酸碱平衡医学知识讲座培训课件

酸碱平衡医学知识讲座2OUTLINE（内容提要）BodyFluid（体液）WaterandSodiumDisorders（水钠失衡）DisturbanceofPotassiumMetabolism（钾代谢失衡）Acid-baseBalance（酸碱失衡）酸碱平衡医学知识讲座3Section1BodyFluidSection1BodyFluid（体液）酸碱平衡医学知识讲座4Bodyfluid’sattributes

体液的属性Volume容积Ingredients:electrolytes成分Osmoticpressure渗透压Powerofhydrogen酸碱度酸碱平衡医学知识讲座5Bodyfluid’sVOLUME（体液的容积）Bodyfluidsconstitute55-60%ofbodymass酸碱平衡医学知识讲座6Bodyfluiddistribution（体液的分布）TWOcompartmentsICF细胞内液(2/3TBF,40%TBW)ECF细胞外液(1/3TBF,20%TBW)Plasma血浆(1/4ECF,5%TBW)Interstitialfluid组织间液(3/4ECF,15%TBW)酸碱平衡医学知识讲座7Developmentinbodyfluidproportion

年龄性别的差别AgeNeonate12-14adultTotalfluid80706560ICF35404040ECF45302520Plasma5555Interstitialfluid40252015HigherinyoungHigherinmalesDifferenceinmuscleandfat酸碱平衡医学知识讲座8Dailywatergainandloss

每日水的摄入和丢失Watergain1500ml~60%Drink750ml~30%Food150ml~10%metabolicwaterWaterloss1500ml~60%urine600ml~28%sweatandevaporation300ml~8%respiration100ml~4%stoolIndailylife,ahealthadultmanusuallyexchangeabout2500mlofthebodyfluidtotheenvironment.酸碱平衡医学知识讲座91532002001541531541421421504534324010103114150273010351635140Bodyfluid’sIngredients:

Electrolytes（电解质）Payattention:ThedominatingcationoftheECFisNa+ThedominatingcationoftheICFisK+酸碱平衡医学知识讲座10Howtodifferentiatefunctionandnon-functioninterstitialfluids

功能性和非功能性组织间液Function:Takingpartinmodulatingthebalanceofbodyfluids.参与体液平衡调节Non-function:Fluidsincavityinnormalstatus.Includingcerebrospinal,joint,pericardiumandabdominalcavityfluids脑脊液、关节液、心包夜、腹腔液酸碱平衡医学知识讲座11ThirdSpace（第三间隙）Definition:

Pathophysiologically病理生理,relativelynon-functionalextracellularfluid细胞外液.Mainlyforthechangeofquantityoffunctionalandnon-functionalECF.Distribution:分布

exudatesinburns烧伤渗出;ascites腹水;softtissueinjuries软组织损伤;bowelwall肠壁水肿;peritoneum腹膜;infectedlesions感染.酸碱平衡医学知识讲座12Regulationofwaterandelectrolytes

水电解质的调节酸碱平衡医学知识讲座13OsmoticPressure（渗透压）OsmosisisthediffusionofwateracrossamembraneHYPERTONIC（高渗的）HYPOTONIC（低渗的）ISOTONIC（等渗的）酸碱平衡医学知识讲座14酸碱平衡医学知识讲座15酸碱平衡医学知识讲座16NormalRange=290~310mOsm/Lcationmmol/Lanionmmol/LNaKCaMg14252.51.5HCO3ClHPO3SO3OrgnicacidProtein2710310.5616Total151Total153.5PlasmaOsmoticPressure

血浆渗透压酸碱平衡医学知识讲座17RelationbetweenOsmoticpressureanddistributionofbodyfluid

（渗透压与体液分布）

OsmoticPressure：

Crystal（晶体）OPandColloid（胶体）OPPlasmaticCrystalOP:血浆晶体渗透压

[Na+]contributestoamajorportionofOP酸碱平衡医学知识讲座18PlasmaticColloidOP：血浆胶体渗透压

PlasmaproteincontributesaforceleadingtodistributionofECFInterstitialCrystalOP：组织间隙晶体渗透压

ContributestotheshiftofextracellularandintracellularwaterRelationbetweenOsmoticpressure

anddistributionofbodyfluid

渗透压与体液分布酸碱平衡医学知识讲座19Regulationofvolume&osmoticpressure

（容量与渗透压的调节）Regulationofbodyfluidgaindependsmainlyonvariationoforalintake

Regulationofbodyfluid(&solute)lossdependsmainlyonurinaryexcretion体液渗透压调节三种机制酸碱平衡医学知识讲座201.Neuralregulation神经调节

Hypothalamicosmoreceptor下丘脑渗透压感受器

Hydropenia缺水/overdoseNa+

高钠Serumosmoticpressure↑血清渗透压Hypothalamicosmoreceptor(Thirstcenter)

下丘脑渗透压受体ThirstanddrinkRecovernormal

OsmoticpressureSympatheticnervestimulated刺激交感神经酸碱平衡医学知识讲座212.Endocrinicregulation内分泌调节

Hypothalamus-Posteriorpituitary-ADH

下丘脑-垂体后叶-抗利尿激素Dehydration脱水Serumosmoticpressure

血清渗透压Hypothalamus-Posteriorpituitary-Antidiuretichormone

下丘脑-垂体后叶-抗利尿激素Distalconvolutedtubulereabsorptionofwater↑

远曲小管重吸收水NormalOsmoticpressure酸碱平衡医学知识讲座223.Renin-Angiotensin-Aldosterone

肾素-血管紧张素-醛固酮系统

Bloodvolume↓Bloodpressure↓Na+sensorinmaculadensaofdistalconvolutedtubuleglomerularcellssecreteRenin

AngiotensinIthenIIArteriolecontractPressurereceptorsinrenalglomerulusSympatheticnerveexcitedZonareticularisofadrenalcortexsecreteAldosteroneNormal

BloodvolumeDistalconvolutedtubulesecreteK+/H+,reabsorbNa+/Cl-/H2O酸碱平衡医学知识讲座23Section2WaterandSodiumDisorders

Section2DisordersofWaterandelectrolyte

水电解质紊乱酸碱平衡医学知识讲座24Classificationofbodyfluidandelectrolytedisorder(FourTypes)

水电解质紊乱分类VolumeChanges(ECF)

容量改变

VolumeDeficit；VolumeExcess

ConcentrationChanges浓度改变

Hyponatremia；HypernatremiaMixedvolumeandConcentrationAbnormalities混合改变

ECFDeficitandExcesswithHyponatremiaECFDeficitandExcesswithHypernatremia

CompositionChanges

成分改变

Acid-basedisturbancesPotassium,Calcium,Magnesiumabnormalities酸碱平衡医学知识讲座25HYPERTONICWATERDEFICIT高渗性脱水Hypernatremia:

高钠血症

[Na+]>145mmol/L酸碱平衡医学知识讲座26Etiology(Primary)病因Restrictedwaterintakeandmuchwaterlossincircumstances:水摄入不足、丢失过多Dysphagia吞咽困难

SweatBurnDiabeticcomaHighfever酸碱平衡医学知识讲座27CLINICALMANIFESTATION

临床表现CharacteristicWaterloss>Na+lossIntracellulardehydrationThirst,myospasm,Classification(waterloss)Mild:2~4%Moderate:4~6%Severe:>6%,braindisorderdecreasedelasticityofskin酸碱平衡医学知识讲座28TREATMENT治疗Removecauses5%glucose/0.4%NaCl400~500ml/1%lossofBWWater(ml)=∆[Na+](examined–normal)(mmol/L)×BW(kg)×4½ofcalculatedvolume+dailyrequirement(2000ml)K+whenurine>40ml/hNaHCO3inacidosis酸碱平衡医学知识讲座29ExampleMale,60kg,[Na+]152mmol/LWaterreplenishment(ml)=(152-142)×60×4=2400mlGivinghalfofcalculatedvolumerespectivelyin2daysNa+,K+,acid-baseimbalance酸碱平衡医学知识讲座30ISOTONICWATERDEFICIT

等渗性脱水

(Normalsodiumconcentration)酸碱平衡医学知识讲座31Etiologies(Acute)病因External-losses:

外部丢失gastrointestinalfluidsduetovomiting，nasogastricsuction，diarrhea,anddigestivetractfistula（消化道瘘）Internal-losses:内部丢失sequestration扣押

(ThirdSpace）

Softtissueinjuriesandinfection,burnsIntra-abdominalandretroperitoneal（腹膜后）

inflammationintestinalobstruction,peritonitis酸碱平衡医学知识讲座32CLINICALMANIFESTATION

临床表现Dehydrationsymptom脱水5%ofTBW(20%ofECF)fluidlossShock休克6~7%ofTBW(24~28%ofECF)fluidlossMetabolicacidosis代谢性酸中毒Severeshock酸碱平衡医学知识讲座33TREATMENT治疗RemovecausesFluidtherapyHypovolemia低血容量:Balancesaltfluid3000mlrapidinfusiontorecoverbloodvolumeNormalvolume正常血容量:1500~2000mlBSFrapidinfusionORIsotonicfluid(ml)=∆/NormalHCT×BW(kg)×0.25酸碱平衡医学知识讲座34ExampleMale,60kg,HCT54%Isotonicfluid=[(54-48)/48]×60×0.25=1875ml* BSF1.86%Sodiumlactate:Ringer’sfluid=1:21.25%NaHCO3:Isotonicsaline=1:2酸碱平衡医学知识讲座35HYPOTONICWATERDEFICIT(低渗性脱水)

Hyponatremia:

低钠血症

[Na+]<135mmol/L酸碱平衡医学知识讲座36Etiologies(Secondary)病因Continuestodrinkwaterwhilelosinglargevolumesofgastrointestinalfluids.Thelossofalargeamountofsalt,suchasviasweat,andkidney.Inthepostoperativeperiodwhengastrointestinallossesarereplacedwithonlyhypotonicsodiumsolution.

丢盐多过丢水酸碱平衡医学知识讲座37CLINICALMANIFESTATION

临床表现Mildsodiumdeficit:Symptom0.5gNaCl/Kg,[Na+]<135mmol/LModeratesodiumdeficit:Shock0.5~0.75gNaCl/Kg,[Na+]<130mmol/LSeveresodiumdeficit:Mentalsymptom0.75~1.25gNaCl/Kg,[Na+]<120mmol/L酸碱平衡医学知识讲座38TREATMENT治疗RemovecausesMildtomoderatesodiumdeficitNaCl(g)=EstimatedNaClloss(g/kgBW)×BW(kg)Example:Male,60kg,[Na+]135mmol/LNaCl=0.5g×60=30g5%GNSinfusion2000ml+dailyrequirement2000ml,nextdayforanotherhalf酸碱平衡医学知识讲座39TREATMENTSeveresodiumdeficitRapidreplenishment: Hypertonicsaline(5%NaCl)200~300mlFormularreplenishment: NaCl(g)=∆[Na+](Normal–Examined)

(mmol/L)×BW(kg)×0.6(0.5,female)/17*17mmolNa=1gNaCl酸碱平衡医学知识讲座40ItiswisetoReplenishalkalinefluidwhenaccompaniedbyacidosis伴酸中毒时补碱1.25%NaHCO3100~200mlBalancedsalinefluid200mlUseCrystal:colloid晶胶比attheratioof2~3:1酸碱平衡医学知识讲座41ExampleFemale,55kg,[Na+]118mmol/LNaCl=(142-118)×55×0.50/17=39g1stday:Half(19.5)2/3(13g)≈5%NaCl300ml1/3(6.5)≈0.9%NaCl1000ml2ndday:HalforReassessbymoreexamination酸碱平衡医学知识讲座42Compareofthreekindsof

WATERDEFICIT

三种脱水的比较

酸碱平衡医学知识讲座43CAUSESHypertonicwaterdeficitIsotonicwaterdeficitHypotonicwaterdeficitGain↓WaterintakedecreasesAcutegastrointestinallossIsotonicdehydrationwithmorewaterplacementLoss↑MuchwaterlossFluidintoinfectedareaContinuallossofgastrointestinaljuiceMajorwoundareachronicexudationExcessexcretionsodiumfromkidney酸碱平衡医学知识讲座44PATHOPHYSIOLOGYHypertonicwaterdeficitIsotonicwaterdeficitHypotonicwaterdeficitH2O/Na+balanceWaterloss>Na+lossWaterloss=Na+lossWaterloss<Na+lossWaterflow→ECFECF←→ICF→ICFECF/ICFICF↓ECF↓/ICF↓ECF↓Bloodvolume≈→↓↓↓酸碱平衡医学知识讲座45CLINICALMANIFESTATIONHypertonicwaterdeficitIsotonicwaterdeficitHypotonicwaterdeficitMaindeficitwatersodium&watersodiumThirst++-+Nausea&vomiting-+++Myospasm+++-Othostaticgiddiness-+++Bp≈→↓↓↓↓酸碱平衡医学知识讲座46LABORATORYEXAMINATIONSHypertonicwaterdeficitIsotonicwaterdeficitHypotonicwaterdeficitUrinevolume↓↓↓-UrinespecificG↑-↓UrineCl--↓↓↓SerumNa+↑Normal↓Pachyhemia血液浓缩≈→↑↑↑↑↑酸碱平衡医学知识讲座47TREATMENTHypertonicwaterdeficitIsotonicwaterdeficitHypotonicwaterdeficitFluidinfusionHypotonicsaline/GlucoseIsotonicsaline/BalancedsalineHypertonicsalineFormula:BW(kg)[Na+](mmol/L)H2O(ml)=∆[Na+](examined-normal)×BW×4Isotonicsaline(ml)=∆/

normal

Hct×BW×0.25Na+(mmol)=∆[Na+](normal-examined)×BW×0.60(female0.50)酸碱平衡医学知识讲座48

Waterintoxication水中毒

(Dilutushyponatremia稀释性低钠血症)

Retentionofwaterinthebody[Na+]isdecreased

IntracranialpressureisincreasedhighlyManagementStoppinginfusionofwaterDiuresis利尿

Negativebalanceofwater酸碱平衡医学知识讲座49IsotonicECFexcess

等渗性细胞外液过多酸碱平衡医学知识讲座50Etiology病因Iatrogenic

医源性Secondarytorenalinsufficiency继发于肾功能不全MajoroperationSeveretraumaInfectionRenalvascularconstrictionIncreasedADH&Aldosterone

Retentionofsodium&water酸碱平衡医学知识讲座51Clinicalmanifestations

临床表现Circulatoryoverload

Basilarrales（肺底罗音）

HeartfailureTissuesigns

Subcutaneouspittingedema酸碱平衡医学知识讲座52Fluid&electrolytetherapy治疗Restrictionofwater&sodium

限制水钠Colloid+Diuretics

胶体+利尿Hypertonicdiuresis:

高渗利尿relievecerebro-edema：20%mannitol减轻脑水肿：甘露醇酸碱平衡医学知识讲座53Section3Potassium

PotassiumdisordersDisordersofPotassium,Calcium,Magnesium钾、钙、镁异常Section3酸碱平衡医学知识讲座54DisordersofPotassium

钾代谢异常ThepotassiuminECFconstitutesonly2%oftotalbodypotassium98%potassiumiswithinICFTheserumpotassiumconcentrationisdeterminedprimarilybythepHofECFandthesizeoftheintracelluarK+poolWhenacidosis,anexchangeofintracellularK+forextracellularH+,maycausehyperkalemiaAlkalosishasanoppositeeffect酸碱平衡医学知识讲座55Hypokalemia(K+<3.5mmol/L)

低钾血症Commoncause

Excessiveexcretion:

排出增加Kidney;Digestivetract(Vomiting,Diarrhea,Gastricsuction,Intestinalfistula)Lessin-take:摄入减少Lessdietaryintake;potassium-freeparenteralfluidsRedistribution

再分布Thetransferofextracellularpotassiumintocells（Alkalosis）酸碱平衡医学知识讲座56

2Na+1H+3K+CellH++HCO3-=H2O+CO22Na+1H+3K+酸碱平衡医学知识讲座57Clinicalmanifestations

临床表现General:Anorexia,Nausea,VomitingSkeletalmuscles

(Diminishedtoabsenttendonreflexes,respiratoryhypoventilation)Muscularweakness→Flaccidparalysis(K+

<2.5mmol/L）Smoothmuscles(Paralyticileus麻痹性肠梗阻

)Cardiacmuscles(Hypotension)酸碱平衡医学知识讲座58CNS（Serumpotassium＜2.0mmol/L）

Morbus→Obnubilation、disorientation

无力，神志不清，定向障碍Cardiovascular

ECG:STsegmentdepression,decreasedTwave,IncreasedUwave,T<U

Arhythmia:PrematureventricularandatrialcontractionsventricularandatrialtachyarhythmiasClinicalmanifestations酸碱平衡医学知识讲座59Diagnosis诊断HistoryClinicalsymptomsSerumpotassium＜3.5mmol/LECG酸碱平衡医学知识讲座60Treatment治疗ThequantitiesofsupplementalpotassiumSerumpotassium＜3mmol/L.Toreplace200～400mmol，Maybeincreasedby1mmol/LSerumpotassium3～3.5mmol/LToreplace100～200mmol，Maybeincreasedby1mmol/LTherateofadministration(intravenous)Shouldnotexceed20mmolK+

/hr1gKCI=13.4mmolK+

酸碱平衡医学知识讲座61

Attention：

Infusionspeed<20mmolK+/h,速度concentration<40mmol/L(KCL3.0g)浓度Calciumnotinfused先不补钙Treatment酸碱平衡医学知识讲座62

Hyperkalemia

高钾血症

(K+＞5.5mmol/L）酸碱平衡医学知识讲座63Commoncauses病因Excessivepotassiumenteredintobloodcirculation摄入过多----Infusionofexcessivepotassium----InfusionofavastreserveofbloodRenalexcretiondecreased排出减少

----acuterenalfailure----K+retentiondiureticsAbnormaldistribution异常分布----Acuteintravascularhemolysis----Acidosis酸碱平衡医学知识讲座64Regulationof[K+]:K+-H+exchange酸碱平衡医学知识讲座65Clinicalmanifestations临床表现Gastrointestinal----Nausea&vomiting----Intermittentcolic&diarrheaParesthesia感觉异常&WeaknessCardiovascular----Bradycardia----Microcirculatorydysfunction(cold,cyanosis,paleandhypotension)酸碱平衡医学知识讲座66ClinicalmanifestationsECG--highpeakedTwave--P-Rintervalprolongation--WideningoftheQRScomplex--DepresssionoftheSTsegment---Ventricularasystoleorfibrilation

酸碱平衡医学知识讲座67Diagnosis诊断CausesClinicalmanifestationECGSerumpotassiumion>5.5mmol/L酸碱平衡医学知识讲座68Treatment治疗Withholdingofexogenouslyadministeredpotassium停止摄入Correctionoftheabovecauses纠正病因Anti-arrhythmia抗心律失常

-10%Calciumgluconateinfused酸碱平衡医学知识讲座69Loweringofserumpotassium

降低血钾----Transferpotassiumintocells

（5%NaHCO3;11.2%Sodiumlactate；

50%Glucose+RI,1u/3-4gglucose)----Diuretics----Cation-exchangeresins(oral，clysis)----Peritonealdialysis,orhemodialysis

腹膜或血液透析

Treatment酸碱平衡医学知识讲座70Peritonealdialysis,orhemodialysis

腹膜透析，血液透析酸碱平衡医学知识讲座71HyperkelamiaECGchange？Effectin10mincalciumgluconateIV.RemovecauseInsulinNaHCO3UrinarysystermurinepotassiumgastrointestinalDecreaseoralionexchangeresin,coloclysishemodialysisyesno酸碱平衡医学知识讲座72酸碱平衡医学知识讲座73DisordersofCalcium

Hypocalcemia低钙血症(<2.0mmol/L)血液中钙以三种形式存在：与血浆蛋白结合（40%）、离子钙（50%）、与磷酸根硫酸根枸橼酸根结合(10%)酸碱平衡医学知识讲座74HypocalcemiaCauses病因acutepancreatitis胰腺炎;renalfailure;肾衰intestinalfistula;肠瘘Infusionofavastreserveofblood(citricacid)输入大量库存血bloodpurification血液净化

酸碱平衡医学知识讲座75Manifestation临床表现－Symptoms:numbness;麻木

tingling;激动

Apnea;－Signs:HyperactivetendonreflexesChvostek’sSignspositive（轻扣面神经时面肌痉挛）

convulsions

酸碱平衡医学知识讲座76HypocalcemiaTreatment治疗10%calciumgluconate葡萄糖酸钙5%CalciumChloride氯化钙酸碱平衡医学知识讲座77Hypercalcemia高钙血症(>4.0mmol/L)Causes:hyperparathyroidism甲状旁腺功能亢进;BonyMetastasis肿瘤骨转移Manifestations:Fatigue;Vomiting；comaTreatment:Enhanceca++excretion;EDTA;Na2SO4;Calcitonin酸碱平衡医学知识讲座78Magnesiumdeficiency

低镁血症(<0.7mmol/L)Causes:intaking/absorptionManifestations:Pale/excited/Fret焦急Treatment:25%MgSO4酸碱平衡医学知识讲座79Hypophosphatemia

低磷血症

(<0.96mmol/L)Causes:Burn/Pancreatitis烧伤/胰腺炎Manifestations:Emotionaldisturbance情绪障碍Treatment:Glycophosphate，

KH2PO4)及Na2HPO4的混合剂酸碱平衡医学知识讲座80Section4

Acid-baseimbalanceAcid-baseimbalance酸碱失衡Section4酸碱平衡医学知识讲座81understandingthedatainabloodgaspanelrequiresanappreciationfornotonlyacidsandbases,butalsoventilation,gasexchange,dynamicsofelectrolyteandwatermovement,plasmacomposition,respiratorycontrol,andrenalmechanismsofhydrogenion,electrolyte,andwaterexcretion.“理解血气分析数据不仅需要懂得酸和碱平衡，而且要理解通气，气体交换，水电解质运动，血浆成分，呼吸控制，和肾脏的氢离子、电解质和水的排泄的机制。

from:RawsonRE&QuinlanKM,AdvPhysiolEduc2002;26:85-97酸碱平衡医学知识讲座82Acid-basebalance酸碱平衡1234酸碱平衡医学知识讲座83Keybloodbufferpair

血液缓冲系统Keybufferpair H2CO3

(bufferacid):

HCO3-

(bufferbase)KeybioreactionH++HCO3-←→H2CO3←→CO2+H2O酸碱平衡医学知识讲座84酸碱平衡医学知识讲座852.Lung:RegulatingCO2

肺的调节作用H2CO3<==>CO2+H20酸碱平衡医学知识讲座863.Kidney:肾的调节作用

RegulatingHCO3-andH+LosingHCO3-=GainingH+/ReabsorbingHCO3-=LosingH+酸碱平衡医学知识讲座87Henderson-Hasselbalchequation

NormalrangeofpH:

7.35-7.45PH7.4=40nmolH+/LNormal酸碱平衡医学知识讲座88Fourtypesofacid-baseimbalance

四个酸碱失衡类型MetabolicAcidosisMetabolicAlkalosisHCO3-_________H2CO320:1RespiratoryAcidosisRespiratoryAlkalosisH++HCO3-==H2CO3

==CO2+H2O↓↓↑↑酸碱平衡医学知识讲座89Changesindifferentacid-basedisturbancesHCO3-PaCO2HCO3-———H2CO3pHMetabolicacidosis↓↓Nor↓↓↓Metabolicalkalosis↑↑Nor↑↑↑RespiratoryacidosisNor↑↑↑↓↓RespiratoryalkalosisNor↓↓↓↑↑酸碱平衡医学知识讲座90METABOLICACIDOSIS

代谢性酸中毒

(PrimarilyHCO3-↓pH<7.35)酸碱平衡医学知识讲座91CAUSES病因H+

↑frommetabolicorothercauses(AG↑)

代谢或其他因素造成H+产生增加Shock,anoxiaandischemia→lacticacidosisDiabetesmellitus→ketoacidosis酮症酸中毒RenalexcretingH+dysf.:AcidosisfromdistalconvolutedtubuleHCO3-losses(AGnormal)HCO3-丢失Diarrhea,intestinal,biliary,pancreaticfistulaUreterosigmoidostomy结肠代膀胱:CL-→ECF,HCO3-→urineRenalreaborptingHCO3-

dysf.:Acidosisfromproximalconvolutedtubule酸碱平衡医学知识讲座92AnionGap(AG)阴离子间隙

指血浆中未测定的阴离子(UA)与未测定的阳离子(UC)浓度间的差值

AG =Na+-(Cl-+HCO3-)NormalAG:10~15mmol/L酸碱平衡医学知识讲座93CLASSIFICATIONAGnormal:HCO3-losses，increasedinCl-AGincreased:H+productionincreasedfrommetabolicorothercauses

酸碱平衡医学知识讲座94PATHOPHYSIOLOGY病理生理学Lung↑toexpireCO2→PaCO2↓KidneysecreteH+↑&retainHCO3-↑HCO3-:H2CO3-≈20:1酸碱平衡医学知识讲座95CLINICALMANIFESTATION

临床表现RespiratorysystemRapidanddeeprespiration,KetoneodorinexpiredgasCardiovascularsystemReddishflushface,HR↑,Bp↓,arrhythmiaNeuralsystemFatigue,dizziness,somnolence嗜睡,restlessness躁动,comaOthersAcidicurine,renalfailure,shock酸碱平衡医学知识讲座96DIAGNOSIS诊断HistoryClinicalmanifestationArterygasanalysisDecomp.:Partialdecom.:酸碱平衡医学知识讲座97TREATMENT治疗Removecauses祛除病因Correctdehydration纠正脱水GiveNaHCO3碳酸氢钠酸碱平衡医学知识讲座98NaHCO3therapyMildacidosis(HCO3->16~18mmol/L)UnnecessarySevereacidosis(HCO3-<10mmol/L)HCO3-

(mmol)=∆

[HCO3-](Normal-Examined)

(mmol/L)×BW(kg)×0.4 *HCO3-=22~27mmol/L,Mean24mmol/L *5%NaHCO3100ml=60mmolHCO3-酸碱平衡医学知识讲座99ItiswisetoDilute5%NaHCO3to1.25%Give½ofcalculatedvolumeandreassessGiveCa2+

(hypocalcemiainalkalosis→tetania)GiveK+酸碱平衡医学知识讲座100Case1–PatientwithSevereAbdominalPain

严重腹痛酸碱平衡医学知识讲座101Case1–PatientwithSevereAbdominalPain

Anobese70yearoldmanhasdiabetesof25yearsdurationcomplicatedbycoronaryarterydisease(CABGx4vessels10yearsago),cerebrovasculardisease(carotidarteryendarterectomy3yearsago)andperipheralvasculardisease(Aorto-bifem2yearsago).[“VASCULOPATH”]肥胖、老年、糖尿病、血管病变酸碱平衡医学知识讲座102Case1–PatientwithSevereAbdominalPain

Henowpresentstotheemergencydepartmentwithsevere,poorlylocalisedabdominalpainwitharelativelysuddenonset.严重腹痛、定位不清Tothesurpriseoftheinternthatexamineshim,thepatienthasarelativelynormalabdominalexamination.Justlotsandlotsofpain.Norhasthepatienthadvomiting,diarrhea,orotherGIsymptoms.

腹部体征不明显酸碱平衡医学知识讲座103Case1–PatientwithSevereAbdominalPainTheinternconsidersthedifferentialdiagnosisofsevereabdominalpaininthesettingofadiabeticvasculopathwithoutmuchinthewayofabdominalsigns.Shewondersifthismightbeanothermanifestationofvasculardisease.FollowingaGooglesearchshefindsthefollowingstatementat:Thesinequanonofmesentericischemia肠系膜血管缺血

isarelativelynormalabdominalexaminationinthefaceofsevereabdominalpain.

腹痛严重腹部体征相对不明显酸碱平衡医学知识讲座104Case1–PatientwithIschemicBowel肠缺血Followingdiscussionwithherattending,thepatientistobeadmittedtoaregularnursingfloorwhereheistobeworkedupforhisabdominalpain.However,hemustremainintheemergencydepartmentuntilabedcanbefound.收入院，急诊科待床Whentheinterncomesby3hourslatertorecheckonthepatienthelooksmuchworse.Henowhasabdominaldistention,ileus(nobowelsounds),andsignsofshock(BP75/45).3小时后腹胀、肠梗阻、休克HeisrushedtotheIntensiveCareUnit(ICU).入ICU酸碱平衡医学知识讲座105Case1–PatientwithIschemicBowel

酸碱平衡医学知识讲座106BurnsBJ,BrandtLJ.Intestinalischemia.

GastroenterolClinNorthAm.2003Dec;32(4):1127-43.

Ischemicinjurytothegastrointestinaltractcanthreatenbowelviabilitywithpotentialcatastrophicconsequences,includingintestinalnecrosisandgangrene.Thepresentingsymptomsandsignsarerelativelynonspecificanddiagnosisrequiresahighindexofclinicalsuspicion.Becausemostlaboratoryandradiologicstudiesarenonspecificinearlyischemiaanaggressiveapproachtodiagnosiswithimagingofthesplanchnicvasculaturebymesentericangiographyisadvocated.肠系膜血管造影确诊酸碱平衡医学知识讲座107Case1–PatientwithIschemicBowel

Mortalityratesof70-90%havebeenreportedwithtraditionalmethodsofdiagnosisandtherapy;however,amoreaggressiveapproachmayreducethemortalityrateto45%.Asurvivalrateof90%maybeobtainedifangiographyisobtainedpriortotheonsetofperitonitis.传统诊断治疗死亡率高，早期积极血管造影降低死亡率酸碱平衡医学知识讲座108Case1–PatientwithIschemicBowel

ABGs（血气分析）obtainedintheICUpH 7.18PCO220mmHgHCO37mEq/LWhatistheprimarydisorder?Whatisthephysiologicresponsetothisdisorder?酸碱平衡医学知识讲座109Case1–PatientwithIschemicBowel

Forametabolicdisturbance,istherespiratorysystemcompensatingOK?

"Winter'sformula": ExpectedPCO2inmetabolicacidosis

=1.5xHCO3+8(range:+/-2) =1.5x7+8=18.5

pH 7.18PCO220mmHgHOC37mEq/L酸碱平衡医学知识讲座110AnionGap==135-98-7mEq/L=30mEq/L(ELEVATED)

SERUMELECTROLYTEDATASerumsodium 135 mEq/LSerumbicarbonate 7 mEq/LSerumchloride 98 mEq/LAnionGap=SerumSodium–SerumChloride–SerumBicarbonate

酸碱平衡医学知识讲座111Case1–PatientwithIschemicBowel

“Primarymetabolicacidosis,withincreasedaniongap,withfullrespiratorycompensation”原发性代谢性酸中毒，伴阴离子间隙增加，完全呼吸代偿酸碱平衡医学知识讲座112METABOLICALKALOSIS

代谢性碱中毒

(PrimarilyHCO3-↑pH>7.45)酸碱平衡医学知识讲座113CAUSES病因H+loss:gastricjuicesuctionOverintakeofalkalineHypokalemiaICF3K+

→←ECF2Na++1H+alkalosisUnusualacidicurine:excretesmoreH+&reabsorbsmoreHCO3-

DiureticCl-↓Furosemide→Cl-loss→Na+,HCO3-reabsorption↑→Alkalosis酸碱平衡医学知识讲座114Alkalosis:HypokalemiaduetoK+-H+exchange

AlkalosisHypokalemiaLowserumleaveexchangeintomorecellLow酸碱平衡医学知识讲座115PATHOPHYSIOLOGYLung↓toexpireCO2→PaCO2↑KidneysecreteH+↓&retainHCO3-↓HCO3-↑

:H2CO3-↑≈20:1酸碱平衡医学知识讲座116OHDCshiftleftinalkalosisOxyhemoglobindissociationcurveshiftleftHbO2donotreleaseO2Tissueanoxia“Preferacidicratherthanalkaline”“宁酸勿碱”酸碱平衡医学知识讲座117CLINICALMANIFESTATION

临床表现Breath:shallow&slowNeuropsychicsymptom:delirium谵妄,psychicconfuse,somnolence困倦,coma酸碱平衡医学知识讲座118DIAGNOSIS诊断HistorySymptomsuspiciousArterygasanalysisDecomp.:Partialdecom.:+K+↓+Cl-↓酸碱平衡医学知识讲座119TREATMENT治疗RemovecausesFluidreplenishmentGiveIS/GNStocorrecthypochloremiaGiveK+tocorrecthypokalemiaHCltherapyForseverealkalosis(HCO3-45~50mmol/L,pH>7.65)酸碱平衡医学知识讲座120HCltherapyHCl(mmol)=∆HCO3-

(Examined-expected)(mmol/L)×BW(kg)×0.4HCl(mmol)=∆Cl-

(Normal-examined)(mmol/L)×BW(kg)×0.6×0.2IsotonicHCl12mmol/LHCl20ml+H2O→0.2mmol/LHCl1200ml+10%GS1200ml→0.1mmol/LHCl2400ml→Centralveins酸碱平衡医学知识讲座121ItiswisetoHalf1stdayMildreplenishmentMonitorurine[Cl-]酸碱平衡医学知识讲座122A23-year-oldwomanis12weekspregnant.Forthelastwith10daysshehashadworseningnauseaandvomiting.Whenseenbyherphysician,sheisdehydratedandhasshallowrespirations.Arterialbloodgasdataisasfollows: pH 7.56

PCO2 54mmHg

Case2–PregnantWomanwithPersistentVomiting

妊娠伴持续呕吐酸碱平衡医学知识讲座123

DIAGNOSISMetabolicAlkalosisfromPersistentVomiting

pH 7.56

PCO2 54mmHg酸碱平衡医学知识讲座124

妊娠恶心呕吐极为常见.恶心、呕吐发生率66-89%和38-57%.一般9-10周开始of,11-13周最严重,50%在12-14后缓解.约1-10%孕妇,症状持续超过20-22周.

最严重的妊娠恶心呕吐称为妊娠剧吐症

（hyperemesisgravidarum，HEG).HEG的特征是持续恶心呕吐伴碱中毒和体重下降(>5%)，可引起血容量丢失