英文班水电解质授课

1、 病病 例例 分分 析析 男性男性 2929岁，王岁，王XX,XX,因急性上腹部疼痛因急性上腹部疼痛 1212小时小时，急诊收住入院。诊断为重症急性胰腺炎。，急诊收住入院。诊断为重症急性胰腺炎。入院后病人主诉上腹部胀痛和极度口渴。入院后病人主诉上腹部胀痛和极度口渴。HR HR 150150次次/ /分，分，R 38R 38次次/ /分，分，BP 170/98mmHgBP 170/98mmHg，无，无尿。腹部体征示，压痛、反跳痛、严重的腹尿。腹部体征示，压痛、反跳痛、严重的腹胀，后背部有凹陷性水肿。诊断性穿刺游离胀，后背部有凹陷性水肿。诊断性穿刺游离腹腔内有棕褐色腹腔渗液，腹腔内有棕褐色腹腔渗液

2、， CTCT发现肠腔内有发现肠腔内有大量的液体积聚。大量的液体积聚。伴有水、电和酸、碱紊乱的程度伴有水、电和酸、碱紊乱的程度1 1 存在严重的脱水存在严重的脱水, ,如何补液？如何补液？2 2 第三间隙的液体急剧积聚，何为第三间第三间隙的液体急剧积聚，何为第三间隙？隙？3 Na3 Na+ + 155mmol/l, Cl 155mmol/l, Cl- - 115mmol/l, K 115mmol/l, K + + 6.5mmol/l, Ca 1.0mmmol/l6.5mmol/l, Ca 1.0mmmol/l，如何纠正？，如何纠正？4 4 伴有代谢性酸中毒、呼吸性碱中毒，如伴有代谢性酸中毒、呼吸

3、性碱中毒，如何处理？何处理？Fluid & ElEctrolytE Fluid & ElEctrolytE and acid-and acid-basE disturbancEsbasE disturbancEsEnqiang Mao Ph.D.Department of Surgery, Ruijin Hospital ,ShanghaiFig15Body Weight40Body Weight （Female 35）PO4-Na+Na+Na +CI- CI- HCO3- HCO3- K+K+K+protein5% Body WeightNa+ K+ ATPaseInters

4、titial Fluid (ISF)PlasmaIntracellular Fluid (ICF)Extracellular FluidIntracellular Fluid（ECF）（ICF）Anatomy of Body Fluids Compartments Mg2+ProteinHow to differentiate function and non-function interstitial fluids Function:Taking part in modulating the balance of body fluids.Non-function: Fluids in cav

5、ity in normal status.Including cerebrospinal ,joint,pericardium and abdominal cavity fluids.Third Space Definition: Pathophysiologicly,relatively nonfunctional extracellular fluid.Mainly for the change of quantity of nonfunctional ECF. Distribution:exudates in burns; ascites; soft tissue injuries. b

6、owel wall;peritoneum;infected lesions.Attention: not confused with the nonfunctioning components from interstitial fluid. The Concept of Osmotic Pressure Pressure leading to the shift of water through semi-permeable membranewaterwaterSemi-permeable membraneAnion and Cation as well as non-electrolyte

7、 particles Definition the number of osmotically active particles or ions per unit volume. Unit : milliosmoles per liter （mOsm / L） Plasma Osmotic Pressurecation mmol / L anion mmol / L Na+ 142 HCO- 27 K+ 5 CI- 103 Ca+ 2.5 HPO- 1 Mg+ 1.5 SO- 0.5 orgnic acid 6 Protein 0.8 Total 151 Total 138.3 3 3 -4

8、4 - 4 4 Normal Range =290310mOsm/LRelation between Osmotic pressure and distribution of body fluid Osmotic Pressure：Crystal OP and Colloid OP Plasma Crystal OP :Na+ contributes a major portion of OP Plasmatic Colloid OP：Plasma protein contributes a force leading to distribution of ECF Interstitial C

9、rystal OP：Contributes to the shift of extracellular and intracellular waterPlasmaInterstitial FluidICFECFNaNa+ +Colloid OP Plasmatic proteinCrystal OPCrystal OPSemi-permeable membraneCrystal OPCrystal OPColloid OPCrystal OPCrystal OPThe Regulation of Body Fluid Balance Maintaining normal osmotic pre

10、ssure Maintaining normal concentration & Integral dose of natrium Maintaining normal Volume (Blood-volume) Maintaining osmotic pressureposterior hypophysisA D H Distal renal tubules & collecting tubuleshypothalamusosmotic pressure receptor Sensitivity： ECF Osmotic pressure 12（6 mOsm）Release

11、of ADH Maintaining the concentration & Integral dose of natrium: Distal renal tublemacular densaadrenal cortexrenin angiotoninaldosterone Increased Nareabsorption & eliminating K、Decreased removing HCO3-、 acid urine Volume regulation(Blood-volume )Glomerulus paracell+Assaying CVP、AP& PAW

12、Prenin angiotoninadrenal cortexaldosteroneClassification of body fluid change(Four Types) Volume Changes(ECF) Volume DeficitVolume Excess Concentration ChangesHyponatremia Hypernatremia Mixed volume and Concentration AbnormalitiesECF Deficit and Excess with HyponatremiaECF Deficit and Excess with Hy

13、pernatremia Composition Changes Acid-base disturbances Potassium, Calcium, Magnesium abnormalitiesVolume Changes Isotonic ECF deficitEtiologies ( Acute )External-losses: gastrointestinal fluids due to vomiting, nasogastic suction, diarrhea, and digestive tract fistulaInternal-losses :sequestration (

14、Third Space）Soft tissue injuries and infection, burnsIntra-abdominal and retroperitoneal inflammationintestinal obstruction, bowel wall,peritonitis Clinical manifestations Seeing Table below Moderate Severe CNS Sleepiness Decreased tendon reflexesApathy Anesthesia of distal extremities Slow response

15、s Stupor Anorexia Coma Cessation of usual activity GI Progressive decrease in Nausea, Vomiting food consumption Refusal to eat Silent ileus and distention Moderate SevereCV Orthostatic hypotension Cutaneous lividity Tachycardia Hypotension Collapsed veins Distant heart sounds Collapsing pulse Cold e

16、xtremitiesTissue signs Soft,small tongue Atonic muscles longitudinal wrinkling Sunken eyes Decreased skin turgor(充盈充盈)Metablism Temperature Temperature Isotonic ECF deficitDiagnosis Etiology Clinical manifestation:Seeing Table mentioned above.LaboratoryIncreased RBC,WBC,PLT and plasma proteinIncreas

17、ed HCTNormal serum sodium & chloridehyperbaric urineIsotonic ECF deficit Fluid & electrolyte therapy To eliminate etiologies Quality of Solution - Isotonic sodium solution - Lactated Ringers solution Quantity hydropenic quantitycontinuous losses quantityRate and Goal To moderate BP & Pul

18、se rate Urinary Output 30 50 ml / hrIsotonic ECF excess Etiology Iatrogenic Secondary to renal insufficiencymajor operationSevere traumaInfection Renal vascular constrictionIncreased ADH & Aldosterone Retention ofsodium & waterIsotonic ECF excess Clinical manifestations Circulatory overload

19、Basilar rales Heart failure Tissue signs Subcutaneous pitting edema Isotonic ECF excess Fluid & electrolyte therapy Restriction of water & sodium Colloid + Diuretics Hypertonic diuresis: relieve cerebro-edema 20% mannitolMixed Volume and Concentration Abnormalities Hypotonic ECF deficit Cont

20、inues to drink water while losing large volumes of gastrointestinal fluids.The loss of a large amount of salt, such as via sweat, and kidney.Etiologies(Secondary)In the postoperative period when gastrointestinal losses are replaced with only 5% dextrone in water or hypotonic sodium solution.Hypotoni

21、c ECF deficit Clinical manifestations CNS signs increased intracranial pressure & secondary hypertension Tissue signs excessive intracellular water Digestive system: Vomiting, Nausea Hyponatremic states Clinical manifestations Shock:Progressing to oliguric renal failure promptly Asymptomatic Unt

22、ill the serum sodium falls below 120 mmol/LOne important exception Closed head injury, in which mild hyponatremia may be extremely deleteriousHypotonic ECF deficit -Diagnosis Etiology LaboratorySerum sodium concentration 135 mmol/LDecreased urinary sodium and Hypobaric urine（ 1.010）Increased HCT and

23、 serum BUN & NPN Clinic manifestation Serum sodium (mmol/L) NaCl deficit ( g/kg ) Mild Symptomless 131135 0.5 Moderate Increased ICP (compensated) 130121 0.50.75 Severe Increased ICP (decompensated) 120 0.751.25 Clinical ManifestationMild or moderate hyponatremia Fluid & electrolyte therapy

24、Eliminating etiologies Quality of solution: NS、5%GNS and or 10%NaclSevere hyponatremia Fluid & electrolyte therapy TBW (liters) =Body weight ( kg )0.6 (female 0.5) Sodium deficit (mmol)= Serum sodium (standardactual)TBW Total Amount:Half of sodium deficit + Requisite amount per day Quality:5%sod

25、ium chloride solution (2/3) + Isotonic sodium chloride (1/3) Shock colloid: crystalloid=1:23Convulsions or coma 5%NaCl 100 250 ml Rate of increment of sodium is 0.51mmol/L/h; and no more than 12 mmol/L within 24 hs.Complication:Osmotic Demyelination Syndrome(ODS). Pontine demyelination (桥脑脱桥脑脱髓鞘样变髓鞘

26、样变)Management of severe acute and chronic hyponatremia EFW: electrolyte free waterTherapy for Severe Acute hyponatremia Aim: Shrink the size of brain cells with hypertonic saline Na+120mmol/L, having seizures. To raise the plasma Na+ by 5mmol/L during the next hour.Raising Na + to 130mmol/L at 12mmo

27、l/h; and 12mmol/L within 24 h.How to calculate the amount of 10NaCl per hour Raising Na + /h Kg 0.6(女女0.5)= the amount of mmol of NaClTherapy for Severe Chronic hyponatremia Convulsion or Coma: PNa rise 5mmol/L in 2-3 hours No convulsion: - PNa rise 150mmol/L) & HCTHyperbaric urineClinical Manif

28、estationExtremely thirstyHigh feverOliguriaHypertonic ECF deficit Fluid & electrolyte therapy Principles -Adopting 5 GS , 0.45% NaCl , water via intestine -Half of volume deficit Requisite amount per day MeasuresWith loss 1% body weight，infusing 400500mlsupplemental quantities (ml)= actual serum

29、 sodium normal serum sodium (mmol/L)body weight (kg) 4 Classification of ECF changes ECF deficit ECF excess Isotonic normal Na+ normal Na+ hypotonic hyponatrium hyponatrium hypertonic hypernatrium hypernatrium Composition ChangesHypokelamia(3.5mmol/L) Common cause Excessive excretion: Kidney ; Diges

30、tive tract ( Vomiting, Diarrhea, Gastric suction, Intestinal fistula )Less in-take: Less dietary intake ; potassium-free parenteral fluids RedistributionThe transfer of extracellular potassium into cells（Alkalosis） 2K+1H+3Na+CellH+HCO3- =H2O+CO22K+1H+3Na+ General: Anorexia,Nausea,Vomiting Skeletal m

31、uscles (Diminished to absent tendon reflexes, respiratory hypoventilation) Smooth muscles(Paralytic ileus ) Cardiac muscles (Hypotension)Hypokelamia Clinical manifestations Muscular weakness Flaccid paralysis ( k + 2.5mmol / L） CNS（Serum potassium2.0mmol/L） MorbusObnubilation(神志不清神志不清)、disorientatio

32、nHypokelamia Clinical manifestationsCardiovascular ECG: ST segment depression, decreased T wave, Increased U wave, T 5.5mmol/L) Common causesRenal excretion decreasedAbnormal distribution AcidosisAcute tumor lysis, burn, Acute intravascular hemolysisgastrointestinalNausea & vomitingIntermittent

33、colic & diarrheaParesthesia(感觉异常感觉异常) & WeaknessHyperkelamia Clinical manifestationsCardiovascularBradycardiaMicrocirculatory dysfunction ( Be cold, cyanosis, pale and hypotension) EKGShortening of QT interval and high peaked T wave Widened QRS , PR interval prolongation disappearance of P w

34、ave degeneration of the QRS to a sine wave pattern Ventricular asystole(心搏停止心搏停止) or fibrilationHyperkelamia Clinical manifestations Any inexplicable symptoms ECG Serum potassium ion 5.5mmol/LHyperkelamia Diagnosis Withholding of exogenously administered potassium correction of the underlying cause

35、Anti- arrhythmia - 10% Calcium gluconate infusedHyperkelamia TreatmentLowering of serum potassium - Transfer potassium into cells（5% NaHCO3;11.2% Sodium lactate, GI- diuretics - Cation-exchange resins (oral ; maintaining clysis)- peritoneal dialysis, or hemodialysis, hemofiltration高钾血症高钾血症EKGEKG变化？变

36、化？1010分钟内起效？分钟内起效？静脉推注葡静脉推注葡酸钙酸钙去除病因去除病因转移到细胞内：转移到细胞内：胰岛素胰岛素NaHCONaHCO3 3泌尿系统泌尿系统测尿钾测尿钾胃肠道胃肠道减少口服减少口服离子交换树脂口服或离子交换树脂口服或灌肠灌肠尿钾低尿钾低血液透析血液透析增加尿钾排出：增加尿钾排出：盐皮质激素盐皮质激素NaHCONaHCO3 3乙酰唑胺乙酰唑胺是是不不Disturbances of CalciumHypocalcemia(4.0mmol/L) Causes:hyperparathyroidism; Bony Metastasis Manifestations:Fatigue;

37、 Vomiting Treatment: EDTA; Na2SO4Acid-base imbalanceBuffer system A weak acid or base & the salt of that acid or baseIntracellular Extracellular Red cellB.Protein/H.Protein B.HCO3/H2CO3 B.Hb/HHbB2HPO4/ BH2PO4 B.HbO2/HHbO2Anion Gap=Na+Cl-+HCO3- Assumption:pre- existing potassium depletion Outcome

38、:Intracellular (3 K)and extracellular ( 2Na+、1 H+ ) exchangeIn the regulation of acid-base balance The important role of potassium Decreased H+ and K+ exchange, Increased H+ and Na+ exchange in renal tubuleParadoxical acid urine Metabolic alkalosis is aggravated Sensible acids are excreted via the l

39、ung HCINaHCO3 NaCIH2CO3 H2O CO2 The important role of the lung Insensible acids excreted by kidney Inorganic acid anions （hydrochloric、sulfuric、phosphoric acids） with hydrogen（H+Na+ exchange） ammonium salts（H+NH3NH4-）The important role of the kidneyorganic acid anions（lactic、keto、pyruvic acids） Be m

40、etabolizedSome renal excretion（with high levels） BHCO3- pHpKlog H2CO3 27mmol/L 6.1log 1.35mmol/L 2 0 6.1log 1 6.1 1.3 = 7.4Henderson - Hasselbalch equationHenderson - Hasselbalch equation氧离曲线与组织的缺氧氧离曲线与组织的缺氧 Bohr Bohr 效应（效应（H H+ + 、COCO2 2、O O2 2三者与三者与HbHb的关系）的关系） H HHbOHbO2 2+H+H+ +CO+CO2 2 Hb +O H

41、b +O2 2 CO2 CO2组织组织肺部肺部氧饱和度氧饱和度(SaO(SaO2 2) )氧分压氧分压 (PaO(PaO2 2) )正常正常右移右移左移左移HbOHbO2 2的的O O2 2解离曲线解离曲线(S(S型型) )Defects Causes Compensation BHCO3-/H2CO3 Retention of Fixed acids (Anion gap increased) Diabetes, Starvation Lactic acid, Azotemia Pulmonary(rapid): increased rate and depth of breathing 2

42、0 1（Numerator） Metabolic Acidosis(pH7.35) DefectsLoss of base bicarbonate(Anion gap normality)CauseDiarrhea, Small bowel , pancreatic fistulasCompensationRenal(slow): Retention of HCO3-,Excretion of acid salts, ammonia formation,Chloride into RBC Metabolic acidosis Clinical manifestations Increased

43、in depth & frequency of respiration (Kussmaul breathing) Peripheral vessels dilated ，Circulatory shock, Cerise lip Decreased muscular tension & tendon reflex mergedUnconsciousness Metabolic acidosis Treatments Principles Therapy for basic disease Alkali treatment: dose initials 1 / 3 1 / 2 r

44、equisite amount Pre-treatment: serum K+ & Ca+The amount of Alkali necessary-（normal CO2-CP serum CO2-CP）TBW（Kg）0.4-（BE3）BW（Kg）0.4-（normal SB observed SB）BW（Kg）0.4Loss of base ( mEq )Metabolic acidosis TreatmentSome of alkalescent solution contains HCO 3 - 1 gm NaHCO312 mmol HCO3 -1ml - 11.2%NaC3

45、H5O31 mmol HCO3 -1ml - 3.63%THAM(三羟甲基氨基甲烷三羟甲基氨基甲烷)0.3 mmol HCO3 -Metabolic acidosis TreatmentRespiratory Acidosis(pH7.45)Defect Common Cause Compensation BHCO3/H2CO3 Loss of fixed acids Vomiting or gastric suction with pyloric Pulmonary (rapid):decreased rate & 20 1 Gain of base bicarbonate Pota

46、ssium,chloride of depletion obstruction Excessive intake of bicarbonate Diuretics depth of breathing Renal (slow):Excretion of bicarbonate, retention of acid salts, decreased ammonia formation （Numerator） Peripheral vessel constricted Mental symptoms:Delirium,DrowsinessMetabolic alkalosis Clinical manifestationsDecreased in depth & frequency of respiration Tetany &am