体液失调英文版.pptx

Fluid-Electrolyte-Acid-base Management General surgery department The first affiliated hospital to Soochow Universityoverviewcompositionsofbodyfluidregulationsoffluidbalanceacid-basebalanceimportanceoffluidbalanceContentsofdiscuss fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management catalogcatalogadjustoffluidmetabolismdemonstratechartsbasicprinciplesoftreatmentsNormalbodyfluid,osmoticpressureandelectrolytearethebasisofbodymetabolismandorganfunctions.Trauma,operationandmanyclinicaldisordersleadtofluid,electrolyteandacid-baseimbalance,managementoftheseproblemsisaveryimportantmatterinthesurgicaltherapy.-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)Fatcontainslesswater.(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,children are near tomanhood.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidMostintracellularfluidisinskeletalmuscle;intracellularfluidaccount40%ofbodyweightformale,forfemaleis35%.Extracellularfluidaccount20%ofbodyweightforbothofmaleandfemale.Extracellularfluidisfurtherdividedintoplasmaandinterstitialfluid;plasmaoccupy5%ofbodyweight;Interstitialfluidoccupy15%ofbodyweight.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidMostofinterstitialfluidcanexchangewithplasmaorintracellularfluidquickly,andgettobalance,whichisveryimportantinfluidandelectrolytemanagement,calledfunctionalextracellularfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidOtherinterstitialfluidcanonlyexchangeandgettobalanceslowly,theyhavedifferentfunctions,buttheyarelessimportantinthemaintainofbodyfluidbalance,callednonfunctionalextracelluarfluid.Connectivetissuefluidandpenetrablefluidofcell,e.g.cerebrospinalfluid,synovialfluidanddigestivejuice,andsoon,areallcallednonfunctionalextracelluarfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidThechangesofsomenonfunctionalextracelluarfluidcanleadtoimbalanceofbodyfluid,electrolyteandacid-baseobviously.Themostfamiliarexampleisagreatdeallossofdigestivejuice,itcanleadtomarkedchangeofbodyfluidvolumeandelements.-2Nonfunctionalextracelluarfluidoccupies1%-2%ofbodyweight,andabout10%ofinterstitialfluid.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidThemostimportantcationinextracelluarfluidisNa+,andthemainanionareCl-,HCO3-andprotein.ThemaincationinintracelluarfluidareK+andMg2+,themainanionareHPO42-andprotein.Theosmolalityofextracelluarfluidandintracelluarfluidareequal,theosmolalityofplasmais290-310mmolL.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management composition compositions of body fluids of body fluidThestabilityofbodyfluidandosmoticpressureisadjustedbynerve-incretionsystem.Thenormalosmoticpressureofbodyfluidisresumedandmaintainedbythalamo-posthypophysis-antidiureticsystem.Thevolumeofbloodisresumedandmaintainedbyrenin-aldosteronesystem.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustextracellularextracellularosmoticosmoticpressurepressure thalamo-thalamo-posthypophysis-antidiuretic-antidiureticsystemsystemantidiuretichormoneisverysensitivetothechangesofextracellularosmoticpressure,evenoverstep2extra-extra-cellularcellularosmoticosmoticpressurepressurefalltofalltonormalnormalwaterlosethirst，drinkmorewaterresorburinereducewaterisreserved keephomeostasis fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjuststimulatestimulate reninrenin adrenaladrenalaldosteronealdosterone withincreasedresorptionofwithincreasedresorptionofnatrium,morewaterisresorbnatrium,morewaterisresorbextra-extra-cellularcellularosmoticosmoticpressurepressurefalltofalltonormalnormalbloodvolumebloodpressureNa+resorbK+drainageH+drainagekeephomeostasis fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustBothofthetwosystemsallactonBothofthetwosystemsallactonkidneytoadjusttheabsorptionandkidneytoadjusttheabsorptionanddrainageofelectrolyteaswateranddrainageofelectrolyteaswaterandnatriumandsoon,togetthebodyfluidnatriumandsoon,togetthebodyfluidbalanceandinternalenvironmentbalanceandinternalenvironmentstability.stability.ThebloodvolumeismoreimportantThebloodvolumeismoreimportantthanosmoticpressureforbody.thanosmoticpressureforbody.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustSoasthebloodvolumereducedgreatlyandinthesametimetheplasmaosmoticpressurereduced,theaccelerationforantidiuretichormonebyformerplayamuchmoreimportantrolethanthedepressionforthehormonebylatter.-3Thepurposeisatfirsttokeepandresumebloodvolume,ensuretheenoughbloodforvitals,maintainthesafeofpatientslife.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management fluid balance and osmotic pressure adjustfluid balance and osmotic pressure adjustThenormalphysiologicalandmetabolismfunctionneednormalbodyfluidwithproperhydrogen.UsuallythebodyfluidmaintainacertainconcentrationofH+,alsomaintainacertainpH(arterialplasmaspHbetween7.400.05).Butintheprocessofmetabolism,bodypersistentlyproduceacidandalkalisubstance,inthisway,theconcentrationofH+alsochangesregularly.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceInordertokeepthefluctuationofconcentrationofH+inasmallrange,thebodyadjusttheacidandalklaibybuffersystem,breathingwithlungandexcretionwithkidney.ThemostimportantbuffersysteminbloodisHCO3-/H2CO3.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base 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 management management of acid-base balancemanagement of acid-base balanceBreathoflungadjusttheacid-basebalancebydischargingCO2fromlung,thiscanreducePaCO2inblood,inthesametime,alsoadjustH2CO3inblood.Ifrespiratoryisinsufficiency,itwillleadacid-basedisorder,anditwillalsodepressitscompensatorycapacityofacid-basebalance.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceKidneyplaythemostimpotantmanangementroleintheacid-basebalancesystem,kidneymaintainnormalconcentrationofHCO3-inplasmabychangingoutputoffixedacidandalkalitokeeppHofplasmainnormalrange.Ifkidneyisabnormal,itnotonlyeffectthenormaladjustofacid-basebalance,butalsoleadacid-baseimbalance.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management management of acid-base balancemanagement of acid-base balanceIntheclinicalwork,wemaymeetmanyIntheclinicalwork,wemaymeetmanyproblemsaboutwater,electrolyteandacid-baseproblemsaboutwater,electrolyteandacid-basebalancewithdifferentcharactersanddegrees.balancewithdifferentcharactersanddegrees.ManysuddenandserioussicknessesoftheManysuddenandserioussicknessesoftheinternalmedicineandsurgery,e.g.shock,internalmedicineandsurgery,e.g.shock,massivehemorrhageofdigestivetract,largemassivehemorrhageofdigestivetract,largeareaburns,digestivetractfistula,intestinalareaburns,digestivetractfistula,intestinalobstructionandseriousperitonitis,allthesecanobstructionandseriousperitonitis,allthesecanleadbadlyinternalenvironmentdisordersforleadbadlyinternalenvironmentdisordersfordehydration,hypovolemia,hypokalemiaandhypovolemia,hypokalemiaandacidosis.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance Recognizingintimeandactivelycorrectingtheseabnormalitiesisthefirstjobinourtherapies,becausetheaggravationforeachofwater,electrolyteandacid-baseimbalancewillleadthepatientsdeath.Whenthethepatientswithelectrolytedisorderoracidosis,thedangerforoperationwillincreaseobviously.-5Eventheoperationissuccessful,Ifweignorethemaintenanceofinternalenvironment,itwillresulttothefailureoftherapyatlast.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance T Therearemanyherearemanydifferentdifferentclinicalclinicalmanifestationsofmanifestationsofbodyfluid,electrolyteandacid-baseimbalance.Thereareusuallymixedabnormalitiesinthesametime,notonlybodyfluidandelectrolytedisorder,butalsoacid-baseimbalance.Soweshouldcorrectthemoverall,anddonnotmissanyone.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management importanceimportance VolumeDisorders:isotonicbodyfluiddecreaseorincrease.Itonlycausesextracellularfluidvaried,andintracellularfluidisusuallynormal.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid metabolismmaladjustment of fluid metabolismConcentrationDisorders:thewaterofextracellularfluiddecreaseorincrease,itleadingthechangesofconcentrationofinfiltrationparticulates,sotheosmoticpressurealsochanges.Because90infiltratingparticulatesofextracellularfluidareconstitutedbyNa+，sothattheconcentrationdisordersdisplayashyponatremiaorhypernatremia.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid metabolismmaladjustment of fluid metabolismCompositionsDisorders:thechangeofconcentrationofotherionsinextracellularfluid,exceptNa+.Althoughtheseionscancausesomephysio-pathologicaleffect,theamountofpenetrableparticulatesaresolittle,theironlyhaveslightinfluencetoextracelluarfluid.Forexample:hypopotassaemiaorhyperpotassaemia,hypocalcemiaorhypercalcemia,andacidosisoralkalosis,andsoon.fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management maladjustment of fluid metabolismmaladjustment of fluid metabolismhypertonicdehydrationbodyfluiddecreaseintracellularfluidwaterlosssaltlossosmoticpressurethirstextracellularfluidintracellularfluidMoveintracellularintoextracellularfluidfluidsweatglandsecreteosmoticpressureskinevaporationseriouscerebrocellulardehydrationcentralnervoussystemADHsecret coma fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management changes and effect of hypertonic dehydrationchanges and effect of hypertonic dehydrationADHsecretextracellularfluiddehydrationslightlyBPslightlychangelittle renaltubulereabsorbwaterandnatriumALDexcretenormalhypourocriniaearlyperiodUNanotdecrease fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base 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 dehydrationhypotonicdehydrationbodyfluiddecreasesaltlosswaterlossinterstitialeyeholeintrocessionfluidSkinelasticityECFosmoticECFintocellECFdecreasepressurepachemiabloodvolumeveincollapsedecreaseBPdecreaseADHsecreteSeverityshockICFdecreasenotobviouslyALDsecreterenaltubulereabsorbrenaltubulereabsorbwaterandnatrumwaterandnatrumearlierperiodurinaryUNadecreaseorabolitionvolumenotdecrease fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management comparisoncomparisontypeisotonicdehydrationhypertonicdehydrationhypotonicdehydrationoverhydrationwater/saltwaterdepletionsaltdepletionwaterdepletionsaltdepletionwaterdepletionsaltdepletionrehydrationreinforcesaltplasmamillisomole(mmol/L)290-310310290290plasmaNa+EQU(mmol/L)130-150150130130etiologywaterandsaltallloss,noadditionintimewaterintakedeficientorlosstoomuchafterbodyfluidlossonlygivewaterwaterintakewaterloss,leadtowatersave fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management comparisoncomparisontypeisotonicdehydration hypertonicdehydrationhypotonicdehydration overhydration physiologyECFECF isotonic,ICFandECFECFarealllossECFECFhypertonic,mainlyICFICFlossECFECFhypotonic,mainlyECFECFlossECFECFhypotonic,ICFandECFECFareallincreaseclinicalmanifestationhydrodipsia,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 managementfluid-electrolyte-acid-base management cause and effect of cause and effect of hypokalemia hypokalemia lowingestionobstructionhypokalemiaK+SBrespiratoryacidosisABSBrespiratoryalkalosisABSBmetabolicacidosisABSBmetabolicalkalosisbufferbase(BB)(includeHCO3-):45-55mmol/Lbufferexcess(BE):-3-+3mmol/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_metabolicacidosisHCO3-/H2CO320/1pH7.35breathdeepenandquickenPaCO2glomerulopathyLosewithurineplasmaH2CO3RestrainenzymediuretickidneydrainageH+HCO3-resorbfixedacidincrease,NaHCO3consumedproduceoverabundanceacidhypoxia,lacticacidacidicurinesteatolysiskidneydrainageK+insulinintra-andextra-cellK+outofcellacidretentionH+intocelltakeinmoreacidicdrugcentralnervefatigue,comabluntness,Hyperkale-miaH+exchangek+betweencellcardio-vascularcardiaccontractionHCO3-cardiacoutputnephrictubuledrainageH+arrhythmiadilutionacidosisskeletalfiberintenerate fluid-electrolyte-acid-base managementfluid-electrolyte-acid-base management cause and effect of cause and effect of metabolic alkalosis metabolic alkalosis gastricjuicesloseoverabundanceseverevomitloseamountofH+andCL-SBbufferbaseNegativeBECO2CPbloodHCO3_metabolicalkalosisHCO3-/H2CO320/1pH7.45breathslowshallowPaCO2GIdecompressplasmaH2CO3HCO3-cantcounteractedabsorbedbybloodkidneydrainageH+HCO3-resorbinceptorinjectmorealkalinedrugalkalineurinekidneydrainageK+hypokale-miaH+exchangek+betweencellIntra-andextra-cellK+intocellHCO3-H+outofcellnephrictubuledrainageH+centralnervedysphoria,deliriumlongtimeusesomediureticneuro-muscularmusclefinetremortetany fluid-ele