FLUIDANDELECTROLYTEMANAGEMENT水电解质平衡.ppt

1 FLUIDANDELECTROLYTEMANAGEMENT 中山二院心胸外科熊利华 2 Forsurgicalpatients Diseases injuries operativetrauma lackofalimentation metabolismofsalt water otherelectrolytes 3 TotalBodyWater60 ofbodyweigh50 ofbodyweight75 to80 leanindividual obeseperson 4 WaterExchange Drink1000 1300Food700 900Metabolicwater300 Urine800 1500Lung350Skin500Stool250 2500 2500 5 WaterExchangeApatientdeprivedofallexternalaccesstowatermuststillexcreteaminimumof500to800ml ofurineperdayinordertoexcretetheproductsofcatabolism Insensiblelossofwateroccursthroughtheskin 75 andthelungs 25 andisincreasedbyhypermetabolism hyperventilation andfever 6 CompositionofUrine WaterNitrogen containingmaterial urea uricacid creatine creatinine aminoacidandamonia Organiccompound hippuricacid glucuronate lacticacid ethanedioic Electrolyte Cl Na Kandphosphate Littleproteinandsugar positiveinurinepathology 7 Threefunctionalcompartmentsofthebodywater intracellularwater40 extracellularwater20 bodyweight60 plasma5 interstitialfluid15 8 Totalbloodvolumeofhumanbody Generally8 ofbodyweight About5000mlforanadult increase23 25 inpregnancywomen About80 oftotalvolumeincirculationOther20 storedinliverandspleen 9 PlasmaIntestitialfluidIntracellularfluid Chemicalcompositionofbodyfluidcompartment 10 OsmoticPressureDependsonthenumberofparticlespresentperunitvolume 1mMNaCl sodium chloride contributes2mM 1mMNa2SO4 3particles contributes3mM 1mMglucoseisequalto1mMofthesubstance NormalOsmoticPressure Cations 151 Anions 139 nonelectrolyte 10 300mmol L 280 310mmol L 11 semipermeablemembraneThecellwallmaintainedthedifferencesinioniccompositionbetweenICFandECF Thecellmembranesarecompletelypermeabletowater 12 colloidosmoticpressureThedissolvedproteinsintheplasmaareprimarilyresponsibleforeffectiveosmoticpressurebetweentheplasmaandtheinterstitialfluidcompartments 13 Theeffectiveosmoticpressure intracellular extracellulardissolvedproteins plasma interstitialfluid 14 TheeffectiveosmoticpressureThedifferenceofpressurebetweentheECFandICFcompartmentsinducedbyanysubstancethatdoesnottraversethecellmembranesfreely 15 CLASSIFICATIONOFBODYFLUIDCHANGESThedisordersinfluidbalance volumedeficitorExcessconcentrationcomposition 16 VolumeDeficitThemostcommondisordersleadingtoanECFvolumedeficitinclude lossesofgastrointestinalfluidsduetovomiting nasogastricsuction diarrhea fistuladrainage sequestrationoffluidinsofttissueinjuriesandinfections intra abdominalandperitonitis intestinalobstruction andburns 17 VolumeExcessGenerallysecondarytorenalinsufficiency Boththeplasmaandtheinterstitialfluidvolumesareincreased 18 CONCENTRATIONCHANGESECF Na represent90 ofparticlesconcentration Hyponatremiaandhypernatremiacanbediagnosedbyclinicalmanifestations laboratorytests 19 MechanismofHyponatremia Waterintakeexcess Sodiumintakedeficient Renalinadequacy Vomite suction 20 HyponatremiaAsymptomaticuntiltheserumsodiumlevelfalls120mmolperliter Acutesymptomatichyponatremia CNSsigns Increasedintracranialpressure tissuesignsofexcessiveintracellularwater 21 Hyponatremia Waterintoxication serumsodiumlevellessthan120mmol LCNS ModeratesevereMuscletwitchingConvulsionsHyperactivetendonreflexesLossofreflexesincreasedintracranialpressureCardioVascular BpchangeTissue increasedsalivationWaterydiarrheaRenal OliguriaprogressingtoanuriaMetabolic None 22 MechanismofHypernatremia Waterintakedeficient Diseasesofdigestivetract Excesslosswater excessperspiration Vomite diarrhea suction 23 Hypernatremia Waterdeficit serumsodiumlevelgreaterthan150mmol LCNS ModeratesevereRestlessnessDeliriumWeaknessManiacalbehaviorCardioVascular Tachycardia HypotensionTissue DecreasedsalivaandtearsDryandstickymucousmembranesRenal OliguriaMetabolic Fever 24 MIXEDVOLUMEANDCONCENTRATIONABNORMALITIESConsequenceofthediseasestateoroccasionallyfrominappropriateparenteralfluidtherapy 1 ThemorecommonisanECFdeficitandhyponatremia Hypotonicdehydration 2 ECFvolumedeficit hypernatremia Hypotonicdehydration glucosuria3 ECFvolumeexcessandhypernatremia excessivequantitiesofsodiumsalts4 ECFvolumeexcessandhyponatremia Waterintoxication oliguricrenalfailure 25 COMPOSITIONCHANGESCompositionalabnormalitiesinclude concentrationchangesofpotassium calcium magnesiumchangesinacid basebalance 26 PotassiumThenormaldietaryintakeofpotassiumisapproximately50to100mmol daily 98 ofthepotassiumislocatedintheICcompartmentataconcentrationof150mmol perliter Extracellularpotassiumis3 5 5 5mmol L Mostofthisisexcretedintheurine 27 PotassiumAbnormaliliesHyperkalemiaExtracellularpotassium 5 5mmol L HypokalemiaExtracellularpotassium 3 5mmol L 28 HyperkalemiaSignificantquantitiesofintracellularpotassiumarereleasedintotheextracellularspace Cause severeinjuryorsurgicalstressAcidosisthecatabolicstate oliguricoranuricrenalfailure 29 HyperkalemiaSigns Thegastrointestinalsymptomsincludenausea vomiting intermittentintestinalcolic anddiarrhea ThecardiovascularsignsareapparentontheECGinitially withhighpeakedTwaves widenedQRScomplex anddepressedS Tsegments DisappearanceofTwaves heartblock anddiastoliccardiacarrestmaydevelopwithincreasinglevelsofpotassium 30 HyperkalemiaTreatment intravenousadministrationof1gm of10 calciumgluconateunderECGmonitoringadministrationofbicarbonateandglucosewithinsulin 1 4gG RapidalkalinizationoftheECFwitheithersodiumlactateorbicarbonatepromotestransferofpotassiumintocellsdefinitiveremovalofexcesspotassiumbycation exchangeresins peritonealdialysis orhemodialysis 31 HypokalemiaAmorecommonprobleminthesurgicalpatientmayoccurasaresultof excessiverenalexcretion 1g 500ml movementofpotassiumintocellsprolongedadministrationofpotassium freeparenteralfluidswithcontinuedobligatoryrenallossofpotassiumparenteralnutritionwithinadequatepotassiumreplacement lossofgastrointestinalsecretions 32 HypokalemiaThesignsofpotassiumdeficit failureofnormalcontractilityofskeletal smooth andcardiacmuscleweaknesstoflaccidparalysis diminishedtoabsenttendonreflexes andparalyticileus SensitivitytodigitaliswithcardiacarrhythmiasandECGsignsoflowvoltage flatteningofTwaves anddepressionofS Tsegments 33 NormalHypokalemiaHyperkalemia 34 HypokalemiaTreatmentofhypokalemiainvolves Firstpreventionofthesestate IntravenousadministrationofpotassiumNomorethan40mmolshouldbeaddedto1literofintravenousfluidTherateofadministrationshouldnotexceed20mmol hourunlesstheECGisbeingmonitored Administrationofpotassiumisabout3 6g day1gramofKCl 13 4mmolofpotassium 35 CompositionofGastrointestinalSecretionsVolumeNaKClHCO3 ml 24hr mmol Lmmol Lmmol Lmmol LSalivary150010261030StomacDuodenum100 20001405104 Ileum3000140510430Colon 603040 Pancreas100 800140575115Bile50 800145510035 36 CalciumAbnormalitiesMostofbodycalcium 99 isfoundintheboneintheformofphosphateandcarbonate Normaldailyintakeofcalciumisbetween1and3gm Mostofthisisexcretedviathegastrointestinaltract and200mg orlessisexcretedintheurinedaily Thenormalserumlevelisbetween2 25 2 75mmol LThe45 istheionizedportionthatisresponsibleforneuromuscularstability 37 HypocalcemiaThecommoncauses AcutepancreatitisMassivesofttissueinfectionsAcuteandchronicrenalfailurePancreaticandsmallintestinalfistulasHypoparathyroidism 38 HypocalcemiaThesymptoms serumlevellessthan2 25mmol L Numbnessandtinglingofthecircumoralregionandthetipsofthefingersandtoes Hyperactivetendonreflexes Muscleandabdominalcramps convulsions withseveredeficit Chvostek ssignandTrousseau signpositive 39 HypocalcemiaTreatment correctionoftheunderlyingcausewithconcomitantrepletionofthedeficit IntravenousadministrationofcalciumgluconateorcalciumchlorideCalciumlactatemaybegivenorally WithorwithoutsupplementalvitaminD inapatientrequiringprolongedreplacement 40 HypercalcemiaThetwomajorcauses HyperparathyroidismCancerwithbonymetastasis Thelatterismostfrequentlyseeninapatientwithmetastaticbreastcancer 41 HypercalcemiaThemanifestationsofhypercalcemiainclude Easyfatigue lassitude weaknessofvaryingdegree Anorexia nausea vomiting andweightloss Lassitude stupor andfinallycoma Severeheadaches painsinthebackandextremities thirst 42 HypercalcemiaTreatment vigorousvolumerepletionwithsaltsolutionslowersthecalciumlevelbydilutionandincreasedurinarycalciumexcretion Concomitantuseoflargedosesofintravenousfurosemidetoincreaseurinarycalciumexcretion OralorintravenousinorganicphosphatesIntravenoussodiumsulfatealsolowersserumcalcium 43 MagnesiumAbnormalitiesThetotalbodycontentofmagnesiumisapproximately1000mmol AbouthalfofwhichisinboneandthemajorotherportionbeingintracellularSerummagnesiumconcentrationnormallyrangesbetween0 7 1 1mmol L Thenormaldietaryintakeofmagnesiumisapproximately20mmol 240mg daily Thelargerpartisexcretedinthefecesandtheremainderintheurine Thekidneyshavearemarkableabilitytoconservemagnesium 44 MagnesiumDeficiencyCause starvation malabsorptionsyndromes protractedlossesofgastrointestinalfluid prolongedparenteralfluidtherapywithmagnesium freesolutions Acutepancreatitis diabeticacidosisduringtreatment primaryaldosteronism chronicalcoholism 45 MagnesiumDeficiencyThesignsandsymptomsThemagnesiumionisessentialforproperfunctionofmostenzymesystems anddepletionischaracterizedbyneuromuscularandCNShyperactivity whicharequitesimilartothoseofcalciumdeficiency 46 MagnesiumDeficiencyTreamientInasymptomaticpatients oralreplacement Severesymptomaticdeficit Theintravenousrouteispreferablefortheinitialtreatment Whenlargedosesaregivenintravenously theheartrate bloodpressure respiration andECGshouldbemonitoredcloselyforsignsofmagnesiumtoxicity whichcouldleadtocardiacarrest 47 MagnesiumExcessCause 1 Patientswithimpairedrenalfunction2 Early stageburns3 Massivetraumaorsurgicalstress4 SevereECFvolumedeficit5 Severeacidosis 48 MagnesiumExcesssignsandsymptomsinclude lethargyandweaknesswithprogressivelossofdeeptendonreflexes InterferencewithcardiacconductionECGchanges increasedP Rinterval widenedQRScomplex andelevatedTwaves resemblethoseseenwithhyperkalemia Somnolenceleadingtocomaandmuscularparalysisoccursinthelaterstages anddeathisusuallycausedbyrespiratoryorcardiacarrest 49 MagnesiumExcessTreatmentCorrectinganyacidosis ReplenishinganypreexistingECFvolumedeficitStopexogenouslyadministeredmagnesium Acutesymptomsmaybecontrolledbyslowintravenousadministrationof2 5to5mmol ofcalciumgluconate about10 calciumgluconate10 20ml Ifelevatedlevelsorsymptomspersist peritonealdialysisorhemodialysisisindicated 50 PhosphoniumAbnormalities About85 ofphosphoniumexiteinboneNormalserumphosphoniumlevel 0 96 1 62mmol LParticipatephosphorateofprotein cellmembrainandacid basebalance 51 Hypophosphatemia Cause Hyperparathyroidism severeburnorinfectionSyptom manifestationinnervous muscle Treatment administrationofsodiumglycerophosphate10ml 52 Hyperphosphatemia Cause acuterenalfailure Hypoparathyroidism acidosisSyptom likehypocalcemia ectopiccalcificationTreatment treatmentofhypocalcemia dialysis 53 Acid baseBalance Acidbase sourceandregulation Source Acidvolatile H2CO3 fixedacid Resp regul Renalregul 54 Alkalisaltamonia Acid baseBalance Source 55 AsidandAlkaliinbody volatileacid carbonicacid H2CO3 fixedacid H2SO4 H2PO4 ketobodies Acid Alkali HCO3 Hb Na2HPO4 NH3 56 Acid baseBalance IntracellularPH proteinsandphosphates ECFspace bicarbonate carbonicacidsystemredcellhemoglobinPHofbodyfluidsmaintainedbyseveralbuffersystemsandsubsequentlyexcretedbythelungsandkidneys 57 Acidbase sourceandregulation Bloodbuffer pH Reactquick 58 Regulationbylungandkidney 59 ExcreteH andreuptakeNaHCO3 Proximalnephron 60 Acid baseBalance 1 PH NormalbloodPH 7 35 7 452 PCO2 Normal 35 45mmHg 40mmHg 3 Buffuerexcess BE Representascidosisoralkolosis Normal 3 3mmol L 0 4 Actualbicarbonateradical AB actualHCO3 inplasma5 Standardbicarbonateradical SB HCO3 contentmeasuredwhenPaCO2 40mmHg HbO2 100 T 37 0 NormalAB SB 22 27mmol L average24mmol L 61 pH Conception NegativelogarithmofH concentrationinsolutionNormalvalue Arteryblood7 35 7 45Meaning Todistinguishacidosisoralkalosis 7 357 45 Acidosis 6 8 Alkalosis 7 8 death death pH 16nmol L 40 160 H 62 Hendeison HasselbalchequationpH pK logBHCO3 H2CO3 6 1 logHCO3 0 03 PaCO2 6 1 log24 0 03 40 6 1 log20 1 7 4PKrepresentsthedissociationconstantofcarbonicacidinthepresenceofbasebicarbonateHCO3 representthefactorofmetabolismPaCO2representthefactorofrespiration 63 Six SteptotheInterpretationofArterialBloodGasWithSerumSodium Potassium andChlorideConcentrations 64 Simpletype Metab alkalosis Metab acidosis Resp acidosis Resp alkalosis Thefourtypesofacid basedisturbances 65 Thefourtypesofacid basedisturbancesAcuteChronicpHPCO2HCO3 pHPCO2HCO3 RespacidNRespalkaNMetaacidNMetaalkaN 66 AcidosisandAlkalosisDefectCauseRespacidRetentionofCO2DepressionofrespiratoryRespalkaExcessivelossofCO2HyperventilationMetaacidRetentionoffixedacidsDiabetes diarrheaLossofbasebicarbonateLacticacidaccumulationMetaalkaLossoffixedacidsVomitingorgastricsuctionGainofbasebicarbonateExcessiveintakeofPotassiumdepletionbicarbonate 67 RespiratoryAcidosis HypoventilationPCO2iselevatedandplasmabicarbonateconcentrationisnormal Inthechronicform Pco2remainselevatedandbicarbonateconcentrationrisesasrenalcompensationoccurs Cause Airwayobstruction Foreignbody pneumonia emphysema CNS Depression injury tumor Thoracicinjury Pneumothorax flailchest tracheal Mechanicalventilation Inadequaterateand ortidalvolume 68 Mecanismofventilationdysfunction InhibitResp centerResp m paralysisThoraclungdisea AirwayobstructionMal ventilation 69 co2 o2 co2 co2 O2 HbHbO2 o2 o2 o2 co2 co2 Hb HbcO Externalrespiration Internalrespiration Airway Pulm alveolus bloodvessel Cell Respirationcourse 70 RespiratoryAcidosisSigns cheststuffy dyspnea restless cyanosisandheadachecausedbyhypoxia DeliriumevencomaExaminationlaboratoryrevealedadecreasedpH increasedPaCO2 HCO3 mayremainnormal 71 RespiratoryAcidosisTreatment Treatmentprimarydisorder Amelioratethepatient sventilationVentilatormaybeused 72 RespiratoryAlkalosiscauses Hyperventilationapprehension pain hypoxia CNSinjury assistedventilationTreatmentisdirectedprimarilytowardthecauseofthedisorder 73 MetabolicacidosisCause acutecirculatoryfailurewithaccumulationoflacticacid renalfailureretentionorproductionofacids diabeticketoacidosis lacticacidosis lossofbicarbonate diarrhea pancreaticorsmallbowelfistula 74 MetabolicacidosisThecausesofmetabolicacidosiscanbedividedintotwogroupsbydeterminingtheaniongap Normalaniongapandelevatedaniongap Thenormalvalueis10to15mmol L Theunmeasuredanionsthataccountforthegaparesulfateandphosphatepluslactateandotherorganicanions 75 153mmol L153mmol LcationsanionsNa 142Cl 104HCO3 27PO43SO4Organicacid5K 4Ca 5Protein14Mg 2Theaniongap 76 AG aniongap Na HCO3 AG Normalvalue 12mmol L Meaning AG Fixacid Metab Acid AG UA UC AG Na HCO3 Cl 77 metabolicacidosis Simple Feature AGNormal AG AG Normal 78 MetabolicacidosisSigns Inmildpatient maybeasymptomaticInseverepatient lassitude weakness restlessness deepandquickrateofrespirationIncreasedheartrate decreasedbloodpreasure cardiacarrhythmiasLossofreflexes comaDecreasedpH HCO3 79 Influence Simple Cardiovascularsystem Arrhythmia Cardiaccontract pH 7 2 80 compensation Simple Blood Lung Cell Kidney 81 MetabolicacidosisTreatment Treatmentprimarydisorder ReplenishinganypreexistingECFvolumedeficitInfusionwith5 NaHCO3100 250mlIntravenousadministrationofcalciumgluconateorcalciumchloride 82 MetabolicAlkalosisCausesarelossoffixedacidsorgainofbicarbonateandisaggravatedbyanyexistingpotassiumdeficit BoththepHandtheplasmabicarbonateconcentrationareelevated Compensationoccursprimarilythroughrenalmechanisms 83 InfluenceofMet Alkolosis 1CNS ExcitationMechanism 1 GABA 2 braintissuehypoxia2 Nerve Muscle Excitability Ca 3 K Hypokalemia4 Tissuehypoxia 84 Stomach duodenum Bloodvessel H2CO3 HCO3 H HCO3 H H H2CO3 H HCO3 Cl Na Na Cl Cl gastricfluidlossandmetab Alk Pancreas HCO3 Na esophagus 85 1 H Loss Stomach Vomit H H H H H H Simple 86 1 H Stomach Vomit H H H H H H Simple EntericcavityH PancreaticsecretionHCO3 Metablicalkolosis 87 MetabolicAlkalosisTreatment Treatmentprimarydisorder ReplenishinganypreexistingECFvolumedeficitIntravenousadministrationofKClIntravenousadministrationof0 1mmol L 1mol Lchlorideacid150ml saline1000ml 25 50ml h 88 SaltGainandLossesInanormalindividualthedailysaltintakevariesbetween50and90mmol 3to5gm assodiumchloride Balanceismaintainedprimarilybythekidneys whichexcretetheexcesssalt 89 SaltGainandLossesSodiumExchangeAverageSodiumGainDiet50 90mmol daySodiumlossSkin sweat 10 60mmol dayUrine10 80mmol dayIntestine0 20mmol day 90 FLUIDANDELECTROLYTETHERAPYlactatedRinger ssolution AgoodavailableisotonicsaltsolutionforreplacinggastrointestinallossesandECFvolumedeficits Thissolutionisphysiologicandcontains130mmol ofsodiumbalancedby109mmol ofchlorideand28mmol oflactate Lactateisusedinsteadofbicarbonate Thelactateisreadilyconvertedtobicarbonatebytheliverafterinfusion 91 PREOPERATIVEFLUIDTHERAPYPreoperativeevaluationandcorrectionofexistingfluiddisordersCorrectionofVolumeChanges VolumedeficitCorrectionofConcentrationChanges severesymptomatichyponatremiaorhypernatremiaCompositionandMiscellaneousConsiderations Correctionofpotassiumdeficits 92 INTRAOPERATIVEMANAGEMENTOFFLUIDSPreoperativereplacementofECFvolumeincompleteBloodlostduringtheoperativeprocedure usuallyunnecessarytoreplacebloodlossoflessthan500ml OtherECFlossesduringmajoroperativeprocedures edema fluidintheperitonealcavity 93 Someclin