水電解質(zhì)代謝與酸堿平衡失調(diào)課件

FluidsandElectrolytesManagementoftheSurgicalPatientZongfangLi(李宗芳),MD.PHDProfessorofGeneralSurgerylzf2568@.cn1水電解質(zhì)代謝與酸堿平衡失調(diào)和諧社會(huì)水電解質(zhì)代謝與酸堿平衡失調(diào)旱災(zāi)水電解質(zhì)代謝與酸堿平衡失調(diào)水災(zāi)水電解質(zhì)代謝與酸堿平衡失調(diào)

Case1：

王某，女，23歲。以“嘔吐、腹瀉36小時(shí)”入院患者于36小時(shí)前，吃剩飯后即感上腹不適，繼則腹痛、嘔吐頻繁，嘔吐出大量食物和胃液，并腹瀉十余次，為大量黃色稀水便。逐漸出現(xiàn)口渴、尿少、惡心、厭食、軟弱無(wú)力。半小時(shí)前便后起立時(shí)，突然暈倒在廁所，救醒后速送醫(yī)院求治。入院查體：體溫37.8℃,脈搏120次/分.呼吸深快(28次/分),血壓90/70mmHg，體重50Kg，神志淡漠，面色蒼白，皮膚彈性差，眼眶凹陷。肢端濕泠，腹部輕度深壓痛。

化驗(yàn)：①血常規(guī)：RBC550萬(wàn)/mm3，Hb12g%，WBC15000/mm3，N80%；②尿常規(guī)：比重1.030,強(qiáng)酸性；③糞常規(guī)：黃色稀水便，WBC(＋)；④血清Na+138mEg/L、K+3.5mEg/L、CO2CP30VOL%，BUN39mg/ml。

Diagnosis:?Prescription:?水電解質(zhì)代謝與酸堿平衡失調(diào)

Case2

趙××，男性，60歲，體重65Kg

“膽囊切除，膽總管探查術(shù)后第一天”

術(shù)后從胃管內(nèi)共抽出液體600ml。

T管引流出膽汁400ml。煙卷引流出滲液約240ml

體溫持續(xù)在38.2℃Prescriptionoffluidreplacement:?6水電解質(zhì)代謝與酸堿平衡失調(diào)

BodyFluid&ItsCompartmentsComposition:Water＋ElectrolytesVolume:50%（female）～60%（male）

80%（infant）ofbodyweight

FACTOR：sex、age、lean&fatDistribution(figure1):

ExtracellularFluid（20%）Plasma5%、InterstitialFluid15%

IntracellularFluid（35%～40%）Skeletalmuscle35%Electrolyte：ECF：Na＋/CI－、HCO3－、proteinICF：K＋、Mg＋＋/P3－、proteinTheeffectiveosmoticpressureinthetwocompartmentsareconsideredequal,about290-310mOsm／L.

以上的穩(wěn)定持機(jī)體新陳代謝正常進(jìn)行的保證7水電解質(zhì)代謝與酸堿平衡失調(diào)FunctionofWater

Waterisoneofthemostimportantmaterialtomaintainthemormalfunctionsofhumanbody.

人只飲水可生存十日之久，無(wú)水只能生存數(shù)日

①調(diào)節(jié)體溫Regulatebodyheat②促進(jìn)物質(zhì)代謝Facilitatemetabolism:

溶解dissolve,、運(yùn)輸

transportation③潤(rùn)滑作用lubrication8水電解質(zhì)代謝與酸堿平衡失調(diào)FunctionofElectrolytes①M(fèi)aintainingtheOsmoticPressureandthebalanceofwater：

K＋/HPO4－；Na＋/CI－②MaintainingAcid-baseBalance：Buffersysteminbodyfluids.③Maintainingtheexcitabilityofnerveandmuscle：

[Na＋]＋[K＋]theexcitability∝[Ca＋＋]＋[Mg＋＋]＋[H+]④K＋

istheactivatorofmanyenzymesinhumanbody：

K＋

takepartinthebiosynthesisofglycogenandprotein.9水電解質(zhì)代謝與酸堿平衡失調(diào)水的攝入與排出

Watergainandloss

每天代謝產(chǎn)生固體廢物35～40g，每g至少需尿15ml將它排出。因此，每天尿量不應(yīng)少于500ml（1.030）.但每天尿量1500ml±（1.012）時(shí)腎臟負(fù)擔(dān)最輕?！郃normaladultneedatleast1500mlwatereveryday,but2500mlismorereasonable.H2OGain（ml）H2OLossOralfluids1000～1500 Urine1000～1500Solidfoods700 Stool150endogeny300 InsensibleSkin500Lungs350Total2000～2500Total2000～250010水電解質(zhì)代謝與酸堿平衡失調(diào)ElectrolyteContentofBodyFluid1正常人血漿or血清中的電解質(zhì)濃度

positiveionmEg/LnegativeionmEg/LNa＋

142CI－

103K＋

5HCO3－

27Ca＋＋

HPO4-22

SO4-21Mg＋＋

organicacid5Protein16Total154Total15411水電解質(zhì)代謝與酸堿平衡失調(diào)ElectrolyteContentofBodyFluid2各種消化液每日分泌量（ml）及其電解質(zhì)濃（mEg/L）DigestivejuiceVolumeofsecretion(ml/day)H+(mEq/l)Na+(mEq/l)K+(mEq/l)Cl-(mEq/l)HCO3-(mEq/l)saliv18Gastricjuice20000~9040~10010~4550~1400~5Bilejuice700135~145580~11035Pancreaticjuice800135~185550~7090Smallintestinaljuice>3000105~1355~20100~12020~30TotalVolume>8000,Only150mlfluidexcretethroughdejectainnormalstate.Duringvomitinganddiarrhea,thebodyfluidwillchange.Lossofanydigestivejuicewillleadtospecificsequent.12水電解質(zhì)代謝與酸堿平衡失調(diào)MetabolizeofElectrolytesElectrolytesisingestedfromfood,comeintoeverytissuethroughblood,andexcretedfromkidneymostly.Theurineofadultcontains:

natrium(≈NaCI6～9g)andkalium(2～3g).TheexcretionofNa+andK+fromkidneyNa+:themoreingested,themoreexcreted,viceversa.noingested,noexcreted.K+:themoreingested,themoreexcreted,viceversa.noingested,stillexcerted.13水電解質(zhì)代謝與酸堿平衡失調(diào)AdjustofBodyFluidBalance1可以分為:出入量的調(diào)節(jié)；細(xì)胞內(nèi)外的調(diào)節(jié)；血管內(nèi)外的調(diào)節(jié)。晶體滲透壓血漿膠滲壓毛細(xì)管通透性毛細(xì)管靜水壓飲水a(chǎn)nd排尿主要通過(guò)腎臟，其調(diào)節(jié)功能受神經(jīng)、內(nèi)分泌反應(yīng)影響首先：Hypothalamus—neurohypophysis—ADHsystemosmoticpressure然后：Rein–angiotensin–aldosteronesystemvolume

但當(dāng)血容量↓↓↓時(shí)，機(jī)體優(yōu)先保持和恢復(fù)血容量，→使重要生命器官的灌流得以保證，維護(hù)生命。

14水電解質(zhì)代謝與酸堿平衡失調(diào)AdjustofBodyFluidBalance2下丘腦、垂體后葉、抗利尿激素S體內(nèi)水份喪失，細(xì)胞外液滲透壓↑（靈敏度2%）

口渴、飲水增加下丘腦、垂體后葉分泌ADH遠(yuǎn)曲腎小管、集合管上皮細(xì)胞吸收水、尿量保留水份于體內(nèi)細(xì)胞外液滲透壓↓細(xì)胞外液滲透壓15水電解質(zhì)代謝與酸堿平衡失調(diào)細(xì)胞外液↓（血容量↓）BP↓腎素醛固酮S

交感神經(jīng)興奮壓力感受器（腎小球入球小動(dòng)脈）腎小球?yàn)V過(guò)率↓經(jīng)遠(yuǎn)曲腎小管的Na+↓鈉感受器（遠(yuǎn)曲腎小管致密斑）腎小球旁細(xì)胞分泌腎素血管緊張素原血管緊張素Ⅰ血管緊張素Ⅱ腎上腺皮質(zhì)球狀帶醛固酮合成分泌↑血漿中遠(yuǎn)曲腎小管再吸收Na＋↑→CI－↑→H2O↑（排泌K＋、H＋↑）細(xì)胞外液↑循環(huán)血量↑BP↑AdjustofBodyFluidBalance316水電解質(zhì)代謝與酸堿平衡失調(diào)神經(jīng)-內(nèi)分泌對(duì)細(xì)胞外液的調(diào)節(jié)細(xì)胞外液變化滲透壓↑容量↓下丘腦腎素↑口喝ＡＤＨ↑血管緊張素Ⅰ飲水↑保水（尿量↓）血管緊張素Ⅱ醛固酮↑保Na（尿Na↓）滲透壓↓容量↑細(xì)胞外液恢復(fù)AdjustofBodyFluidBalance417水電解質(zhì)代謝與酸堿平衡失調(diào)BodyFluidAbnormalitiesTotalBodyWaterLossDehydration=saltdeficient+waterdeficientInsurgicalpatients,waterandsaltdeficitsmoreoftenoccurtogether.

Dehydrationcanbeclassifiedintothreecategories:hypertonic,hypotonic,isotonic.18水電解質(zhì)代謝與酸堿平衡失調(diào)高滲性脫水.1

Hypertonicdehydration

Definition:waterdeficient>sodiumdeficientPNa+>150mEq/L(hypertonia)Cause:Intakedeficient--unabletoregulateintake,fountaindiscontinuity

Overabundantloss–

profuse

sweatingfromardentfever,excessivediuresisIt’salsocalledprimarywaterdeficits.Pathophysiology:ECFvolumedeficitaccompaniedbyhypernatremia,ADH↑，aldostenrone↑19水電解質(zhì)代謝與酸堿平衡失調(diào)高滲性脫水.2

Hypertonicdehydration

LaboratoryInvestigation:WBC↑、Concentratedblood,increasedurinespecificgravity(spgr?1.035).Plasmaprotein,Potassium,Natrium,Chlorine,BUN,andOsmoticpressureareallincreased.ExtentWeight↓%ClinicalfindingLight2ThirstyModerate3~4Severethirsty,Ligulaxeransis,Flexibilityofskindecerase,Sunkeneyes,Apathy,Xeransisinaxillaandinguen,Oliguria,increasedurinespecificgravitySevereAbove5~6Severethirsty+obvioussymptomofcentralnervoussystem,Mania,Hallucination,Phrenitis,Hyperpyrexia,Eclampsia,coma,DecreasedBP,Shock20水電解質(zhì)代謝與酸堿平衡失調(diào)2.低滲性脫水.1

Hypotonicdehydration

Definition:waterdeficient<sodiumdeficientPNa+<135mEq/L(hypotonia)Cause:

Chronicbodyfluidlossor

bodyfluidlossarereplacedwithonlywithnoly5%dextroseinwaterorahypotonicsodiumsolution.It’salsocalledChronicwaterdeficits.Pathophysiology:

ECFvolumedeficitandhyponatremia,Circulationfailurepresentsintheearlystage.ADHdecreasesinearlystageandincreasesinterminalstage,Increasedaldostenrone21水電解質(zhì)代謝與酸堿平衡失調(diào)2.低滲性脫水.2Hypotonicdehydration

LaboratoryInvestigation:Concentratedblood,increasedMCV,MCHC,Oliguria,non-increasedurinespecificgravity,SeverelydecreasedNatriumandChlorineinurine.IncreasedplasmaproteinandBUN,DecreasedplasmaNatriumandChlorine,DecreasedOsmoticpressure.ExtentΔNaCl/kgBWPNa(meq/L)ClinicalfindingLight0.5g130~135Tired,Apathy,Faint,extremeanaesthesia,Withoutthirsty,decreasedurineNa,normalurinevolumeModerate0.6~0.8g120~130Theabovesymptomaggravate,Anorexia,Nausea,Vomiting,Sleepiness,Collapsedveinsandpulse,UnsteadyordecreasedBP,illegibleeyesight,Orthostaticfaint,Oliguria,withoutchlorideinurine

SevereAbove0.8gbelow120CNSsymptom:Dottiness,Jerk,Decreasedtendonreflexes,Anesthsiaofdistalextremities,shock.22水電解質(zhì)代謝與酸堿平衡失調(diào)3.等滲性脫水.1

IsotonicdehydrationDefinition:ThelossoffluidiswaterandelectrolytesinapproximatelythesameproportionasthatinthichtheyexistinnormalECF.PlasmaNa+isnormal.(isotonia)Cause:Acutelossesofgastrointestinalfluidsduetovomiting,diarrhea.Ponderosusascitedrainage,Earlystageoflargeareaempyrosis(exudation).It’salsocalledacutewaterdeficits.Pathophysiology:DecreasedECF,Severevolumedepletion,Increasedaldostenrone

23水電解質(zhì)代謝與酸堿平衡失調(diào)Clinicalfinding:Hydropeniasyndrome:Thirsty,Oliguria,Withthesodiumdeficit:Anorexia,nausea,adynamia.Above4%ofweight:Symptomofseverevolumedepletion.Absentperipheralpulses,Coldextremities,unsteadyordecreasedBP.Above6%ofweight:peripheralcirculatoryfailure,ShockItisoftenaccompaniedwithmetabolicacidosis.Whenthegastricjuicelostseverely,itwillbeaccompaniedwithmetabolicalkalosis.LaboratoryInvestigation:Concentratedblood,NormalMCV,MCHC,Increasedurinespecificgravity,DecreasedNatriumandChlorineinurine.IncreasedplasmaproteinandBUN,NormalplasmaNatrium,Chlorine,andOsmoticpressure3.等滲性脫水.2

Isotonicdehydration24水電解質(zhì)代謝與酸堿平衡失調(diào)Thetreatmentoftheprimarydiease.Restoringvolumeandthedeficientelectrolytes.Thecontentsoffluidreplacementcontain:thevolumeofphysiologicalrequirements,Preexistingdeficits,andongoinglosses.Thereplacementofexistingdeficitsofvolume:theextentandcategoryofdehydrationdecidethevolumeandthetypeofsolution(G/N),respectively.Hypertonicdehydration----5-10%GlucoseSolution.

Hypotonicdehydration----normalsalineor3~5％saline(Hypertonic)Isotonicdehydration---5%GNSTakeorallyasfaraspossible,supplyfromveinswhenthepatientcannottakeorally.

2.脫水的處理原則

Thetherapicprincipleofdehydration25水電解質(zhì)代謝與酸堿平衡失調(diào)ElectrolyteDisordersHypokalemia26水電解質(zhì)代謝與酸堿平衡失調(diào)①

Transportationbetweenextra-andintracellular:Physiologicfactor:Na＋－K＋ATPenzyme,Digitaloiddrugs，Catecholamine,Insulin,Bloodglucoseconcentration,BloodPotassiumconcentration,Heavyexercise.

Pathologicfactor:PlasmapH(inorganicacid),Hypertonia,histoclasia,excessivegrowth.②Regulationofbody：

IntakeandexcretedofPotassium：

Kidney：aldosterone(actatcollectingtubuletopromotethesecretionofPotassium)glucocorticosteroid(keepnatriumandexcretePotassium)AdjustofSerumPotassium27水電解質(zhì)代謝與酸堿平衡失調(diào)Definition:SerumPotassium<3.5mmol/L.

體內(nèi)缺鉀300mmol以上時(shí)，血清鉀才下降。Cause:

①

鉀攝入量不足：禁食、厭食、拒食時(shí)間較久②

鉀損失過(guò)多：大量出汗、嘔吐、腹瀉、胃腸減壓、腸瘺；利尿藥、腎小管酸中毒、棉酚中毒Conn綜合征et.al.③

體內(nèi)分布異常：糖元、蛋白合成，堿中毒，低鉀性周期性麻痹，兒茶酚胺制劑，細(xì)胞生長(zhǎng)過(guò)速，鉀進(jìn)入細(xì)胞內(nèi)Hypokalemia128水電解質(zhì)代謝與酸堿平衡失調(diào)Clinicalfinding：

鉀的丟失主要來(lái)自細(xì)胞內(nèi)，C內(nèi)含鉀很豐富，故機(jī)體丟鉀350mmol以下時(shí)，無(wú)臨床表現(xiàn)；臨床表現(xiàn)的嚴(yán)重與否、取決于鉀丟失的多少及丟失的速度。

臨床表現(xiàn)包括以下6個(gè)方面：

①循環(huán)系統(tǒng)；②神經(jīng)肌肉系統(tǒng)；③

CN系統(tǒng)；

④泌尿系統(tǒng)；⑤消化系統(tǒng)；⑥肌纖維溶解；⑦酸堿平衡失調(diào)。Hypokalemia229水電解質(zhì)代謝與酸堿平衡失調(diào)①Circulationsystemcardiacdamage：壞死、細(xì)胞侵潤(rùn)、瘢痕－心衰arhythmia：期前收縮、陣發(fā)性心動(dòng)過(guò)速、室撲或室顫、猝死Susceptibletodigitalisintoxication：

ECG：K＋﹤3.0，U波出現(xiàn)、TU融合

K＋﹤2.5，ST段下移、T波倒置

U波出現(xiàn)，體內(nèi)缺鉀400mmol以上

hypopiesia：植物N功能紊亂、血管擴(kuò)張引起

Hypokalemia3臨床表現(xiàn)：30水電解質(zhì)代謝與酸堿平衡失調(diào)②neuromuscularsystem

骨骼?。杭o(wú)力(K＋﹤3.0)、肌痛、肌麻痹、軟癱(K＋﹤2.5)

平滑?。焊姑?、便秘、麻痹性腸梗阻、尿潴留

K＋是許多酶的激活劑,與三羧循環(huán).乙酰膽堿合成有關(guān)③centralnervoussystem

神志淡漠、目光呆滯、疲乏；煩躁不安、情緒激動(dòng)、精神不振；嗜睡、定向力障礙、昏迷(K＋﹤2.0)

與糖代謝障礙、能量生成及乙酰膽堿生成減少有關(guān)

Hypokalemia4臨床表現(xiàn)：31水電解質(zhì)代謝與酸堿平衡失調(diào)④urinarysystem

多尿、夜尿增多、甚至腎衰－煩渴、多飲

缺鉀可引起腎小管上皮細(xì)胞損害；體內(nèi)缺鉀200mmol時(shí)腎小管濃縮功能↓⑤digestivesystem

食欲不振、惡心、嘔吐、腹脹、便秘⑥musclefibrolysis

K＋﹤2.5，肌紅蛋白尿、甚至急性腎衰

Hypokalemia5臨床表現(xiàn)：32水電解質(zhì)代謝與酸堿平衡失調(diào)Hypokalemia6臨床表現(xiàn)：⑦cid-basedisturbance

metabolicalkalosis

paradoxicalaciduria低鉀時(shí)，①C內(nèi)K＋與C外H＋交換↑，

C內(nèi)H＋↑→C內(nèi)酸中毒；

C外H＋→C外液堿中毒。②腎保Cl-↓，尿Cl-↑，

Na＋重吸收時(shí)不能與Cl-

而與HCO3-→HCO3-重吸收↑低鉀時(shí)，代謝性堿中毒腎小管上皮細(xì)胞內(nèi)K＋↓，

K＋與腎小管管腔中的Na＋交換↓，H＋與Na＋交換↑，尿呈酸性，腎排H＋↑33水電解質(zhì)代謝與酸堿平衡失調(diào)Diagnosis：主要依靠病史＋表現(xiàn)血清Ｋ＋<3.5mEg/L,EKG特征改變→確診注意:酸中毒、脫水時(shí)，重癥才出現(xiàn)Therapy：

積極治療原發(fā)病，必要時(shí)補(bǔ)充鉀鹽。

注意：盡量口服，不能口服者V補(bǔ)給（常用10％KCl）；尿少不補(bǔ)K；濃度不宜過(guò)高（≤0.3%）；速度不宜過(guò)快(<80d/分)；總量不宜過(guò)多(6g左右)

最好加入NS，加入GS有可能使血鉀更低；丟正糖尿病酮癥酸中毒時(shí)，應(yīng)特別注意低鉀可能。Hypokalemia734水電解質(zhì)代謝與酸堿平衡失調(diào)Acid-baseBalance35水電解質(zhì)代謝與酸堿平衡失調(diào)

Theph(thenegativelogarithmofthehydrogenionconcentrationPH=7.35~7.45)ofthebodyfluidsisnormallymaintainedwithinnarrowlimitsdespitetheratherlargeloadofacidproducedendogenouslyasaby-productofbodymetabolism.包括四個(gè)方面:A.buffersystem

（作用快,僅能應(yīng)付急需）

HCO3－

27mmol/L20==(PH7.4)H2CO31.351mmol/L1

B.CO2

excretedviathelungs

（體內(nèi)揮發(fā)性酸H2CO3）

調(diào)節(jié)血液中的呼吸性成分，即H2CO3（PCO3）

1.MaintainofAcid-baseBalance136水電解質(zhì)代謝與酸堿平衡失調(diào)1.MaintainofAcid-baseBalance2C.Kidney

—排出固定酸和過(guò)多的堿性物質(zhì)維持血中HCO3－濃度的穩(wěn)定機(jī)理：H＋—Na+交換；HCO3－重吸收；正常尿液PH值6，最低4.4

—腎有強(qiáng)排酸功能D.Bufferingeffectofcell

細(xì)胞內(nèi)每進(jìn)入1個(gè)H＋＋2個(gè)Na＋→3個(gè)K＋替換出堿中毒：H＋出細(xì)胞內(nèi)→K＋入細(xì)胞內(nèi)—低血鉀酸中毒：H＋入細(xì)胞內(nèi)→K＋出細(xì)胞內(nèi)—高血鉀37水電解質(zhì)代謝與酸堿平衡失調(diào)2.DisturbancesofAcid-baseBalanceMetabolicacidosis（CO2CP↓，PH↓）Metabolicalkalosis（CO2CP↑，PH↑）Respiratoryacidosis

（PCO2↑、CO2CP↑、PH↓）Respiratoryalkalosis

（PCO2↓、CO2CP↓、PH↑）HCO3－H2CO3增多減少增多減少38水電解質(zhì)代謝與酸堿平衡失調(diào)Metabolicacidosis1

Retentionoffixedacidsorlossofbasebicarbonate.Thecausesofmetabolicacidosiscanbedividedintotwomanageablegroupsbydeterminingtheaniongap：

高AG代酸-常見(jiàn)于尿毒癥、糖尿病酮癥酸中毒、乳酸中毒

正常AG代酸—常見(jiàn)于HCO-3丟失過(guò)多及應(yīng)用含有Cl-的藥物Aniongap,AG:Amountoftheunmeasuredanions(i.e.sulfateandphosphatepluslactateandotherorganicanions).正常值：10～15mmol/L.AG=（Na++K+）-(HCO-3+Cl-)均以mEq/L為單位

145/155134/155

（95%）（85%）

=未測(cè)定陰離子-未測(cè)定陽(yáng)離子

因K+很低，所以AG=Na+-(HCO-3+Cl-)39水電解質(zhì)代謝與酸堿平衡失調(diào)Metabolicacidosis2

Cause：Excessivelossesofbicarbonate

—見(jiàn)于消化道瘺、嘔吐、腹瀉Retentionofacids

—腹膜炎、休克、高熱、長(zhǎng)期未進(jìn)食者ExcretionofH+andresorptionofHCO3-decrease

—腎衰40水電解質(zhì)代謝與酸堿平衡失調(diào)Metabolicacidosis3

Clinicalfinding：

輕者：常被原發(fā)病所遮蓋

重者：疲乏、眩暈、嗜睡、遲鈍、煩躁不安

呼吸深快、帶酮味（爛蘋(píng)果味）面部潮紅、心率↑、BP↓、神態(tài)不清-昏迷常伴嚴(yán)重脫水、休克、尿少、尿酸性反應(yīng)。Diagnosis：病史＋臨床表現(xiàn)＋血?dú)夥治?/p>

41水電解質(zhì)代謝與酸堿平衡失調(diào)Metabolicacidosis4

Therapy：嚴(yán)重者，才需V補(bǔ)堿性藥物

5%NaHCO3ml=（50-CO2CP）×Kg×0.5

(作用快、效確切最常用)

11.2乳酸鈉ml=（50-CO2CP）×Kg×0.3

(休克、肝功不良禁用)

3.6%THAMml=（50-CO2CP）×Kg×1

(細(xì)胞內(nèi)外均能起作用,但副作用多,一般不用)

※公式計(jì)算量易偏多，實(shí)際中常先輸入計(jì)算量1/2～2/3※也可先按提示10vol%的CO2CP補(bǔ)給，再據(jù)測(cè)得的CO2CP值調(diào)整。

45vol%以上、尿堿性、即停補(bǔ)。尿量↑、注意補(bǔ)鉀。42水電解質(zhì)代謝與酸堿平衡失調(diào)PrinciplesofFluid&ElectrolyteTherapyFluid&ElectrolyteAbnormalities

PreventDisease43水電解質(zhì)代謝與酸堿平衡失調(diào)

Prevent1.

Thevolumeofphysiologicalrequirements(2000～2500ml):

5-10%GS1500ml

等滲鹽500～1000ml10%KCI30ml2.Recruitthesensiblelossesintime

體溫每增加1℃，每公斤體重需增補(bǔ)液體3～5ml

汗?jié)?襯衣、褲-增補(bǔ)1000ml

氣管切開(kāi)-增補(bǔ)1000ml/日3.Perioperativefluidreplacement

小手術(shù)—不需大手術(shù)—術(shù)日清晨開(kāi)始急癥手術(shù)、有紊亂者術(shù)前盡可能部分糾正，術(shù)后繼續(xù)術(shù)后胃腸功能未恢復(fù)補(bǔ)生理需要量有胃腸減壓者—酌情↑術(shù)后1-2日不補(bǔ)K＋，3日后仍不能進(jìn)食、補(bǔ)鉀3-4g/日44水電解質(zhì)代謝與酸堿平衡失調(diào)Therapy11．CalculationoffluidreplacementPhysiologicalrequirements：2000～2500ml，其中NS500mlPreexistingdeficits：On-goinglosses：胃腸道繼續(xù)丟失；內(nèi)在性失液；發(fā)熱出汗酌情于當(dāng)天or次日補(bǔ)給,丟失什么,補(bǔ)什么

45水電解質(zhì)代謝與酸堿平衡失調(diào)Therapy2已喪失量的估計(jì)方法◎缺水的日數(shù)：脫水1日喪失體重的2%◎體重的減輕數(shù)：◎臨床表現(xiàn)：◎血清Na＋濃度：高滲：降1mmol/L的Na＋需補(bǔ)男4ml、女3ml/Kg體重低滲：缺Na＋量mmol/L=體重Kg×0.6×(140－[Na＋])∵1LNaCI=154mol.∴NS量(L)=缺Na量／15446水電解質(zhì)代謝與酸堿平衡失調(diào)Therapy3

根據(jù)臨床表現(xiàn)估計(jì)Preexistingdeficits程度高滲脫水缺水占體重需補(bǔ)液量ml/Kg體重低滲缺水缺NaCI量（g/Kg體重）補(bǔ)NS量ml/Kg體重輕度2～4%200.525中度4%～6%20～400.7520～40重度7～%40～601.040～6047水電解質(zhì)代謝與酸堿平衡失調(diào)Therapy4常用溶液的電解質(zhì)含量(mEg/L)SolutionNa＋CI－K＋Ca＋＋Mg＋＋HCO3－lactatePlasma142103552275Balancedsaline1541545％saline850850Ringer'ssolution14715746SodiumLactate170170LactatedRinger's1301024427635%NaHCO359559510%KCI13401340intradex15315348水電解質(zhì)代謝與酸堿平衡失調(diào)

Therapy5

注意事項(xiàng)1.managementforprimarydisease2.Identifytheextentandtypeofdehydration3.Takenoticeofthefunctionofpatient’sheart,lung,kidney,especiallyforagedpeople.4.Thedisturbanceofwater,electrolytes,acid-basebalancemayoccuratthesametime.5.Closelymonitorthechangeofpathogeneticcond