水电解质代谢与酸碱平衡失调-E070914-20105医学

1,Fluids and Electrolytes Management of the Surgical Patient,Zongfang Li(李宗芳), MD.PHDProfessor of General S,2,和谐社会,3,旱灾,4,水灾,5,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/mm3，Hb12g%，WBC15000/mm3，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:?,6,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38.2Prescription of fluid replacement:?,7,Body Fluid & Its Compartments,Composition: WaterElectrolytesVolume: 50%（female） 60%（male） 80%（infant）of body weight FACTOR：sex、age、lean & fatDistribution (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/P3、 protein The effective osmotic pressure in the two compartments are considered equal, about 290-310mOsmL.,以上的稳定持机体新陈代谢正常进行的保证,8,Function of Water,Water is one of the most important material to maintain the mormal functions of human body. 人只饮水可生存十日之久，无水只能生存数日,调节体温 Regulate body heat促进物质代谢 Facilitate metabolism: 溶解dissolve, 、运输 transportation 润滑作用 lubrication,9,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： NaK the excitability CaMgH+K is the activator of many enzymes in human body： K take part in the biosynthesis of glycogen and protein.,10,水的摄入与排出 Water gain and loss,每天代谢产生固体废物3540g，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.,11,Electrolyte Content of Body Fluid 1,正常人血浆or血清中的电解质浓度,12,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）,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.,13,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 69g) and kalium (23g).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.,14,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：HypothalamusneurohypophysisADH 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。,15,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,16,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NaCIH2O（排泌K、H）,细胞外液循环血量,BP,Adjust of Body Fluid Balance 3,17,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 4,18,Body Fluid Abnormalities,Total Body Water LossDehydration = 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.,19,高渗性脱水.1 Hypertonic dehydration,Definition: water deficient sodium deficientPNa+150mEq/L (hypertonia)Cause: Intake deficient- unable to regulate intake, fountain discontinuity Overabundant loss profuse sweating from ardent fever, excessive diuresisIts also called primary water deficits.Pathophysiology: ECF volume deficit accompanied by hypernatremia, ADH，aldostenrone,20,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.,21,2. 低渗性脱水.1 Hypotonic dehydration,Definition: water deficient sodium deficientPNa+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. Its 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,22,2. 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.,23,3. 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,24,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, ShockIt 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,25,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 35saline (Hypertonic) Isotonic dehydration - 5%GNSTake 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,26,Electrolyte Disorders,Hypokalemia,27, Transportation between extra-and intracellular:Physiologic factor: NaK 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,28,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 1,29,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 2,30, Circulation systemcardiac 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：K3.0，U波出现、TU融合 K2.5，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：,31, neuromuscular system 骨骼肌：肌无力( K3.0)、肌痛、肌麻痹、 软瘫( K2.5) 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( K2.0) 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：,32, 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 K2.5，肌红蛋白尿、甚至急性肾衰,Hypokalemia 5,临床表现：,33,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HC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HCO3- HCO3-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 ,34,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10KCl）； 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 7,35,Acid-base Balance,36,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） HCO3 27mmol/L 20 = = (PH7.4) H2CO3 1.351 mmol/L 1 B. CO2 excreted via the lungs （体内挥发性酸H2CO3） 调节血液中的呼吸性成分，即H2CO3（PCO3）,1.Maintain of Acid-base Balance 1,37,1.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HCO3浓度的稳定 机理：HNa+交换； HCO3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H2个Na3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,38,2.Disturbances of Acid-base Balance,Metabolic acidosis（CO2CP，PH）,Metabolic alkalosis（CO2CP，PH）,Respiratory acidosis （PCO2、CO2CP、PH）,Respiratory alkalosis （PCO2、CO2CP、PH）,HCO3H2CO3,增多,减少,增多,减少,39,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：1015mmol/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- ),40,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,41,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,42,Metabolic acidosis 4,Therapy：严重者，才需V补碱性药物 5%Na HCO3ml=（50-CO2CP）Kg0.5 (作用快、效确切最常用) 11.2乳酸钠ml=（50-CO2CP）Kg0.3 (休克、肝功不良禁用) 3.6%THAM ml=（50-CO2CP）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1/22/3 也可先按提示10vol%的CO2CP补给，再据测得的CO2CP值调整。 45 vol%以上、尿碱性、即停补。尿量、注意补钾。,43,Principles of Fluid & Electrolyte Therapy,Fluid & ElectrolyteAbnormalities,Prevent,Disease,44,Prevent,1. The volume of physiological requirements(20002500ml): 5-10% GS 1500 ml 等渗盐5001000 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35 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,45,Therapy 1,1Calculation of fluid replacementPhysiological requirements：20002500ml，其中NS 500 mlPreexisting 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,46,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(140Na) 1L NaCI=154mol. NS量(L)=缺Na量154,47,Therapy 3,根据临床表现估计Preexisting deficits,48,Therapy 4,常用溶液的电解质含量(mEg/L),49,Therapy 5,注意事项1.management for primary disease2.Identify the extent and type of dehydration3.Take notice of the function of patients heart, lung, kidney, especially for aged people.4.The disturbance of water, electrol