电解质代谢的生理基础.ppt

Waterandelectrolytedisorders 一 水 电解质代谢的生理基础 一 体液1 体液及其分布IntracellularfluidTotal ICF 40 60 interstitialfluid15 extracellularfluidplasma5 ECF 20 transcellularfluid2 透细胞液 2 体液中主要电解质及其分布extracellularfluid Na Cl HCO3 intracellularfluid K HPO42 在Na K ATPase作用下 细胞内外Na K 保持不对等分布 3 Osmoticpressureofbodyfluid plasma Positiveion 151mmol LNegativeion 139mmol Ltotal280 310mmol LNonelectrolyte 10mmol L 678 3kpa Plasmacolloidalosmoticpressure 3 72kpa 28mmHg 二 movementofwaterandelectrolytes1 plasmainterstitialfluidcapillaryprotein2 intra andextra cellularfluidproteinsandpositiveion permeabilitywaterandnegativeion permeability watermovementbalanceofosmoticpressure RBC 3 Balanceofbodywaterandsodiumdrink1200mlwaterintakefood1000ml 2000 2500ml oxidation300mlbalanceofwaterurine1200 1500mlwaterlossskin500ml 2000 2500ml respiration350mlfeces150mlBalanceIntake d100 200mmol digestivetract ofsodiumLoss d100 200mmol urinarysystem ECF 50 DistributionICF 10 ofsodium骨基质 40 正常血清钠 130 150mmol 三 RegulationofosmoticpressureandvolumeHypertonicthirstofECF1 bodywaterADH aldosteronesodiumthirstAng ADHbodyvolumealdosteronereceptorofvolumeADH2 bodywatersodiumADHreabsorptionofsodium3 bloodvolumeANPaldosterone ADS tension4 othersADHpain Figure regulationofADHsecretionosmoticpressureRpressureRADHvolumeR heart 二 waterandsodiumdisordershypertonichypertonicdehydrationisotonicwaterexcessisotonichypotonichypotonic 一 细胞外液容量不足 extracellularfluiddeficit 1 Hypotonicdehydrationsodiumloss waterlossserumsodium 130mmol Lplasmaosmoticpressure 280mOsm L 1 causeandPathogenesisexcessivelossofwaterandsodiumreplacedwithwateronly vomiting diarrhea burn diuretics Addison sdisease ADS chronicrenalfailure renaltubularacidosis2 adaptiveresponseandeffectonbody movementofbodyfluidECFICFcellularswellingBloodvolumeExtracellularfluidShockdehydratedsignsedemaofbrainandlung urinaryalterationurinespecificurinevolumegravity Na earlyADH orstageADSlateADHstageADS 注 经肾失钠的低渗性脱水 尿钠不减少 3 principlesoftreatment treatingprimarydisease 0 9 NaCl2 hypertonicdehydration waterloss sodiumloss serumsodium 150mmol L plasmaosmoticpressure 310mOsm L 1 causeandpathogenesislackofwater desert sea intaketodrinkinability coma baby lung hyperpnea hypoxia acidosis skin fever hyperthyroidism sweat exposuretohotenvironment lossdigestivetract vomiting diarrhea babydiarrhea Na 60mmol L kidney diabetes ketosis diabetesinsipidusdiuretic mannitol hypertonicglucose 2 effectonbody hypertonicofECFthirst movementofthebodyfluidICFECFcelldehydrationBraindehydrationSleepinesssubarachnoidspacebleedingDehydrationofsweatglandsdehydratedfeverdehydrationofheatregulatingcenter urinaryalterationurinespecificurinevolumegravity Na earlyADHstageADS lateADHstageADS 3 principlesoftreatment先水 后盐 补水大于补钠 病例1 患者 男性 40岁 吐 泻伴发热 口渴 尿少4天入院 体格检查 体温38 2 血压110 80mmHg 汗少 皮肤黏膜干燥 实验室检查 血Na 155mmol L 血浆渗透压320mOsm L 尿比重 1 020 给予5 葡萄糖溶液2500ml d和抗生素 2天后体温 尿量正常 口不渴 眼窝凹陷 皮肤弹性明显降低 无力 肠鸣音减弱 腹壁反射消失 浅表静脉萎陷 脉搏110次 分 血压72 50mmHg 血Na 120mmol L 血浆渗透压255mOsm L 血K 3 0mmol L 尿比重 1 010 尿钠8mmol L 3 isotonicdehydration waterloss sodiumloss serumsodium 130 150mmol L plasmaosmoticpressure 280 310mOsm L1 causeandpathogenesis vomiting diarrhea gastrointestinalsuction biliaryfistula intestinalfistula asciticfluid pleuraleffusion 2 effectsonbody slightthirst bloodvolumedehydratedsigns BP urinaryalterationurinespecificurinevolumegravity Na earlyADHstageADSlateADHstageADS 3 principlesoftreatment补偏低渗液 先补0 9 NaCl 病例2 患者 女性 38岁 因减肥连续服用泻药一周 现感虚弱乏力 偶有直立性眩晕而入院 体格检查 体温36 7 血压从入院时的110 60mmHg很快降至80 50mmHg 心率100次 分 皮肤弹性差 黏膜干燥 尿量120ml 24h 实验室检查 血Na 140mmol L 血浆渗透压295mOsm L 尿比重1 038 尿钠6mmol L 二 细胞外液容量过多 extracellularfluidexcess 1 waterintoxicationwaterintake totalsodium ECF ICF hyponatremia Serumsodium 130mmol L1 causeexcessivewaterintakerenalloss acuterenalfailure acutecongestiveheartfailure 2 effectsonbodybraincellsswellingwatermovesintocellspulmonaryedema3 principlesoftreatmentdiuresis 病例3 患者 女性 因外伤急救误输异型血200ml后 出现黄疸和无尿 体格检查 体温37 脉搏80次 分 呼吸80次 分 血压从入院时的110 60mmHg很快降至80 50mmHg 神志模糊 表情淡漠 皮肤黏膜干燥 黄染 静脉塌陷 实验室检查 血清尿素氮15 0mmol L 非蛋白氮57 12mmol L 血K 6 7mmol L 入院后急速输入5 10 葡萄糖溶液1500ml 生理盐水500ml后 当晚做血液透析 透析中血压上升并稳定在110 140 70mmHg 透析后查尿素氮为9 46mmol L 非蛋白氮44 3mmol L 血K 5 7mmol L 患者5天内一直无尿 并逐渐出现明显气喘 心慌 不能平卧 嗜睡 呕吐 头痛 精神错乱症状 查体发现 心率120次 分 两肺布满湿罗音 血Na 120mmol L 血浆渗透压230mOsm L 红细胞比容32 2 Edemainterstitialfluidfluidinthebodycavitieshydropsfluidinthecellscellularedema 1 pathogenesis1 imbalanceofexchangebetweenintra andextra bodyfluid retentionofwaterandsodium basicmechanism glomerular tubularimbalance GFRacuteglomerulonephritisheartfailure reabsorptionofproximaltubulesympatheticnervefiltrationfractionANPreabsorptionofwaterandsodium reabsorptionofdistaltubuleADH aldosterone redistributionofrenalbloodflowsympatheticnervesandrenin2 imbalanceofexchangebetweenintra andextra vascularfluid