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceKidneyplaythemostimpotantmanangementroleintheacid-basebalancesystem,kidneymaintainnormalconcentrationofHCO3-inplasmabychangingoutputoffixedacidandal
26、kalitokeeppHofplasmainnormalrange.Ifkidneyisabnormal,itnotonlyeffectthenormaladjustofacid-basebalance,butalsoleadacid-baseimbalance.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceIntheclinicalwork,wemaymeetma
27、nyIntheclinicalwork,wemaymeetmanyproblemsaboutwater,electrolyteandacid-baseproblemsaboutwater,electrolyteandacid-basebalancewithdifferentcharactersanddegrees.balancewithdifferentcharactersanddegrees.ManysuddenandserioussicknessesoftheManysuddenandserioussicknessesoftheinternalmedicineandsurgery,e.g.
28、shock,internalmedicineandsurgery,e.g.shock,massivehemorrhageofdigestivetract,largemassivehemorrhageofdigestivetract,largeareaburns,digestivetractfistula,intestinalareaburns,digestivetractfistula,intestinalobstructionandseriousperitonitis,allthesecanobstructionandseriousperitonitis,allthesecanleadbad
29、lyinternalenvironmentdisordersforleadbadlyinternalenvironmentdisordersfordehydration,hypovolemia,hypokalemiaandhypovolemia,hypokalemiaandacidosis.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance Recognizingintimeandactivelycorrectingtheseabnormalities
30、isthefirstjobinourtherapies,becausetheaggravationforeachofwater,electrolyteandacid-baseimbalancewillleadthepatientsdeath.Whenthethepatientswithelectrolytedisorderoracidosis,thedangerforoperationwillincreaseobviously.-5Eventheoperationissuccessful,Ifweignorethemaintenanceofinternalenvironment,itwillr
31、esulttothefailureoftherapyatlast.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance T Therearemanyherearemanydifferentdifferentclinicalclinicalmanifestationsofmanifestationsofbodyfluid,electrolyteandacid-baseimbalance.Thereareusuallymixedabnormalitiesin
32、thesametime,notonlybodyfluidandelectrolytedisorder,butalsoacid-baseimbalance.Soweshouldcorrectthemoverall,anddonnotmissanyone.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance VolumeDisorders:isotonicbodyfluiddecreaseorincrease.Itonlycausesextracellula
33、rfluidvaried,andintracellularfluidisusuallynormal.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid metabolismmaladjustment of fluid metabolismConcentrationDisorders:thewaterofextracellularfluiddecreaseorincrease,itleadingthechangesofconcentrationofi
34、nfiltrationparticulates,sotheosmoticpressurealsochanges.Because90infiltratingparticulatesofextracellularfluidareconstitutedbyNa+,sothattheconcentrationdisordersdisplayashyponatremiaorhypernatremia.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid met
35、abolismmaladjustment of fluid metabolismCompositionsDisorders:thechangeofconcentrationofotherionsinextracellularfluid,exceptNa+.Althoughtheseionscancausesomephysio-pathologicaleffect,theamountofpenetrableparticulatesaresolittle,theironlyhaveslightinfluencetoextracelluarfluid.Forexample:hypopotassaem
36、iaorhyperpotassaemia,hypocalcemiaorhypercalcemia,andacidosisoralkalosis,andsoon.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid metabolismmaladjustment of fluid metabolismhypertonicdehydrationbodyfluiddecreaseintracellularfluidwaterlosssaltlossosmo
37、ticpressurethirstextracellularfluidintracellularfluidMoveintracellularintoextracellularfluidfluidsweatglandsecreteosmoticpressureskinevaporationseriouscerebrocellulardehydrationcentralnervoussystemADHsecret coma fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management changes and
38、 effect of hypertonic dehydrationchanges and effect of hypertonic dehydrationADHsecretextracellularfluiddehydrationslightlyBPslightlychangelittle renaltubulereabsorbwaterandnatriumALDexcretenormalhypourocriniaearlyperiodUNanotdecrease fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base
39、 management changes and effect of hypertonic dehydrationchanges and effect of hypertonic dehydration fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management changes and effect of hypotonic dehydrationchanges and effect of hypotonic dehydrationhypotonicdehydrationbodyfluiddecreas
40、esaltlosswaterlossinterstitialeyeholeintrocessionfluidSkinelasticityECFosmoticECFintocellECFdecreasepressurepachemiabloodvolumeveincollapsedecreaseBPdecreaseADHsecreteSeverityshockICFdecreasenotobviouslyALDsecreterenaltubulereabsorbrenaltubulereabsorbwaterandnatrumwaterandnatrumearlierperiodurinaryU
41、Nadecreaseorabolitionvolumenotdecrease fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management comparisoncomparisontypeisotonicdehydrationhypertonicdehydrationhypotonicdehydrationoverhydrationwater/saltwaterdepletionsaltdepletionwaterdepletionsaltdepletionwaterdepletionsaltdeple
42、tionrehydrationreinforcesaltplasmamillisomole(mmol/L)290-310310290290plasmaNa+EQU(mmol/L)130-150150130130etiologywaterandsaltallloss,noadditionintimewaterintakedeficientorlosstoomuchafterbodyfluidlossonlygivewaterwaterintakewaterloss,leadtowatersave fluid-electrolyte-acid-base managementfluid-electr
43、olyte-acid-base management comparisoncomparisontypeisotonicdehydration hypertonicdehydrationhypotonicdehydration overhydration physiologyECFECF isotonic,ICFandECFECFarealllossECFECFhypertonic,mainlyICFICFlossECFECFhypotonic,mainlyECFECFlossECFECFhypotonic,ICFandECFECFareallincreaseclinicalmanifestat
44、ionhydrodipsia,oliguria,dehydration,shockhydrodipsia,oliguria,braincelldehydrationcomadehydration,flabbiness,weak,shockbraincellularswellingcause intracranialhypertension,headachetherapeuticprincipleNSNS+5%GS5%GS225%GS5%GS+NS+NS2NS2NS+5%GS5%GS20%20%(mannitol)MNT+diuretic fluid-electrolyte-acid-base
45、managementfluid-electrolyte-acid-base management cause and effect of cause and effect of hypokalemia hypokalemia lowingestionobstructionhypokalemiaK+SBrespiratoryacidosisABSBrespiratoryalkalosisABSBmetabolicacidosisABSBmetabolicalkalosisbufferbase(BB)(includeHCO3-):45-55mmol/Lbufferexcess(BE):-3-+3m
46、mol/LPCO2:4.67-6.0kPa(35-45mmHg)PO2:8.0kPa(60mmHg)fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management cause and effect of cause and effect of metabolic acidosis metabolic acidosis NaHCO3loseoverabundancediarrhea,fistuladigestivejuiceLoseSBbufferbaseNegativeBECO2CPbloodHCO3_m
47、etabolicacidosisHCO3-/H2CO320/1pH7.35breathdeepenandquickenPaCO2glomerulopathyLosewithurineplasmaH2CO3RestrainenzymediuretickidneydrainageH+HCO3-resorbfixedacidincrease,NaHCO3consumedproduceoverabundanceacidhypoxia,lacticacidacidicurinesteatolysiskidneydrainageK+insulinintra-andextra-cellK+outofcell
48、acidretentionH+intocelltakeinmoreacidicdrugcentralnervefatigue,comabluntness,Hyperkale-miaH+exchangek+betweencellcardio-vascularcardiaccontractionHCO3-cardiacoutputnephrictubuledrainageH+arrhythmiadilutionacidosisskeletalfiberintenerate fluid-electrolyte-acid-base managementfluid-electrolyte-acid-ba
49、se management cause and effect of cause and effect of metabolic alkalosis metabolic alkalosis gastricjuicesloseoverabundanceseverevomitloseamountofH+andCL-SBbufferbaseNegativeBECO2CPbloodHCO3_metabolicalkalosisHCO3-/H2CO320/1pH7.45breathslowshallowPaCO2GIdecompressplasmaH2CO3HCO3-cantcounteractedabs
50、orbedbybloodkidneydrainageH+HCO3-resorbinceptorinjectmorealkalinedrugalkalineurinekidneydrainageK+hypokale-miaH+exchangek+betweencellIntra-andextra-cellK+intocellHCO3-H+outofcellnephrictubuledrainageH+centralnervedysphoria,deliriumlongtimeusesomediureticneuro-muscularmusclefinetremortetany fluid-ele