英文班水电解质授课

1、,病 例 分 析 男性 29岁，王XX,因急性上腹部疼痛 12小时，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。HR 150次/分，R 38次/分，BP 170/98mmHg，无尿。腹部体征示，压痛、反跳痛、严重的腹胀，后背部有凹陷性水肿。诊断性穿刺游离腹腔内有棕褐色腹腔渗液， CT发现肠腔内有大量的液体积聚。,伴有水、电和酸、碱紊乱的程度 1 存在严重的脱水,如何补液？ 2 第三间隙的液体急剧积聚，何为第三间隙？ 3 Na+ 155mmol/l, Cl- 115mmol/l, K + 6.5mmol/l, Ca 1.0mmmol/l，如何纠正？ 4 伴有代谢性酸

2、中毒、呼吸性碱中毒，如何处理？,Fluid ascites; soft tissue injuries. bowel 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 membrane,water,water,Semi-per

3、meable membrane,Anion and Cation as well as non-electrolyte particles,Definition the number of osmotically active particles or ions per unit volume. Unit : milliosmoles per liter （mOsm / L）,Plasma Osmotic Pressure,Normal Range =290310mOsm/L,Relation between Osmotic pressure and distribution of body

4、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 Crystal OP：Contributes to the shift of extracellular and intracellular water,Plasma,Interstiti

5、al Fluid,ICF,ECF,Na+,Colloid OP Plasmatic protein,Crystal OP,Semi-permeable membrane,Crystal OP,Colloid OP,Crystal OP,The Regulation of Body Fluid Balance,Maintaining normal osmotic pressure Maintaining normal concentration and no more than 12 mmol/L within 24 hs. Complication:Osmotic Demyelination

6、Syndrome(ODS). Pontine demyelination (桥脑脱髓鞘样变),Management of severe acute and chronic hyponatremia,EFW: electrolyte free water,Therapy 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

7、 next hour.,Raising Na + to 130mmol/L at 12mmol/h; and 12mmol/L within 24 h. How to calculate the amount of 10NaCl per hour Raising Na + /h Kg 0.6(女0.5)= the amount of mmol of NaCl,Therapy for Severe Chronic hyponatremia,Convulsion or Coma: PNa rise 5mmol/L in 2-3 hours No convulsion: PNa rise 8mmol

8、/L/day Restrict water Think ICF K+,Hypertonic ECF deficit,Etiology(Primary) Restricted water intake in circumstances: Sweat Burn Diabetic coma,Hypertonic ECF deficit Clinical manifestations,Central nerve system restless,weakness,delirium,maniacal behevior,coma tissue signs -dry and thirsty, sticky m

9、ucous membranes,Dehydration fever Tachycardia Oliguria,Hypertonic ECF deficit Diagnosis,Etiology Laboratory Increased sodium ( 150mmol/L) Digestive tract ( Vomiting, Diarrhea, Gastric suction, Intestinal fistula ),Less in-take: Less dietary intake ; potassium-free parenteral fluids Redistribution Th

10、e transfer of extracellular potassium into cells（Alkalosis）,2K+ 1H+,3Na+,Cell,H+HCO3- =H2O+CO2,2K+ 1H+,3Na+,General: Anorexia,Nausea,Vomiting Skeletal muscles (Diminished to absent tendon reflexes, respiratory hypoventilation) Smooth muscles(Paralytic ileus ) Cardiac muscles (Hypotension),Hypokelami

11、a Clinical manifestations,Muscular weakness Flaccid paralysis ( k + 2.5mmol / L） CNS（Serum potassium2.0mmol/L） MorbusObnubilation(神志不清)、disorientation,Hypokelamia Clinical manifestations,Cardiovascular ECG: ST segment depression, decreased T wave, Increased U wave, T U Arhythmia: Premature ventricul

12、ar and atrial contractions ventricular and atrial tachyarhythmias,History Clinical symptoms Serum potassium3.5 mmol/L EKG,Hypokelamia Diagnosis,The quantities of supplemental potassium Serum potassium 3 mmol/L. To replace 200400mmol，May be increased by 1mmol/L Serum potassium 33.5mmol/L To replace 1

13、00200mmol， May be increased by 1mmol/L,Hypokelamia Treatment,The rate of administration (intravenous) Should not exceed 20 mmol K+ / hr,Hypokelamia Treatment,Attention Therapy of shock Urine output arrive at 40 ml/hr, and potassium infused - No more than 40 mmol K+added to 1 liter (0.03%) of IV flui

14、ds via peripheral vein infused,No more than 100200 mmol infused per day Calcium not infused,Excessive potassium entered into blood circulation Iatrogenicity , Infusion of excessive potassium Infusion of a vast reserve of blood,Hyperkelamia(5.5mmol/L) Common causes,Renal excretion decreased Abnormal

15、distribution Acidosis Acute tumor lysis, burn, Acute intravascular hemolysis,gastrointestinal Nausea 11.2% Sodium lactate, GI - diuretics - Cation-exchange resins (oral ; maintaining clysis) - peritoneal dialysis, or hemodialysis, hemofiltration,高钾血症,EKG变化？,10分钟内起效？,静脉推注葡酸钙 去除病因,转移到细胞内： 胰岛素 NaHCO3,泌

16、尿系统,测尿钾,胃肠道,减少口服 离子交换树脂口服或灌肠,尿钾低,血液透析,增加尿钾排出： 盐皮质激素 NaHCO3 乙酰唑胺,是,不,Disturbances of CalciumHypocalcemia(2.0mmol/L),Causes: acute pancreatitis;renal failure;intestinal fistula; Infusion of a vast reserve of blood Manifestation Symptoms:numbness; tingling(麻刺感);Apnea; Tetany Signs: Hyperactive tendon r

17、eflexes; Chvosteks Signs,Treatments:10%calcium gluconate;5%Calcium Chloride,Disturbances of CalciumHypercalcemia(4.0mmol/L),Causes:hyperparathyroidism; Bony Metastasis Manifestations:Fatigue; Vomiting Treatment: EDTA; Na2SO4,Acid-base imbalance,Buffer system A weak acid or base & the salt of that ac

18、id or base Intracellular Extracellular Red cell B.Protein/H.Protein B.HCO3/H2CO3 B.Hb/HHb B2HPO4/ BH2PO4 B.HbO2/HHbO2 Anion Gap=Na+Cl-+HCO3-,Assumption:pre- existing potassium depletion Outcome: Intracellular (3 K)and extracellular ( 2Na+、1 H+ ) exchange,In the regulation of acid-base balance The im

19、portant role of potassium,Decreased H+ and K+ exchange, Increased H+ and Na+ exchange in renal tubule Paradoxical acid urine Metabolic alkalosis is aggravated,Sensible acids are excreted via the lung HCINaHCO3 NaCIH2CO3 H2O CO2,The important role of the lung,Insensible acids excreted by kidney Inorg

20、anic acid anions （hydrochloric、sulfuric、phosphoric acids） with hydrogen（H+Na+ exchange） ammonium salts（H+NH3NH4-）,The important role of the kidney,organic acid anions（lactic、keto、pyruvic acids） Be metabolized Some renal excretion（with high levels）,BHCO3- pHpKlog H2CO3 27mmol/L 6.1log 1.35mmol/L 2 0

21、6.1log 1 6.1 1.3 = 7.4,Henderson - Hasselbalch equation,氧离曲线与组织的缺氧,Bohr 效应（H+ 、CO2、O2三者与Hb的关系） H HbO2+H+CO2 Hb +O2 CO2,组织,肺部,氧饱和度(SaO2),氧分压 (PaO2),正常,右移,左移,HbO2的O2解离曲线(S型),Metabolic Acidosis(pH7.35),Metabolic acidosis Clinical manifestations,Increased in depth & frequency of respiration (Kussmaul br

22、eathing) Peripheral vessels dilated ，Circulatory shock, Cerise lip,Decreased muscular tension & tendon reflex merged Unconsciousness,Metabolic acidosis Treatments,Principles Therapy for basic disease Alkali treatment: dose initials 1 / 3 1 / 2 requisite amount Pre-treatment: serum K+ & Ca+,The amoun

23、t of Alkali necessary,-（normal CO2-CP serum CO2-CP）TBW（Kg）0.4,-（BE3）BW（Kg）0.4,-（normal SB observed SB）BW（Kg）0.4,Loss of base ( mEq ),Metabolic acidosis Treatment,Some of alkalescent solution contains HCO 3 -,1 gm NaHCO312 mmol HCO3 - 1ml - 11.2%NaC3H5O31 mmol HCO3 - 1ml - 3.63%THAM(三羟甲基氨基甲烷)0.3 mmol

24、 HCO3 -,Metabolic acidosis Treatment,Respiratory Acidosis(pH7.35),Respiratory Acidosis Clinical manifestation,Advanced respiratory insufficiency(Apnea) Metabolic encephalopathy (headache, drowsiness, stupor and coma, papilledema),Blood pressure elevated reduced Ventricular fibrillation (hyperkalemia

25、),Respiratory Acidosis Treatment,Treatment of Causes To improve ventilation Alkalescent solution is harmful !,Metabolic alkalosis(pH7.45),Peripheral vessel constricted Mental symptoms:Delirium,Drowsiness,Metabolic alkalosis Clinical manifestations,Decreased in depth & frequency of respiration Tetany & tendon reflex accentuation,Therapy for basic disease Correction of the underlying disturbances Loss of gastric fluid replaced with NS or GNS potassium deficit correction of hypokalemia Serum HCO3,4550 mmol/L，pH7.65 0.1 M hydrochlori