最好的课件体液失调解析

2 27 20201 53PM 外科病人的体液失调FluidDisordersofSurgicalPatients 2 27 20201 53PM 有用的概念UsefulConcepts 2 27 20201 53PM 体液 脊椎动物进化于海水脊椎动物身体的大约2 3是水大多数脊椎动物的细胞外液的浓度是恒定的体液 水 电解质 蛋白质 气体 2 27 20201 53PM BodyFluid体液 MajorFactorsAffectingBodyFluidsAgeGenderBodyfat 影响体液的主要因素年龄性别体脂 2 27 20201 53PM BodyFluid体液 Birth 75 80 ofbodycomposition1year 65 Afterpuberty60 males50 femalesOlderadults50 males40 females 出生 75 80 身体成分1岁 65 青春期后60 男50 女老年50 男40 女 2 27 20201 53PM BodyFluid体液 IntracellularFluid ICF 40 BWformale35 forfemale ExtracellularFluid ECF 20 BWPlasma5 BWInterstitalFluid15 BW 细胞内液 ICF 40 体重 男 35 体重 女 细胞外液 ECF 20 体重血浆5 体重组织间液15 体重 2 27 20201 53PM BodyFluid体液 细胞内液Na CI HCO3 Protein 细胞外液K Mg HPO42 Protein 2 27 20201 53PM Homeostasis内稳态 Homeostasis fromtheGreekwordsfor same and steady DefinedasthedynamicconstancyoftheinternalenvironmentdespitechangesintheexternalenvironmentMoreadynamicstateinwhichinternalconditionsvarywithinnarrowlimits 内稳态一词来自希腊文 相同的 和 稳定的 指无论外环境如何变化 保持内环境的动态稳定内环境的多数的动态变化仅限于很窄的范围 2 27 20201 53PM Homeostasis内稳态 NecessaryforsurvivalMostofthesemechanismsoperatebynegativefeedbackEveryorgansystemplaysaroleinmaintaininghomeostasisNervousandendocrinesystemsaremajorcommunicationsystems 内稳态为生存所必需大多数以负反馈机制调节每一器官系统对维持内稳态具有作用神经内分泌系统是主要的信息传递系统 2 27 20201 53PM OsmoticPressure渗透压 ThepressurerequiredtostoposmosisthroughasemipermeablemembranebetweenasolutionandpuresolventItisproportionaltotheosmolalityofthesolution Normalvalue290 310mmol LFormula2 Na K BUN Glu 指为维持通过半透膜所隔开的溶液与纯溶剂之间的渗透平衡而需要的压力与重量克分子渗透压浓度一致正常值290 310mmol L公式2 钠 钾 尿素氮 葡萄糖 2 27 20201 53PM FluidBalance体液平衡 WaterbalanceWaterintake lossareequalElectrolytebalanceEctrolytesabsorbedinsmallintestine amountlostinurineAcid basebalanceHydrogenionslost hydrogenionsproducedbymetabolism 水平衡水摄入 水丢失电解质平衡小肠吸收电解质量 尿中丢失量酸碱平衡氢离子丢失 代谢产生 2 27 20201 53PM FluidRegulation体液调节 ThirstKidneysADHAldosteroneAngiotensinIIProstaglandinsGlucocorticoidsAtrialNatriureticPeptide 渴感肾脏抗利尿激素醛固酮血管紧张素前列腺素糖皮质激素心钠素 2 27 20201 53PM 水 钠代谢紊乱WaterandSodiumDisorders 2 27 20201 53PM WaterBalance水的平衡 2 27 20201 53PM WaterBalance水的平衡 NPO nonperos Anorexia 摄入水 INPUT 2 27 20201 53PM Sodium钠 Sincesodium Na isthemajorosmoticallyactivecationintheECFcompartment changesintotalbodyNacontentareparalleledbychangesinECFvolume 钠是细胞外液间隙中主要的渗透性活性阳离子 体内钠含量的变化与细胞外液容量的变化是平行的 2 27 20201 53PM CompositionofGISecretions消化液成分 2 27 20201 53PM Dehydration缺水 Dehydrationisaconditionthatoccurswhenthelossofbodyfluids exceedstheamountthatistakeninIsotonicdehydrationHypotonicdehydrationHypertonicdehydration 缺水指体液丢失超过摄入等渗性缺水低渗性缺水高渗性缺水 2 27 20201 53PM Dehydration缺水 NormalRBCs IsotonicSolution Equalmovementofwaterintoandoutofcells Netmovementofwateroutofcells Netmovementofwaterintocells ShriveledRBCs SwollenRBCs HypertonicSolution HypotonicSolution 2 27 20201 53PM Isotonicdehydration等渗性缺水 Usuallycalledfluidvolumedeficit orhypovolemiainWestSodiumloss waterlossSerumNa unchangedPlasmaosmoticpressureunchanged 在西方通常称作容量缺乏或低血容量钠丢失 水丢失血清钠不变血浆渗透压不变 2 27 20201 53PM Isotonicdehydration等渗性缺水 CausesExcessiveFluidLossesVomiting diarrhea GIsuction hemorrhage intestinalfistulae burn intestinalobstruction intra abdominalinfection ect Poor InadequateFluidIntake 病因体液丢失过多呕吐 腹泻 胃肠减压 出血 肠瘘 肠梗阻 腹腔感染等摄入不足 2 27 20201 53PM Isotonicdehydration等渗性缺水 ClinicalManifestationsAcuteweightloss UrinaryOutputAnorexiaFlattenedneckveinsMuscleweaknessMaynotthirstCool clammyskin SkinturgorWeak rapidpulseOrthostatichypotension 临床表现急性体重丢失尿量减少厌食颈静脉萎陷肌肉无力可能不口渴皮肤湿冷皮肤弹性下降脉搏细弱体位性低血压 2 27 20201 53PM Isotonicdehydration等渗性缺水 ManagementReplaceECFlossAddressunderlyingcauseIVroute IsotonicSolutions LactatedRingers LR 处理补充细胞外液量去除病因静脉补液 等渗溶液 乳酸林格氏液 2 27 20201 53PM HypotonicDehydration低渗性缺水 DefinitionSodiumloss waterlossosmoticpressure 290mmol LNa 135mmol LAlsocalledhypovolemichyponatremia 定义钠丢失 水丢失血浆渗透压 290mmol L血清Na 135mmol L也称作低血容量性低钠血症 2 27 20201 53PM HypotonicDehydration低渗性缺水 CausesGIlosses Vomitinganddiarrhea intestinalobstruction fistulas drainageandNGtubes chronic Renallosses UseofdiureticsExtensivewounds burn Thirdspacing peritonitis pancreatitis intestinalobstruction ascites 病因胃肠道丢失 长期呕吐和腹泻 慢性肠梗阻 肠瘘 引流管和鼻肠管肾脏丢失 利尿剂的应用大面积创伤 烧伤 第三间隙丢失 腹膜炎 胰腺炎 肠梗阻 腹水 2 27 20201 53PM HypotonicDehydration低渗性缺水 ClinicalManifestationsNeurologicalHeadacheLethargyConfusionSeizuresComaGastrointestinalAnorexiaNauseaandvomiting 临床表现神经系统头痛嗜睡意识错乱癫痫发作昏迷胃肠道厌食恶心和呕吐 2 27 20201 53PM HypotonicDehydration低渗性缺水 SeverityofIllnessMild SerumNa 135mmol LModerate SerumNa 130mmol LSevere SerumNa 120mmol L 分度轻度 血清钠 135mmol L中度 血清钠 130mmol L重度 血清钠 120mmol L 2 27 20201 53PM HypotonicDehydration低渗性缺水 DiagnosisHistoryClinicalfindingsLabSerumNa 135mmol L RBC Hb Ht BUN Urinegravity osmolalityandNa 诊断病史临床表现实验室检查血清钠 135mmol L红细胞计数 血红蛋白 血细胞压积 尿素氮 尿比重 渗透压 钠 2 27 20201 53PM HypotonicDehydration低渗性缺水 ManagementFluidreplacementNaClsolutionsinfusionFomulaNarequired mmol L desiredNa mmol L actualNa mmol L xWt kg x0 6 male 0 5 female 17mmolNa 1gNaCl 治疗补液注射含氯化钠溶液公式补钠量 mmol L 血钠正常值 mmol L 血钠测得值 mmol L x体重 kg x0 6 男 0 5 女 17mmol钠 1g氯化钠 2 27 20201 53PM HypotonicDehydration低渗性缺水 Management cont MildormoderatehypovolemichyponatremiaIsotonicorHypertonicsaltsolutionsSeverehypovolemichyponatremiaHypertonicsaltsolutionscolloids 治疗 续 轻 中度低血容量性低钠血症等渗或高渗盐溶液重度低血容量性低钠血症高渗盐溶液胶体 2 27 20201 53PM Hyponatremia低钠血症 HyponatremiaincludehypovolemichyponatremiaHypervolemichyponatremiaEuvolemicHyponatremia 低钠血症包括低血容量的低钠血症高血容量的低钠血症正常血容量的低钠血症 2 27 20201 53PM Hyponatremia低钠血症 PathophysiologyHyponatremiaisphysiologicallysignificantwhenitindicatesastateofextracellularhypo osmolarityandatendencyforfreewatertoshiftfromthevascularspacetotheintracellularspace Althoughcellularedemaiswelltoleratedbymosttissues itisnotwelltoleratedwithintherigidconfinesofthebonycalvarium Therefore clinicalmanifestationsofhyponatremiaarerelatedprimarilytocerebraledema 病理生理学低钠血症可导致细胞外低渗状态和自由水从血管间隙转移至细胞内间隙 尽管多数组织可以耐受细胞水肿 但是在坚硬的颅盖骨范围内却难以耐受 因此 低钠血症的临床表现主要与脑水肿有关 2 27 20201 53PM Pseudohyponatremia假性低钠血症 Pseudohyponatremiaiscausedbyanincreasedserumproteinorlipidconcentrationproducinga space occupyinglesion inserumwaterItmustbeassessedinhyponatremicpatientswith forexample paraproteinemiaorhyperlipemicdiabeticcoma 假性低钠血症是由于血清中蛋白质和脂肪浓度增高产生的 空间占位病变 所致在低血钠病人 合并病变蛋白血症或高脂糖尿病昏迷者 需要评估其可能性 2 27 20201 53PM HypertonicDehydration高渗性缺水 Waterloss sodiumlossSerumNa 150mmol LPlasmaosmoticpressure 310mmol LAlsocalledhypovolemichypernatremia 水丢失 钠丢失血清钠Na 150mmol L血浆渗透压 310mmol L也称作低血容量性高钠血症 2 27 20201 53PM HypertonicDehydration高渗性缺水 CausesSodiumExcessDietaryIntakeFoodsMedicationshighinsodiumWaterDeficitInadequateintakeIncreasedinsensiblelosses i e fever WaterydiarrheaOsmoticDiuresis 病因钠过多饮食摄入食物高钠药物水缺乏摄入不足非显性失水增加 发热 水样泻渗透性利尿 2 27 20201 53PM HypertonicDehydration高渗性缺水 ClinicalManifestationsNeurologicalRestlessnessAgitationConfusionSeizuresComaOtherSeverethirst drymucousmembranes musculartwitching hyperactivedeeptendonreflexes anorexia nauseaandvomiting 临床表现神经系统烦躁兴奋意识混乱癫痫昏迷其他重度口渴 粘膜干燥 肌肉抽搐 腱反射亢进 厌食 恶心 呕吐 2 27 20201 53PM HypertonicDehydration高渗性缺水 DegreeMild 2 4 lossBWor6 BWor30 40 BVShock 8 BWor 40 BVLabSerumNa 150mmol L RBC Hb Ht Urinegravityandosmolality 分度轻度 血容量2 4 体重或6 体重或30 40 血容量休克 8 体重或 40 血容量实验室血清钠 150mmol L红细胞 血红蛋白 压积升高尿比重和渗透压浓度升高 2 27 20201 53PM HypertonicDehydration高渗性缺水 Management5 glucose0 45 NaCl 处理5 葡萄糖0 45 氯化钠 2 27 20201 53PM FluidVolumeExcess体液容量过多 ClinicalManifestationsRapidweightgainPeripheralEdemaDistendedneckveinsShortnessofbreathBoundingpulse BloodpressureCracklesOrthopnea 临床表现快速体重增加外周水肿颈静脉扩张气短洪脉血压升高湿罗音端坐呼吸 2 27 20201 53PM FluidReplacement补液 MaintenanceDeficitActualweightlossvsestimateGive infirst8hrsand innext16hrsOngoinglossesNGlosses fistulas thirdspace etc 维持量缺乏量急性体重丢失 相对于评估 头8小时给与1 2 后16小时给与1 2继续丢失量鼻胃管丢失 瘘 第三间隙等 2 27 20201 53PM Colloidstorestoreperfusion胶体恢复灌注 IndicationsHypotensionTachycardiaOliguriaCoolperipheriesKnownbloodlossMajorsurgicalprocedureSeveretraumaSepsisOtherCriticalillness 指征低血压心动过速少尿外周冷已知血液丢失大手术严重创伤脓毒症其它危重病 2 27 20201 53PM 钾的异常PostassiumDisorders 2 27 20201 53PM PostassiumDisorders钾的异常 MostabundantcationinICFNormalserumK 3 5 5 5mmol LEvenminorvariationsinserumpotassiumlevelsaresignificantMajorfunctionsMaintainingelectricalneutrality osmolalityAssistsinneuromusculartransmissionofimpulsesAssistsinskeletalandcardiacmuscleincontraction electricalconductivityMaintainingacid basebalances 细胞内最多的阳离子正常血清钾 3 5 5 5mmol L即使血清钾水平微小变化都可能产生显著影响主要功能维持电中和与渗透压浓度促进神经肌肉冲动传播维持酸碱平衡 2 27 20201 53PM Hypokalemia低钾血症 SerumK 3 5mmol LEtiologyInadequateintakemalnutritionIVFdeficientinpotassiumGILossesVomiting gastricsuctioninganddiarrheaOther long termabuseoflaxativesorenemasGUlossesDiuretics Non KSparing renaltubularacidosisIntracellularuptakewithredistributionseeninacutealkalosis insulintherapy andanabolism 血钾 3 5mmol L病因摄入不足营养不良补液缺钾胃肠道丢失呕吐 胃肠减压 腹泻长期泄剂滥用或灌肠泌尿系丢失利尿剂 非保钾 肾小管酸中毒细胞内摄取重新分布 见于急性酸中毒 应用胰岛素和合成代谢 2 27 20201 53PM Hypokalemia低钾血症 ClinicalManifestationsCardiacWeak irregularpulseDysrhythmiasandEKGchangesCardiacarrestanddeathNeuromuscularSkeletalmuscleweaknessHypoactivedeeptendonreflexesEnteroparalysisOtherConstipation fatigue anorexia N V 临床表现心血管脉搏细弱不规律心律失常 心电图改变心跳停止 死亡神经肌肉骨骼肌无力腱反射减弱肠麻痹其他便秘 乏力 厌食 恶心 呕吐 2 27 20201 53PM Hypokalemia低钾血症 EKGlow flatT waves STdepression andUwaves 心电图T波低平 ST压低 U波 2 27 20201 53PM Hypokalemia低钾血症 TreatmentTreatalkalosisIVK 20mmol hr 40mmol L 3gKCl 1gKCl 13 4mmol L 治疗治疗碱中毒静脉补钾 20mmol 小时 40mmol L 3g氯化钾 1g氯化钾 13 4mmol L 2 27 20201 53PM Hyperkalemia高钾血症 SerumK 5 5mmol LEtiologyDecreasedrenalexcretioni e RenalfailureIncreasedKintakeDiet DietarysupplementsCellulardeathTrauma burns crushinjuriesSevereinfectionChemotherapyBloodtransfusions 血钾 5 5mmol L病因肾排泻减少 肾衰 钾摄入过多细胞死亡创伤 烧伤 积压伤重度感染化疗输血 2 27 20201 53PM Hyperkalemia高钾血症 ClinicalManifestationsCardiacIrregularpulseDysrhythmiasandEKGchangesCardiacarrestanddeathNeuromuscularFlaccidparalysisParesthesiasMuscleweaknessOtherFatigue irritability anorexiaandN V 临床表现心血管脉搏不齐心律失常 心电图改变心跳停止 死亡神经肌肉迟缓型麻痹感觉异常肌无力其他疲乏 兴奋 厌食 恶心 呕吐 2 27 20201 53PM Hyperkalemia高钾血症 EKGEarly peakedTwavesthenflatPwaves prolongedQT widenedQRSprogressing 心电图早期高尖T波 P波平坦 ST段压低 QT延长 QRS增宽 2 27 20201 53PM Hyperkalemia高钾血症 TreatmentRemoveiatrogeniccausesCa gluconateSodiumbicarbonateGlucoseRegularinsulinEmergentdialysisHydrationanddiuresisKayexalateSorbitolHemodialysis 治疗去除病因葡萄糖酸钙碳酸氢钠葡萄糖胰岛素水化利尿降钾树脂山梨醇血液透析 2 27 20201 53PM 钙的异常CalciumAbnormalities 2 27 20201 53PM CalciumAbnormalities钙的异常 MajorFunctionsFormationandstructureofteethandbonesAssistsinmaintainingcellstructure functionTransmissionofnerveimpulsesRoleinsmooth skeletalandcardiacmusclescontraction relaxationRoleinthebloodclottingprocesses 主要功能牙骨构成维持细胞结构和功能传送神经冲动平滑肌 骨骼肌 心肌收缩和放松凝血 2 27 20201 53PM CalciumAbnormalities钙的异常 NormalserumCa2 2 25 2 75mmol LCalciumandPhosphateBalancePTHBones breakdownGI Ca2 absorptionandVitDactivationKidneys IncreabsorptionCa2 decresorptionPO42 CalcitoninDepositCa2 inBone 正常钙 2 25 2 75mmol L钙磷平衡甲状旁腺激素骨分解胃肠钙吸收 维生素D活性肾钙重吸收增加 磷酸再吸收减少降钙素骨钙沉积 2 27 20201 53PM Hypocalcemia低钙血症 Ca2 2 25mmol lCausesInadequateDietaryIntakeHypoparathyroidismThyroidandparathyroidsurgeriesVitaminDDeficiencyChronicdiarrheaPancreatitis 钙 2 25mmol l病因摄入不足甲状旁腺功能减退甲状腺和甲状旁腺手术维生素D缺乏慢性腹泻胰腺炎 2 27 20201 53PM Hypocalcemia低钙血症 ClinicalManifestationsNeuromuscularParesthesias Toes fingersandaroundthemouthMuscletremors cramps spasmsortwitchingTetany Trousseau s Chvostek ssignHyperactivedeeptendonreflexesCardiacCardiacdysrhythmiasEKGchangesOtherConfusion irritability seizures abdominalcramping diarrheaandimpairedclottingtimes 临床表现神经肌肉感觉异常 趾 指 口周肌肉震颤痉挛抽筋抽搐手足搐搦束臂试验 面神经叩击征阳性腱反射亢进心血管心律失常心电图改变其他意识混乱 兴奋 癫痫 腹痛 腹泻 血凝损害 2 27 20201 53PM Hypocalcemia低钙血症 Tetany手足搐搦 2 27 20201 53PM Hypocalcemia低钙血症 Trousseau ssignChvostek ssign 2 27 20201 53PM Hypocalcemia低钙血症 ECGhasprolongedQTinterval 心电图QT间期延长 2 27 20201 53PM Hypocalcemia低钙血症 ManagementAcute intravenouscalciumgluconateorcalciumchlorideChronic oralcalciumandVitaminDAssessserumPhos 治疗急性 静脉补充葡萄酸钙或氯化钙慢性 口服补钙和维生素D评估血清磷 2 27 20201 53PM Hypercalcemia高钙血症 Ca2 2 75mmol LCausesExcessiveIntakeHyperparathyroidismMetastaticcancerBreastLungRenal 钙 2 75mmol L病因摄入过多甲状旁腺功能亢进转移癌乳腺肺肾 2 27 20201 53PM Hypercalcemia高钙血症 ClinicalManifestationsNeurologicalConfusion fatigue lethargy acutepsychoticbehaviorandcomaNeuromuscularMuscleweakness incoordinationandhypoactivedeeptendonreflexesCardiacDysrhythmiasandECGchangesOtherAnorexia n v weakness bonepain constipation abdominalpain 临床表现神经系统意识混乱 疲乏 嗜睡 精神病行为 昏迷神经肌肉肌肉无力 共济失调 腱反射减弱心血管心律失常 心电图改变其他厌食 恶心 呕吐 虚弱 骨痛 便秘 腹痛 2 27 20201 53PM Hypercalcemia高钙血症 ManagementRehydratewithnormalsalinePromotediuresis 治疗水化利尿 2 27 20201 53PM 镁的异常MagnesiumAbnormalities 2 27 20201 53PM MagnesiumAbnormalities镁的异常 NormalserumMg2 0 70 1 10mmol LMajorfunctionsPromotesenzymereactionswithinthecellAssistsinbothcarbohydrateandproteinmetabolismAssistsinproducingandusingATPforenergyInfluencesvasodilation assistingthecardiovascularsystemtofunctionproperlyImportantroleinmaintainingneuromuscularfunction 正常血镁0 70 1 10mmol L主要功能促进细胞酶反应促进碳水化合物和蛋白质代谢促进ATP的生成和利用影响血管舒张 维持心血管功能维持神经肌肉功能 2 27 20201 53PM Hypomagnesemia低镁血症 CausesPoordietaryintakeMalnutritionChronicETOHabuseGIlossesProlongeddiarrheaorlaxativeabuseGULossesProlongeduseoflooporthiazidediuretics 病因摄入不足营养不良酗酒胃肠道丢失长期腹泻 泻剂滥用泌尿系丢失长期应用襻类或噻嗪类利尿剂 2 27 20201 53PM Hypomagnesemia低镁血症 ClinicalManifestationsSymptomsthesameashypocalcemiaCardiacventriculardysrhythmias 临床表现症状类似低钙血症室性心律失常 2 27 20201 53PM Hypomagnesemia低镁血症 ManagementMagnesiumrepletionMagnesiumsulfateIV 治疗补镁静脉注射硫酸镁 2 27 20201 53PM Hypermagnesemia高镁血症 CausesExcessiveIntakeAntacidsandlaxativescontainingMgImpairedGUFunction 病因摄入过多制酸剂 含镁泻剂肾功损害 2 27 20201 53PM Hypermagnesemia高镁血症 ClinicalManifestationsNeuromuscularHypoactiveDeepTendonReflexesMuscleweakness paralysisOtherDrowsiness lethargy ComaFacialflushingRespiratorydepressionWeakpulse bradycardia andcardiacarrestHypotension 临床表现神经肌肉腱反射减弱肌肉无力或麻痹其他嗜睡 昏迷脸红呼吸抑制脉搏减弱 心动过缓 心跳停止低血压 2 27 20201 53PM Hypermagnesemia高镁血症 ManagementProtecttheheartCalciumgluconateVolumeresuscitateEliminateexcessmagnesiumStopmagnesiumadministrationCorrectacidosisNormalkidneys loopdiureticsAbnormalkidneys hemodialysis 治疗保护心脏葡萄糖酸钙容量复苏排镁停止镁摄入纠正酸中毒正常肾 利尿剂异常肾 血液透析 2 27 20201 53PM 磷的异常PhosphateAbnormalities 2 27 20201 53PM PhosphateAbnormalities磷的异常 NormalserumPhos 0 96 1 62mol L 正常磷 0 96 1 62mol L 2 27 20201 53PM Hyperphosphatemia高磷血症 CausesExcessiveintakeofPhosphorusVitaminDExcessRenalFailureHypoparathyroidismChemotherapy 病因磷摄入过多维生素D过多肾衰甲状旁腺功能减退化疗 2 27 20201 53PM Hyperphosphatemia高磷血症 ClinicalManifestationsNeuromuscularParesthesiasMuscleweakness crampsorspasmsTetany Trousseau s Chvostek ssignHyperactivedeeptendonreflexesOtherConfusion dysrhythmias anorexiaandn vReciprocalHypocalcemia 临床表现神经肌肉感觉异常肌肉无力 抽筋手足抽搐 束臂试验 面神经叩击征阳性腱反射亢进其他意识混乱 心律失常 厌食 恶心 呕吐低钙血症 2 27 20201 53PM Hyperphosphatemia高磷血症 ManagementIntravenousCaHemodialysis 治疗静脉补钙血液透析 2 27 20201 53PM Hypophosphatemia低磷血症 Causes Intake LossHyperparathyroidismGIDiarrheaPhosphate bindingantacids RequirmentGlucose insulin Anabolism 病因摄入减少丢失增加甲状旁腺功能亢进胃肠道腹泻磷结合制酸剂需求增加葡萄糖 胰岛素合成代谢增加 2 27 20201 53PM Hypophosphatemia低磷血症 ManagementIntravenousphos Glyphos FDP 治疗静脉补磷 2 27 20201 53PM 酸碱平衡的失调Acid baseImbalances 2 27 20201 53PM A BImbalances酸碱平衡的失调 MetabolismdependsonenzymesEnzymesaresensitivetopHBloodandtissuefluid normalpH 7 35to7 45HCO3 24to26mmol LPCO2 35to45mmHg 代谢依赖于酶酶对pH敏感血液和体液正常pH 7 35 7 45HCO3 24 26mmol LPCO2 35 45mmHg 2 27 20201 53PM A BImbalances酸碱平衡的失调 Compensation 代偿 2 27 20201 53PM A BImbalances酸碱平衡的失调 MetabolicAcidosisDecreasedpH7 45PCO2normal35 45mmHgHCO3 Increased 26mmol L 代谢性酸中毒pH降低7 45PCO2正常35 45mmHgHCO3 升高 26mmol L 2 27 20201 53PM A BImbalances酸碱平衡的失调 Respiratoryacidosis DecreasedpH45mmHgHCO3 normal24 26mmol LRespiratoryalkalosisIncreasedpH 7 45PCO2decreased 35mmHgHCO3 normal24 26mmol L 呼吸性酸中毒pH降低45mmHgHCO3 正常24 26mmol L呼吸性碱中毒pH升高 7 45PCO2降低 35mmHgHCO3 正常24 26mmol L 2 27 20201 53PM A BImbalances酸碱平衡的失调 2 27 20201 53PM A BImbalances酸碱平衡的失调 Acid Base PotassiumImbalancessAcidosisH diffusesintocellsanddrivesoutK elevatingK concentrationinECFH bufferedbyproteininICF causingmembranehyperpolarization nerveandmusclecellsarehardertostimulate CNSdepressionfromconfusiontodeath 酸碱与钾失衡酸中毒H 弥散进入细胞 K 排出细胞 提高K 在细胞外的浓度H 在细胞内液被蛋白质缓冲 导致膜超极化 神经肌肉难以刺激 中枢神经系统抑制 2 27 20201 53PM A BImbalances酸碱平衡的失调 Acid Base PotassiumImbalancessAlkalosisH diffusesoutofcellsandK diffusesin membranesdepolarized nervesoverstimulatemusclescausingspasms tetany 酸碱与钾失衡碱中毒H 弥散出细胞外 K 进入 膜去极化 神经过度刺激肌肉导致抽筋 手足抽搐 2 27 20201 53PM 代谢性酸中毒MetabolicAcidosis 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 Aniongap AG Anions cationsintheserumAG Na K Cl HCO3 NormalGap 12 8 16 ORAG Na Cl HCO3 Differencedueto hidden anionslikealbuminAbnormal elevatedwith hidden acids 阴离子间隙 AG 血清中阴离子 阳离子AG Na K Cl HCO3 正常间隙 12 8 16 或AG Na Cl HCO3 其差是由于 隐藏的 阴离子 如白蛋白其异常 升高 是由于 隐藏的 酸增加 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 CausesLossofHCO3 normalAG GIlossDiarrheafistulaRenalTubularacidosisHyperchloremiaAdditionofacid aniongap LacticacidKetoacidsRenalfailureIntoxicantsSalicylates methanol ect 病因HCO3 丢失 正常AG 胃肠道丢失腹泻瘘肾肾小管酸中毒高氯血症酸增多 AG 乳酸酮酸肾衰毒性药物水杨酸 甲醇等 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 Compensation 代偿 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 ClinicalManifestationsNeurologicLethargy stupor andcomamayoccurinseveremetabolicacidosisCardiovascularSevereacidemia ie pH 7 10 canpredisposeapatienttopotentiallyfatalventriculararrhythmiasPulmonaryDemonstratetachypneaandhyperpneaasprominentphysicalsigns 临床表现神经系统重度代谢性酸中毒可出现嗜睡 木僵 昏迷心血管重度酸血症 如pH 7 10 可诱发潜在致命的室性心律失常肺呼吸急促和呼吸过度为显著体征 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 ManagementAcidgain identifyandcorrecttheunderlyingcauseLacticacidosis restoreadequatetissueperfusionKetoacidosis resuscitateandcontrolglucoseRenalfailure hemodialysis 治疗产酸 判断和纠正病因乳酸酸中毒 恢复充足的组织灌注酮症酸中毒 控制血糖肾衰 血液透析 2 27 20201 53PM MetabolicAcidosis代谢性酸中毒 Management cont BicarbonatelossResuscitatewithfluidssimilarinvolumeandcompositiontothoselostCorrecthyperchloremiaBicarbonatereplacementpH 7 20HCO3 10mmol L 治疗 续 碳酸氢丢失体液复苏 与容量与成份丢失的处理相同纠正高氯血症补充碳酸氢pH 7 20HCO3 10mmol L 2 27 20201 53PM 代谢性碱中毒MetabolicAlkalosis 2 27 20201 53PM MetabolicAlkalosis代谢性碱中毒 CausesLossofhydrogenionsGIlossesofHCl NGsuction Shiftofhyd