1、7/30/2018 11:33 PM,外科病人的体液失调Fluid Disorders of Surgical Patients,7/30/2018 11:33 PM,有用的概念Useful Concepts,7/30/2018 11:33 PM,体液,脊椎动物进化于海水脊椎动物身体的大约2/3是水大多数脊椎动物的细胞外液的浓度是恒定的体液=水+电解质+蛋白质+气体,7/30/2018 11:33 PM,Body Fluid 体液,Major Factors Affecting Body FluidsAgeGenderBody fat,影响体液的主要因素年龄性别体脂,7/30/2018 11:
2、33 PM,Body Fluid 体液,Birth: 75-80% of body composition1 year: 65%After puberty60% males50% femalesOlder adults50% males40% females,出生： 75-80% 身体成分1岁：65%青春期后60% 男50% 女老年50% 男40% 女,7/30/2018 11:33 PM,Body Fluid 体液,Intracellular Fluid (ICF) 40% BW for male 35% for female)Extracellular Fluid (ECF) 20% BW
3、Plasma5% BWInterstital Fluid15% BW,细胞内液 (ICF) 40%体重（男）35%体重（女）细胞外液 (ECF) 20%体重血浆5%体重组织间液15%体重,7/30/2018 11:33 PM,Body Fluid 体液,细胞内液Na+ CI- , HCO3 - & Protein -细胞外液K +, Mg + HPO42- & Protein -,7/30/2018 11:33 PM,Homeostasis 内稳态,Homeostasis, from the Greek words for same and steadyDefined as the dynam
4、ic constancy of the internal environment despite changes in the external environmentMore a dynamic state in which internal conditions vary within narrow limits,内稳态一词来自希腊文“相同的”和“稳定的”指无论外环境如何变化，保持内环境的动态稳定内环境的多数的动态变化仅限于很窄的范围,7/30/2018 11:33 PM,Homeostasis 内稳态,Necessary for survivalMost of these mechani
5、sms operate by negative feedbackEvery organ system plays a role in maintaining homeostasisNervous and endocrine systems are major communication systems,内稳态为生存所必需大多数以负反馈机制调节每一器官系统对维持内稳态具有作用神经内分泌系统是主要的信息传递系统,7/30/2018 11:33 PM,Osmotic Pressure 渗透压,The pressure required to stop osmosis through a semipe
6、rmeable membrane between a solution and pure solventIt is proportional to the osmolality of the solution. Normal value290-310 mmol/LFormula2(Na)+K+BUN+Glu,指为维持通过半透膜所隔开的溶液与纯溶剂之间的渗透平衡而需要的压力与重量克分子渗透压浓度一致正常值290-310 mmol/L公式2(钠)+钾+尿素氮+葡萄糖,7/30/2018 11:33 PM,Fluid Balance 体液平衡,Water balanceWater intake &
7、loss are equalElectrolyte balanceEctrolytes absorbed in small intestine = amount lost in urineAcid base balanceHydrogen ions lost = hydrogen ions produced by metabolism,水平衡水摄入=水丢失电解质平衡小肠吸收电解质量=尿中丢失量酸碱平衡氢离子丢失=代谢产生,7/30/2018 11:33 PM,Fluid Regulation 体液调节,ThirstKidneysADHAldosteroneAngiotensin IIProst
8、aglandinsGlucocorticoidsAtrial Natriuretic Peptide,渴感肾脏抗利尿激素醛固酮血管紧张素前列腺素糖皮质激素心钠素,7/30/2018 11:33 PM,水、钠代谢紊乱Water and Sodium Disorders,7/30/2018 11:33 PM,Water Balance 水的平衡,7/30/2018 11:33 PM,Water Balance 水的平衡,NPO (non per os ) Anorexia,摄入水（INPUT）,7/30/2018 11:33 PM,Sodium 钠,Since sodium (Na) is the
9、 major osmotically active cation in the ECF compartment, changes in total body Na content are paralleled by changes in ECF volume,钠是细胞外液间隙中主要的渗透性活性阳离子，体内钠含量的变化与细胞外液容量的变化是平行的,7/30/2018 11:33 PM,Composition of GI Secretions 消化液成分,7/30/2018 11:33 PM,Dehydration 缺水,Dehydration is a condition that occurs
10、 when the loss of body fluids, exceeds the amount that is taken inIsotonic dehydrationHypotonic dehydrationHypertonic dehydration,缺水指体液丢失超过摄入等渗性缺水低渗性缺水高渗性缺水,7/30/2018 11:33 PM,Dehydration 缺水,Normal RBCs,Isotonic Solution,Equal movement of waterinto and out of cells,Net movement ofwater out of cells,
11、Net movement ofwater into cells,Shriveled RBCs,Swollen RBCs,Hypertonic Solution,Hypotonic Solution,7/30/2018 11:33 PM,Isotonic dehydration 等渗性缺水,Usually called fluid volume deficit, or hypovolemia in WestSodium loss = water lossSerum Na+ unchangedPlasma osmotic pressure unchanged,在西方通常称作容量缺乏或低血容量钠丢失
12、=水丢失血清钠不变血浆渗透压不变,7/30/2018 11:33 PM,Isotonic dehydration 等渗性缺水,CausesExcessive Fluid LossesVomiting, diarrhea, GI suction, hemorrhage，intestinal fistulae, burn, intestinal obstruction, intra-abdominal infection, ect. Poor / Inadequate Fluid Intake,病因体液丢失过多呕吐、腹泻、胃肠减压、出血、肠瘘、肠梗阻、腹腔感染等摄入不足,7/30/2018 11:
13、33 PM,Isotonic dehydration 等渗性缺水,Clinical ManifestationsAcute weight lossUrinary Output AnorexiaFlattened neck veins Muscle weakness May not thirstCool, clammy skinSkin turgor Weak, rapid pulseOrthostatic hypotension,临床表现急性体重丢失尿量减少厌食颈静脉萎陷肌肉无力可能不口渴皮肤湿冷皮肤弹性下降脉搏细弱体位性低血压,7/30/2018 11:33 PM,Isotonic dehy
14、dration 等渗性缺水,Management Replace ECF lossAddress underlying cause IV route: Isotonic Solutions (Lactated Ringers, LR),处理补充细胞外液量去除病因静脉补液：等渗溶液（乳酸林格氏液）,7/30/2018 11:33 PM,Hypotonic Dehydration 低渗性缺水,DefinitionSodium losswater lossosmotic pressure 290mmol/LNa+水丢失血浆渗透压 290mmol/L血清Na+ 135mmol/L也称作低血容量性低钠血
15、症,7/30/2018 11:33 PM,Hypotonic Dehydration 低渗性缺水,CausesGI losses: Vomiting and diarrhea, intestinal obstruction, fistulas, drainage and NG tubes (chronic)Renal losses: Use of diuretics Extensive wounds (burn)Third spacing (peritonitis, pancreatitis, intestinal obstruction, ascites),病因胃肠道丢失：长期呕吐和腹泻，慢
16、性肠梗阻，肠瘘，引流管和鼻肠管肾脏丢失：利尿剂的应用大面积创伤(烧伤) 第三间隙丢失：(腹膜炎，胰腺炎，肠梗阻，腹水),7/30/2018 11:33 PM,Hypotonic Dehydration 低渗性缺水,Clinical ManifestationsNeurologicalHeadacheLethargyConfusionSeizuresComaGastrointestinal AnorexiaNausea and vomiting,临床表现神经系统头痛嗜睡意识错乱癫痫发作昏迷胃肠道厌食恶心和呕吐,7/30/2018 11:33 PM,Hypotonic Dehydration 低渗
17、性缺水,Severity of IllnessMild: Serum Na+135mmol/LModerate: Serum Na+130mmol/LSevere: Serum Na+120mmol/L,分度轻度：血清钠+ 135 mmol/L中度：血清钠+ 130 mmol/L重度：血清钠+ 120 mmol/L,7/30/2018 11:33 PM,Hypotonic Dehydration 低渗性缺水,Diagnosis HistoryClinical findingsLabSerum Na+135mmol/L RBC, Hb, Ht, BUN Urine gravity, osmola
18、lity and Na+,诊断病史临床表现实验室检查血清钠+150mmol/LPlasma osmotic pressure310mmol/LAlso called hypovolemic hypernatremia,水丢失钠丢失血清钠Na+150mmol/L血浆渗透压310mmol/L也称作低血容量性高钠血症,7/30/2018 11:33 PM,Hypertonic Dehydration 高渗性缺水,CausesSodium Excess Dietary IntakeFoods Medications high in sodiumWater DeficitInadequate intak
19、e Increased insensible losses (i.e. fever)Watery diarrheaOsmotic Diuresis,病因钠过多饮食摄入食物高钠药物水缺乏摄入不足非显性失水增加（发热）水样泻渗透性利尿,7/30/2018 11:33 PM,Hypertonic Dehydration 高渗性缺水,Clinical Manifestations NeurologicalRestlessnessAgitationConfusionSeizuresComa Other Severe thirst, dry mucous membranes, muscular twitc
20、hing, hyperactive deep tendon reflexes, anorexia, nausea and vomiting,临床表现神经系统烦躁兴奋意识混乱癫痫昏迷其他重度口渴，粘膜干燥，肌肉抽搐，腱反射亢进，厌食，恶心，呕吐,7/30/2018 11:33 PM,Hypertonic Dehydration 高渗性缺水,DegreeMild: 2-4% loss BW or 6% BW or 30-40% BVShock: 8% BW or 40% BVLabSerum Na+150mmol/L RBC, Hb, Ht Urine gravity and osmolality
21、,分度轻度: 血容量2-4%体重或 6%体重或 30-40%血容量休克: 8%体重或 40%血容量实验室血清钠150mmol/L红细胞、血红蛋白、压积升高尿比重和渗透压浓度升高,7/30/2018 11:33 PM,Hypertonic Dehydration 高渗性缺水,Management5%glucose0.45%NaCl,处理5%葡萄糖0.45%氯化钠,7/30/2018 11:33 PM,Fluid Volume Excess 体液容量过多,Clinical ManifestationsRapid weight gainPeripheral EdemaDistended neck v
22、einsShortness of breathBounding pulse Blood pressureCracklesOrthopnea,临床表现快速体重增加外周水肿颈静脉扩张气短洪脉血压升高湿罗音端坐呼吸,7/30/2018 11:33 PM,Fluid Replacement 补液,MaintenanceDeficitActual weight loss vs estimateGive in first 8 hrs and in next 16 hrsOngoing lossesNG losses, fistulas, third space, etc,维持量缺乏量急性体重丢失（相对于评
23、估）头8小时给与1/2，后16小时给与1/2继续丢失量鼻胃管丢失，瘘，第三间隙等,7/30/2018 11:33 PM,Colloids to restore perfusion 胶体恢复灌注,IndicationsHypotensionTachycardiaOliguriaCool peripheriesKnown blood lossMajor surgical procedureSevere traumaSepsisOther Critical illness,指征低血压心动过速少尿外周冷已知血液丢失大手术严重创伤脓毒症其它危重病,7/30/2018 11:33 PM,钾的异常Posta
24、ssium Disorders,7/30/2018 11:33 PM,Postassium Disorders 钾的异常,Most abundant cation in ICFNormal serum K+: 3.55.5mmol/LEven minor variations in serum potassium levels are significant Major functionsMaintaining electrical neutrality & osmolalityAssists in neuromuscular transmission of impulsesAssists i
25、n skeletal and cardiac muscle in contraction & electrical conductivity Maintaining acid-base balances,细胞内最多的阳离子正常血清钾+: 3.55.5mmol/L即使血清钾水平微小变化都可能产生显著影响主要功能维持电中和与渗透压浓度促进神经肌肉冲动传播维持酸碱平衡,7/30/2018 11:33 PM,Hypokalemia 低钾血症,Serum K+ 3.5 mmol / LEtiology Inadequate intakemalnutrition IVF deficient in pota
26、ssium GI LossesVomiting, gastric suctioning and diarrheaOther: long-term abuse of laxatives or enemasGU lossesDiuretics (Non-K Sparing), renal tubular acidosisIntracellular uptake with redistribution seen in acute alkalosis, insulin therapy, and anabolism,血钾 3.5 mmol / L病因摄入不足营养不良补液缺钾胃肠道丢失呕吐，胃肠减压，腹泻
27、长期泄剂滥用或灌肠泌尿系丢失利尿剂（非保钾），肾小管酸中毒细胞内摄取重新分布，见于急性酸中毒，应用胰岛素和合成代谢,7/30/2018 11:33 PM,Hypokalemia 低钾血症,Clinical Manifestations CardiacWeak, irregular pulse Dysrhythmias and EKG changes Cardiac arrest and death Neuromuscular Skeletal muscle weaknessHypoactive deep tendon reflexesEnteroparalysisOther Constipat
28、ion, fatigue, anorexia & N/V,临床表现心血管脉搏细弱不规律心律失常，心电图改变心跳停止，死亡神经肌肉骨骼肌无力腱反射减弱肠麻痹其他便秘，乏力，厌食，恶心，呕吐,7/30/2018 11:33 PM,Hypokalemia 低钾血症,EKGlow, flat T-waves, ST depression, and U waves,心电图T波低平，ST压低，U波,7/30/2018 11:33 PM,Hypokalemia 低钾血症,Treatment Treat alkalosisIV K+20 mmol/hr 40 mmol/L（3gKCl） 1gKCl=13.4m
29、mol/L,治疗治疗碱中毒静脉补钾 5.5 mmol/LEtiologyDecreased renal excretioni.e. Renal failureIncreased K intakeDiet / Dietary supplements Cellular deathTrauma: burns，crush injuriesSevere infectionChemotherapy Blood transfusions,血钾 5.5mmol/L病因肾排泻减少（肾衰）钾摄入过多细胞死亡创伤：烧伤，积压伤重度感染化疗输血,7/30/2018 11:33 PM,Hyperkalemia 高钾血症
30、,Clinical ManifestationsCardiacIrregular pulseDysrhythmias and EKG changesCardiac arrest and death NeuromuscularFlaccid paralysisParesthesiasMuscle weakness OtherFatigue, irritability, anorexia and N/V,临床表现心血管脉搏不齐心律失常，心电图改变心跳停止，死亡神经肌肉迟缓型麻痹感觉异常肌无力其他疲乏，兴奋，厌食，恶心，呕吐,7/30/2018 11:33 PM,Hyperkalemia 高钾血症,
31、EKGEarly peaked T waves then flat P waves, prolonged QT, widened QRS progressing,心电图早期高尖T波,P波平坦， ST段压低，QT延长,QRS增宽,7/30/2018 11:33 PM,Hyperkalemia 高钾血症,TreatmentRemove iatrogenic causesCa-gluconate Sodium bicarbonate GlucoseRegular insulinEmergent dialysisHydration and diuresisKayexalateSorbitolHemod
32、ialysis,治疗去除病因葡萄糖酸钙碳酸氢钠葡萄糖胰岛素水化利尿降钾树脂山梨醇血液透析,7/30/2018 11:33 PM,钙的异常Calcium Abnormalities,7/30/2018 11:33 PM,Calcium Abnormalities钙的异常,Major FunctionsFormation and structure of teeth and bonesAssists in maintaining cell structure & function Transmission of nerve impulses Role in smooth, skeletal and
33、 cardiac muscles contraction & relaxation Role in the blood clotting processes,主要功能牙骨构成维持细胞结构和功能传送神经冲动平滑肌、骨骼肌、心肌收缩和放松凝血,7/30/2018 11:33 PM,Calcium Abnormalities钙的异常,Normal serum Ca2+: 2.252.75mmol/LCalcium and Phosphate BalancePTHBones break downGI Ca2+ absorption and Vit D activationKidneys Inc rea
34、bsorption Ca2+, dec resorption PO42-CalcitoninDeposit Ca2+ in Bone,正常钙：2.252.75mmol/L钙磷平衡甲状旁腺激素骨分解胃肠钙吸收，维生素D活性肾钙重吸收增加，磷酸再吸收减少降钙素骨钙沉积,7/30/2018 11:33 PM,Hypocalcemia低钙血症,Ca2+2.25mmol/lCauses Inadequate Dietary IntakeHypoparathyroidism Thyroid and parathyroid surgeries Vitamin D Deficiency Chronic dia
35、rrhea Pancreatitis,钙+2.75mmol/LCausesExcessive IntakeHyperparathyroidism Metastatic cancerBreastLungRenal,钙 2.75mmol/L病因摄入过多甲状旁腺功能亢进转移癌乳腺肺肾,7/30/2018 11:33 PM,Hypercalcemia高钙血症,Clinical Manifestations Neurological Confusion, fatigue, lethargy, acute psychotic behavior and coma NeuromuscularMuscle we
36、akness, incoordination and hypoactive deep tendon reflexes Cardiac Dysrhythmias and ECG changesOther Anorexia, n/v, weakness, bone pain, constipation, abdominal pain,临床表现神经系统意识混乱，疲乏，嗜睡，精神病行为，昏迷神经肌肉肌肉无力，共济失调，腱反射减弱心血管心律失常，心电图改变其他厌食，恶心，呕吐，虚弱，骨痛，便秘，腹痛,7/30/2018 11:33 PM,Hypercalcemia高钙血症,ManagementRehydrate with normal salinePromote diuresis,治疗水化利尿,7/30/2018 11:33 PM,镁的异常Magnesium Abnormalities,7/30/2018 11:33 PM,Magnesium Abnormalities镁的异常,
