Tan第五章目的基因的导入和重组子的筛选

FluidandelectrolytemanagementGeneralsurgeryFluidandelectrolytemanageme1Anatomyofbodyfluidcompartments1Totalbodywater:Theaveragenormaltotalbodywateris60%ofbodyweightforyoungadultmale.Theaveragenormaltotalbodywateris50%ofbodyweightforyoungadultfemale.Anormalvariationof15%isapplytobothgroup.Anatomyofbodyfluidcompartm2Anatomyofbodyfluidcompartments2Influencefactors:Leanbodymass:fatcontainslittlewaterAge:olderhavemorefatSex:femalehasmoresubcutaneousadiposetissueRace:blackhaslessfattissueAnatomyofbodyfluidcompartm3Anatomyofbodyfluidcompartments3Threefunctionalcompartments:Intercellularfluid:40%,mainlyinthemusclecells.extracellularfluid:20%Interstitialfluid:15%Serum:5%Anatomyofbodyfluidcompartm4Anatomyofbodyfluidcompartments4Interstitialfluid:Functionalcomponent:90%nonfunctionalcomponent:10%ConnectivetissuewaterTranscellularwater:cerebrospinalandjointfluidsAnatomyofbodyfluidcompartm5Anatomyofbodyfluidcompartments5Anatomyofbodyfluidcompartm6Anatomyofbodyfluidcompartments6Anatomyofbodyfluidcompartm7Anatomyofbodyfluidcompartments7Osmoticpressure:Thenumberofparticlespresentperunitvolume(moles/liter).Thenumberofelectricalchangesperunitvolume(equivalents/liter).Thenumberofosmoticallyactiveparticlesperunitvolume(osmoles/liter).Anatomyofbodyfluidcompartm8Anatomyofbodyfluidcompartments8Osmoticpressure:thetotalnumberofosmoticallyactiveparticlesis290~310osmoles/literineachcompartment.Anincreaseineffectiveosmoticpressureinoneplace,whichwouldoccurmostfrequentlythroughincreasesodiumconcentration,causeanettransferofwaterfromoneplacetoanother.Anatomyofbodyfluidcompartm9CompositionofgastrointestinalsecretionsCompositionofgastrointestina10fluidsprovidedforshorttimefastingpatients1compositionneeded:fluidsprovidedforshorttime11fluidsprovidedforshorttimefastingpatients2compositionneeded:Na+:3-5g/dayK+:3-6g/dayWater:2000-2500ml/dayFever:1℃~3-5ml/kgSweat:middle:500-1000ml/dayseverer:1000-1500ml/dayFormulae:supply=hadlost+willlost+neededfluidsprovidedforshorttime12ElectrolytecompositionofreplacementfluidsElectrolytecompositionofrep13regulationofbodywaterKidneyistheprimaryorganBloodvolume:Renin-angiotensin-aldosteroneTissueOsmoticpressure:hypothalamus-pituitary-antidiuretichormoneregulationofbodywaterKidney14ClassificationofbodyfluidchangesVolume:dehydrationConcentration:hyponatremia,hypernatremiaComposition:acidosis,alkalosis,hypokalemia,hyperkalemia,hypocalcemia,hypercalcemia,etal.Classificationofbodyfluidc15Isotonicdehydration1Cause:acutelossofextracellularfluidLossofgastrointestinalfluid:vomiting,bowlfistular,etal.Acutesequestrationoffluidinsofttissue:burns,infections,etal.Isotonicdehydration1Cause:ac16Isotonicdehydration2Clinicfindings:nausea,weakness,oliguria,anorexia,nothirsty;smalltonguewithlongitudinalwrinkling,sunkeneyes,decreasedskinturgor.thelossoffluidisoverthan5%,shock.Oftenaccompanybymetabolicacidosis.Na+andCL-arenormal.Densityofurineincrease,condensedbloodIsotonicdehydration2Clinicf17Isotonicdehydration3Treatment:Therapyoftheunderlinedisease.Supplytheisotonicfluid:whenthelossismorethan5%oftotalbodyweight,3000mlfluidisneeded.SupplyofK+Isotonicdehydration3Treatment18hypotonicdehydration1Cause:Thecontinueloseofgastrointestinalfluid:vomiting,nasogastricsuction,diarrhea,fistulardrainageThecontinuesequestrationoffluidinsoft-tissue:burns,infections,peritonitisDiureticsToomuchfreewaterwasgiven:hypotonicdehydration1Cause:19hypotonicdehydration2Clinicfindings:nothirstyMild:<135mmol/LModerate:<130mmol/LSeverer:<120mmol/Ldensityofurinedecrease,condensedbloodhypotonicdehydration2Clinicf20hypotonicdehydration3Treatment:TherapyoftheunderlinediseaseFormulae:page46Severer:HypertonicNa+canbegivenPayattentiontosupplymentofK+andadjustacid-baseimbalancehypotonicdehydration3Treatmen21hypertonicdehydration1Cause:Extraneouslossoffreewater:fever,hyperventilation,burns,severerdiarrheaExcessiverenalfreewaterloss:osmoticdiureticinducedbyhyperglycemiainsufficientintakeofwater:oesophaguscarcinoma,comapatientshypertonicdehydration1Cause:22hypertonicdehydration2Clinicfindings:Mild:2-4%,thirstyModerate:4-6%,weakness,thirsty,oliguria,smalltongue,sunkeneyes,decreasedskinturgorSeverer:>6%delirium,maniacalbehavior,comahypertonicdehydration2Clinic23hypertonicdehydration3Treatment:TherapyoftheunderlinediseaseSupplementoffluid:page47PayattentiontosupplementofNa+k+andadjusttheacid-basebalance.hypertonicdehydration3Treatme24Waterintoxication1Cause:ToomuchADH(antidiuretichormone)ThefailureofkidneyToomuchwaterisgivenWaterintoxication1Cause:25Waterintoxication2Clinicfindings:Acute:edemaofbraincells,increasedintracranialpressureChronic:weakness,nausea,vomiting,lethargic,increaseofbodyweight,paleandwhiteskin.Waterintoxication2Clinicfind26Waterintoxication3Treatment:StopinfusionofwaterSevere:diureticsshouldbegivenOsmoticdiuretics:Loopdiuretics:PreventionismoreimportantWaterintoxication3Treatment:27Calciumabnormalities1Thebodycaliumstoresareapproximately1000g,withalmost99%apportionedinbone.Theremainderislocatedwithintheextracellularfluidandiseitherfree(40%)orboundtoalbumin(50%)orotheranions.Calciumabnormalities1Thebody28Calciumabnormalities2Acid–basealterationsaffectthebindingofcalciumtoalbumin.Thealkalosisincreasethebindingaffinityofcalciumforalbumin,leadtothereductionofionizedcalciumlevels.Changeinserumproteinwillaffectthetotalserumcalcium.Normalvalue:2.25-2.75mmol/LCalciumabnormalities2Acid–ba29hypocalcemia1Cause:acutepancreatitis,massivesofttissueinfection,small-bowelfistular,hypoparathyroidism,kidneyfailure,massivebloodtransfusion.Clinicalfindings:numbnessortinglinginthecircumoralregionoratthetipsofthefingers,tetanyorseizuremaybeseenatmoreprofoundlevel.trousseau’ssignandchvostek’ssignCa2+<2mmol/Lhypocalcemia1Cause:acutepancr30hypocalcemia2Treatment:Correctingtheunderlyingdisorder10mlof10%calciumgluconateorcalciumchloride+5%glucose100ml,ivdropOralsupplementationinlesssevererpatient.

hypocalcemia2Treatment:31hypercalcemiaCause:primaryhyperparathyroidismandmalignantdiseaseaccountfor90%Clinicalfindings:muscleweakness,nausea,vomiting,pancreatits,renalstone,bonefracture,diuresis.treatment:Correctingtheunderlyingdisorder,hydrationwithnormalsalineisuseful.hypercalcemiaCause:primaryhyp32potassiumabnormalitiesPotassiumisthemajorintracellularcation,onlyabout2%oftotalbodypotassiumislocatedintheextracellularfluid.k+:3.5~5.5mmol/LpotassiumabnormalitiesPotassi33hypokalemia1Cause:Extrerenallosses:gastrointestinal(vomitting,nasogastricsuction);diarrhea;massiveburns;profusesweatingRenalloss:diuretictherapy,tubulardisordersTranscellularfluxofk+intocell:metabolicalkalosis,insullinadministrationOthers:hypokalemia1Cause:34hypokalemia2Clinicalfindings:Muscleweakness:nausea,vomiting,constipateECG:T-waveflatteningorinversionanddepressedSTsegments,developmentofU-wave,aprolongedP-Tinterval.K+<3.5mmol/Lhypokalemia2Clinicalfindings:35hypokalemia3hypokalemia336hypokalemia4treatment:Correctingtheunderlyingdisorder:Notseverer:orallysupplementationLowerthan3mmol/L,intervein:分次补钾(3-5days)，不宜过浓（40mmol/L），不宜过快(20mmol/hr)，见尿补钾(40ml/hr)。hypokalemia4treatment:37hyperkalemia1Cause:ToomuchK+sendintobodyimpairmentofrenalK+excretion:Renalfailure.Transcellularfluxofk+outofthecell:metabolicacidosis,injuryoftissuehyperkalemia1Cause:38hyperkalemia2Clinicfindings:Themostdangerousisstoppingofheartbeat.ECG:T-waveistall,narrow,symmetrical;P-Rsegmentincrease,theQRScomplexwiden,Q-Tintervalincrease.hyperkalemia2Clinicfindings:39hyperkalemia3hyperkalemia340hyperkalemia4hyperkalemia441Regulationofacid-basemetabolismBuffer,kidney,lungareimportantHCO3-/H2CO3=24/1.2=20:1PHisbetween7.35-7.45Lung:theexpirationofCO2Kidney:theprotonexcretionRegulationofacid-basemetabo42Acid-baseimbalanceMetabolicacidosisMetabolicalkalosisRespiratoryacidosisRespiratoryalkalosisAcid-baseimbalanceMeta