FLUIDANDELECTROLYTEMANAGEMENT水電解質(zhì)平衡課件

1、1Total Body Water 60% of body weigh 50% of body weight 75% to 80% lean individual obese person 1Total Body Water2Water ExchangeDrink10001300Food 700 900 Metabolic water300Urine 8001500Lung 350Skin 500 Stool 250250025002Water ExchangeDrink10001300U3Water ExchangeA patient deprived of all external acc

2、ess to water must still excrete a minimum of 500 to 800 ml. of urine per day in order to excrete the products of catabolism, Insensible loss of water occurs through the skin (75%) and the lungs (25%) and is increased by hypermetabolism, hyperventilation, and fever. 3Water Exchange4Composition of Uri

3、neWaterNitrogen-containing material：urea、uric acid、creatine、creatinine、amino acid and amonia。Organic compound：hippuric acid、glucuronate、lactic acid、ethanedioic.Electrolyte：Cl-、Na 、K and phosphate。Little protein and sugar，positive in urine pathology。 4Composition of UrineWater5Three functional compar

4、tments of the body waterintracellular water 40%extracellular water 20%body weight 60%plasma 5%interstitial fluid 15%5Three functional compartments6Total blood volume of human bodyGenerally 8of body weight，About 5000 ml for an adult。increase2325 in pregnancy women。 About 80 of total volume in circula

5、tionOther 20% stored in liver and spleen 6Total blood volume of human b7154mEq/l 154mEq/l153mEq/l 153mEq/l200 mEq/l 200 mEq/l Cation Anions Na+ 142 Cl- 103 HCO3- 27 SO4= PO4 3K+ 4Ca+ 5Mg+ 3 Protein 16 Organic acid 5Cation AnionsNa+ 144 Cl- 114 HCO3- 30 SO4= PO4 3K+ 4Ca+ 3Mg+ 2 Protein 1 Organic acid

6、 5Cation AnionsK+ 150 HPO4= SO4= 150 HCO3- 10Na+ 10Mg+ 40 Protein 40 Plasma Intestitial fluid Intracellular fluidChemical composition of body fluid compartment: 7154mEq/l 154mEq/l153mEq/l 8Osmotic Pressure Depends on the number of particles present per unit volume . 1 mM NaCl =sodium +chloride, cont

7、ributes 2 mM, 1 mM Na2SO4=3 particles, contributes 3 mM. 1 mM glucose is equal to 1 mM of the substance. Normal Osmotic Pressure Cations(151) Anions(139) non electrolyte (10)300mmol/L(280 310mmol/L)8Osmotic Pressure 9semipermeable membrane The cell wall maintained the differences in ionic compositio

8、n between ICF and ECF. The cell membranes are completely permeable to water9semipermeable membrane 10colloid osmotic pressureThe dissolved proteins in the plasma are primarily responsible for effective osmotic pressure between the plasma and the interstitial fluid compartments.10colloid osmotic pres

9、sure11The effective osmotic pressureintracellular extracellular dissolved proteins plasma interstitial fluid 11The effective osmotic pressu12The effective osmotic pressure The difference of pressure between the ECF and ICF compartments induced by any substance that does not traverse the cell membran

10、es freely. 12The effective osmotic pressu13CLASSIFICATION OF BODY FLUID CHANGESThe disorders in fluid balance ：volume deficit or Excessconcentration composition13CLASSIFICATION OF BODY FLUID14Volume DeficitThe most common disorders leading to an ECF volume deficit include:losses of gastrointestinal

11、fluids due to vomiting, nasogastric suction, diarrhea, fistula drainage. sequestration of fluid in soft tissue injuries and infections, intra-abdominal and peritonitis, intestinal obstruction, and burns.14Volume Deficit15Volume Excess Generally secondary to renal insufficiency. Both the plasma and t

12、he interstitial fluid volumes are increased.15Volume Excess16CONCENTRATION CHANGESECF: Na+ represent 90% of particles concentration. Hyponatremia and hypernatremia can be diagnosed by clinical manifestations, laboratory tests.16CONCENTRATION CHANGES17Mechanism of HyponatremiaWater intake excessSodiu

13、m intake deficientRenal inadequacyVomite, suction17Mechanism of HyponatremiaWat18Hyponatremia Asymptomatic until the serum sodium level falls 120 mmol per liter. Acute symptomatic hyponatremia: CNS signs: Increased intracranial pressure; tissue signs of excessive intracellular water.18Hyponatremia 1

14、9Hyponatremia: (Water intoxication )serum sodium level less than 120 mmol/LCNS: Moderate severe Muscle twitching Convulsions Hyperactive tendon reflexes Loss of reflexes increased intracranial pressureCardioVascular: Bp change Tissue: increased salivation Watery diarrhea Renal: Oliguria progressing

15、to anuria Metabolic: None 19Hyponatremia: (Water 20Mechanism of HypernatremiaWater intake deficientDiseases of digestive tractExcess loss waterexcess perspirationVomite, diarrhea, suction20Mechanism of HypernatremiaWa21Hypernatremia: (Water deficit ) serum sodium level greater than 150 mmol/LCNS: Mo

16、derate severe Restlessness Delirium Weakness Maniacal behavior CardioVascular: Tachycardia, HypotensionTissue: Decreased saliva and tears Dry and sticky mucous membranes Renal: OliguriaMetabolic: Fever 21Hypernatremia: (Water22MIXED VOLUME AND CONCENTRATION ABNORMALITIESConsequence of the disease st

17、ate or occasionally from inappropriate parenteral fluid therapy.1. The more common is an ECF deficit and hyponatremia (Hypotonic dehydration). 2. ECF volume deficit + hypernatremia (Hypotonic dehydration). : glucosuria 3. ECF volume excess and hypernatremia: excessive quantities of sodium salts 4. E

18、CF volume excess and hyponatremia (Water intoxication): oliguric renal failure 22MIXED VOLUME AND CONCENTRATI23COMPOSITION CHANGESCompositional abnormalities include:concentration changes of potassium, calcium, magnesiumchanges in acid-base balance 23COMPOSITION CHANGES24PotassiumThe normal dietary

19、intake of potassium is approximately 50 to 100 mmol. daily. 98% of the potassium is located in the IC compartment at a concentration of 150 mmol. per liter. Extracellular potassium is 3.55.5 mmol/L. Most of this is excreted in the urine.24Potassium25Potassium AbnormaliliesHyperkalemiaExtracellular p

20、otassium 5.5 mmol/L. HypokalemiaExtracellular potassium 3.5 mmol/L.25Potassium Abnormalilies26Hyperkalemia Significant quantities of intracellular potassium are released into the extracellular space. Cause:severe injury or surgical stressAcidosis the catabolic state. oliguric or anuric renal failure

21、 26Hyperkalemia 27Hyperkalemia Signs: The gastrointestinal symptoms include nausea, vomiting, intermittent intestinal colic, and diarrhea. The cardiovascular signs are apparent on the ECG initially, with high peaked T waves, widened QRS complex, and depressed S-T segments. Disappearance of T waves,

22、heart block, and diastolic cardiac arrest may develop with increasing levels of potassium.27Hyperkalemia 28HyperkalemiaTreatment: intravenous administration of 1 gm. of 10% calcium gluconate under ECG monitoringadministration of bicarbonate and glucose with insulin (1/4gG)Rapid alkalinization of the

23、 ECF with either sodium lactate or bicarbonate promotes transfer of potassium into cells definitive removal of excess potassium by cation-exchange resins, peritoneal dialysis, or hemodialysis. 28Hyperkalemia29HypokalemiaA more common problem in the surgical patient may occur as a result of:excessive

24、 renal excretion (1g/500ml)movement of potassium into cellsprolonged administration of potassium-free parenteral fluids with continued obligatory renal loss of potassium parenteral nutrition with inadequate potassium replacement, loss of gastrointestinal secretions. 29Hypokalemia30Hypokalemia The si

25、gns of potassium deficit:failure of normal contractility of skeletal, smooth, and cardiac muscle weakness to flaccid paralysis, diminished to absent tendon reflexes, and paralytic ileus. Sensitivity to digitalis with cardiac arrhythmias and ECG signs of low voltage, flattening of T waves, and depres

26、sion of S-T segments30Hypokalemia 31Normal Hypokalemia Hyperkalemia31Normal Hypokalemia 32Hypokalemia Treatment of hypokalemia involves:First prevention of these state. Intravenous administration of potassium No more than 40 mmol should be added to 1 liter of intravenous fluidThe rate of administrat

27、ion should not exceed 20 mmol/ hour unless the ECG is being monitored.Administration of potassium is about 3-6 g /day1 gram of KCl =13.4mmol of potassium 32Hypokalemia 33Composition of Gastrointestinal Secretions Volume Na K Cl HCO3 (ml/24hr) mmol/L mmol/L mmol/L mmol/LSalivary 1500 10 26 10 30 Stom

28、ach 1500 60 10 130 - Duodenum100-2000 140 5 104 -Ileum 3000 140 5 104 30 Colon - 60 30 40 - Pancreas 100-800 140 5 75 115 Bile 50-800 145 5 100 35 33Composition of Gastrointesti34Calcium AbnormalitiesMost of body calcium (99%)is found in the bone in the form of phosphate and carbonate. Normal daily

29、intake of calcium is between 1 and 3 gm. Most of this is excreted via the gastrointestinal tract, and 200 mg. or less is excreted in the urine daily. The normal serum level is between 2.25 2.75 mmol/LThe 45% is the ionized portion that is responsible for neuromuscular stability. 34Calcium Abnormalit

30、ies35Hypocalcemia The common causes: Acute pancreatitisMassive soft tissue infectionsAcute and chronic renal failure Pancreatic and small intestinal fistulas Hypoparathyroidism 35Hypocalcemia 36Hypocalcemia The symptoms (serum level less than 2.25 mmol/L): Numbness and tingling of the circumoral reg

31、ion and the tips of the fingers and toes. Hyperactive tendon reflexes, Muscle and abdominal cramps, convulsions (with severe deficit), Chvosteks sign and Trousseausign positive36Hypocalcemia 37Hypocalcemia Treatment: correction of the underlying cause with concomitant repletion of the deficit. Intra

32、venous administration of calcium gluconate or calcium chloride Calcium lactate may be given orally, With or without supplemental vitamin D, in a patient requiring prolonged replacement.37Hypocalcemia 38Hypercalcemia The two major causes: Hyperparathyroidism Cancer with bony metastasis. The latter is

33、 most frequently seen in a patient with metastatic breast cancer. 38Hypercalcemia 39Hypercalcemia The manifestations of hypercalcemia include: Easy fatigue, lassitude, weakness of varying degree, Anorexia, nausea, vomiting, and weight loss. Lassitude, stupor, and finally coma. Severe headaches, pain

34、s in the back and extremities, thirst. 39Hypercalcemia 40Hypercalcemia Treatment:vigorous volume repletion with salt solutions lowers the calcium level by dilution and increased urinary calcium excretion. Concomitant use of large doses of intravenous furosemide to increase urinary calcium excretion.

35、Oral or intravenous inorganic phosphates Intravenous sodium sulfate also lowers serum calcium 40Hypercalcemia 41Magnesium AbnormalitiesThe total body content of magnesium is approximately 1000 mmol., About half of which is in bone and the major other portion being intracellular Serum magnesium conce

36、ntration normally ranges between 0.71.1mmol/L. The normal dietary intake of magnesium is approximately 20 mmol. (240 mg.) daily. The larger part is excreted in the feces and the remainder in the urine. The kidneys have a remarkable ability to conserve magnesium.41Magnesium Abnormalities42Magnesium D

37、eficiencyCause:starvation, malabsorption syndromes, protracted losses of gastrointestinal fluid, prolonged parenteral fluid therapy with magnesium-free solutions.Acute pancreatitis, diabetic acidosis during treatment. primary aldosteronism, chronic alcoholism.42Magnesium Deficiency43Magnesium Defici

38、ency The signs and symptomsThe magnesium ion is essential for proper function of most enzyme systems, and depletion is characterized by neuromuscular and CNS hyperactivity, which are quite similar to those of calcium deficiency. 43Magnesium Deficiency 44Magnesium Deficiency Treamient In asymptomatic

39、 patients: oral replacement.Severe symptomatic deficit: The intravenous route is preferable for the initial treatment. When large doses are given intravenously, the heart rate, blood pressure, respiration, and ECG should be monitored closely for signs of magnesium toxicity, which could lead to cardi

40、ac arrest. 44Magnesium Deficiency 45Magnesium ExcessCause:1, Patients with impaired renal function 2, Early-stage burns3, Massive trauma or surgical stress4, Severe ECF volume deficit5, Severe acidosis.45Magnesium Excess46Magnesium Excess signs and symptoms include: lethargy and weakness with progre

41、ssive loss of deep tendon reflexes. Interference with cardiac conduction ECG changes (increased P-R interval, widened QRS complex, and elevated T waves) resemble those seen with hyperkalemia. Somnolence leading to coma and muscular paralysis occurs in the later stages, and death is usually caused by

42、 respiratory or cardiac arrest.46Magnesium Excess 47Magnesium Excess Treatment Correcting any acidosis, Replenishing any preexisting ECF volume deficitStop exogenously administered magnesium. Acute symptoms may be controlled by slow intravenous administration of 2.5 to 5 mmol. of calcium gluconate.

43、(about 10% calcium gluconate 1020ml)If elevated levels or symptoms persist, peritoneal dialysis or hemodialysis is indicated. 47Magnesium Excess 48Phosphonium AbnormalitiesAbout 85% of phosphonium exite in boneNormal serum phosphonium level:0.961.62mmol/LParticipate phosphorate of protein, cell memb

44、rain and acid-base balance 48Phosphonium AbnormalitiesAbo49HypophosphatemiaCause: Hyperparathyroidism, severe burn or infectionSyptom: manifestation in nervous-muscle.Treatment: administration of sodium glycerophosphate 10 ml49HypophosphatemiaCause: Hyper50HyperphosphatemiaCause: acute renal failure

45、, Hypoparathyroidism, acidosisSyptom: like hypocalcemia, ectopic calcificationTreatment: treatment of hypocalcemia, dialysis50HyperphosphatemiaCause: acut51Acid-base BalanceAcid base: source and regulation SourceAcidvolatile（H2CO3）fixed acidMetablic foodMaterial release H+Resp. regul.Renal regul51Ac

46、id-base BalanceAcid base: 52AlkalisaltamoniafoodMetablicAcid-base BalanceSourceSth receive H+52AlkalifoodMetablicAcid-base 53Asid and Alkali in bodyvolatile acid: carbonic acid（H2CO3）fixed acid：H2SO4、H2PO4、ketobodiesAcid:Alkali： HCO3- 、Hb-、Na2HPO4 、 NH353Asid and Alkali in bodyvolat54Acid-base Balan

47、ceIntracellular PH: proteins and phosphates, ECF space: bicarbonate-carbonic acid system red cell hemoglobin PH of body fluids maintained by several buffer systems and subsequently excreted by the lungs and kidneys. 54Acid-base BalanceIntracellul55Acid base: source and regulation Blood buffer:H2CO3H

48、CO3HPr PrH2PO 4HPO42-pH React quick55Acid base: source and regula56H+HCO3 CO2H2O+ K+H+Regulation by lung and kidney56H+HCO3 CO2H2O+ K+H+Reg57Excrete H+ and reuptake NaHCO3HCO3Na+HCO3H+H2CO3H2OCO2CAHCO3K+K+Na+Na+Proximal nephronCO2H2OH2CO3CAH+HCO357Excrete H+ and reuptake NaHC58Acid-base Balance1、PH：

49、Normal blood PH: 7.357.452、PCO2： Normal: 35-45mmHg,(40mmHg)3、Buffuer excess（BE）: Represent ascidosis or alkolosis, Normal: +3-3 mmol/L,(0)4、Actual bicarbonate radical（AB）： actual HCO3- in plasma5、Standard bicarbonate radical（SB）： HCO3- content measured when PaCO2=40mmHg, HbO2=100%，T=37.0 Normal AB=S

50、 B=2227mmol/L, average 24mmol/L58Acid-base Balance1、PH：Normal59pH Conception：Negative logarithm of H+ concentration in solutionNormal value：Artery blood 7.357.45Meaning：To distinguish acidosis or alkalosis7.35 7.45Acidosis6.8Alkalosis7.8deathdeathpH16 nmol/L40160【H+】59pH Conception：Negative logar60H

51、endeison-Hasselbalch equationpH = pK + log BHCO3/H2CO3 = 6.1+log HCO3 /0.03 PaCO2 = 6.1 + log 24 /0.03 40 = 6.1+log20/1 = 7.4PK represents the dissociation constant of carbonic acid in the presence of base bicarbonate HCO3 represent the factor of metabolismPaCO2 represent the factor of respiration60

52、Hendeison-Hasselbalch equati61Six-Step to the Interpretation of Arterial Blood Gas With Serum Sodium, Potassium, and Chloride ConcentrationsOBSERVATIONINTERPRETATIONINTERVENTIONpH other than 7.40?Acidosis if 7.45pH 7.55?Severe disorderPrompt correction requiredPaco2 other than 40 mm Hg?Ventilation c

53、ompensates disorderChange ventilation Paco2 compensatesbase deficit other than zero?Bicarbonate loss/gain compensates or contributes to disorder NaCO3 or HCl correct proton concentrationurine pH reflect acidosis/alkalosis?Acid/alkaline urine indicates renal function compensates or contributesRenal-a

54、ctive drugs or electrolyte replacement anion gap 12 mmol/L suggest lactic or ketoacidosisCorrect the primary metabolic problem61Six-Step to the Interpretati62Simple typeH2CO3 (1)HCO3 (20)pH Metab(Alk)Resp.(aci)Metab. alkalosisMetab.acidosisResp. acidosisResp. alkalosisThe four types of acid-base dis

55、turbances62Simple typeH2CO3 (1)HCO3 (263The four types of acid-base disturbances Acute Chronic pH PCO2 HCO3 pH PCO2 HCO3 Resp acid N Resp alka N Meta acid N Meta alka N ? 6364Acidosis and Alkalosis Defect Cause Resp acid Retention of CO2 Depression of respiratoryResp alka Excessive loss of CO2 Hyper

56、ventilationMeta acid Retention of fixed acids Diabetes, diarrhea Loss of base bicarbonate Lactic acid accumulationMeta alka Loss of fixed acids Vomiting or gastric suction Gain of base bicarbonate Excessive intake of Potassium depletion bicarbonate 64Acidosis and Alkalosis 65Respiratory Acidosis: Hy

57、poventilation PCO2 is elevated and plasma bicarbonate concentration is normal. In the chronic form, Pco2 remains elevated and bicarbonate concentration rises as renal compensation occurs.Cause:Airway obstruction: Foreign body, pneumonia, emphysema.CNS: Depression, injury, tumor.Thoracic injury: Pneu

58、mothorax, flail chest, tracheal.Mechanical ventilation: Inadequate rate and/or tidal volume. 65Respiratory Acidosis: Hypove66Mecanism of ventilation dysfunctionInhibition of Resp.centerResp. muscleparalysisLung diseaseThorac.diseseObstruc stenose of airwayInhibit Resp.centerResp. m.paralysisThorac l

59、ung disea.Airway obstructionMal-ventilation66Mecanism of ventilation dysf67co2o2co2co2O2+Hb HbO2o2o2o2co2co2Hb+HbcOExternal respirationInternal respirationAirwayPulm。 alveolusblood vesselCellRespiration course67co2o2co2co2O2+Hb HbO2o2o2o68Respiratory Acidosis Signs：chest stuffy，dyspnea， restless， cy

60、anosis and headache caused by hypoxia， Delirium even comaExamination laboratory revealed a decreased pH, increased PaCO2, HCO3 may remain normal.68Respiratory Acidosis 69Respiratory AcidosisTreatment: Treatment primary disorder.Ameliorate the patients ventilationVentilator may be used69Respiratory A