《外科学总论》课件：Fluid and Electrolyte Management of the Surgical

Fluid and Electrolyte Management of the Surgical PatientReferences:克氏外科学（第15版）Maxwell,M.H.Etal:Clinical disorders of fluid and electrolyte metabolism 4th ed.New York,McGraw-Hill,1987.Mengoli,L.R.:Excerpts from the history of postoperative fluid therapy.Am.J.Surg.121:311,1971.第一节 概述：Total body water 50%-70%of total body weight deuteriun oxide or tritiated water:60%for male adult and 50%for female adult,both normal variation 15%.(lean body mass and age)52%and 47%with elder and 75%-80%for newborn infants,at 1 year of age,65%题外话 我的学、教经历 我的困惑 我的体会70kg Man 3500cc Plasma(5%)10500cc Interstitial fluid (15%)Total Extracellular volume 20%28000cc Total intracellular volume 40%Interstitial fluid:Functioning components(90%)Nonfunctioning components(10%)connective tissue water and transcellular water,which includes cerebrospinal and joint fluids.154mEq/L 154mEq/L cations anionsNa+142 K+4Ca+5Mg+3CL_ 103HCO3_ 27SO4-3PO4-OrganicAcids 5Protein 16 Plasma 153mEq/L 153mEq/L cations anionsNa+144 K+4Ca+3Mg+2CL_ 114HCO3_ 30SO4-3PO4-OrganicAcids 5Protein 1 Interstitial fluid 200mEq/L 200mEq/L cations anionsK+150 Mg+40Na+10SO4-150HPO4-HCO3-10Protein 40 Intracellular fluid Osmotic PressureThe physiologic and chemical activity of electrolytes depends on the number of particles(present per unit volume(moles or millimoles per liter),the number of electrical charges per unit volume(equivalents or milliequvalents per liter),and the number of osmoles or milliosmoles per liter)A Mole=the molecular weight of that substance in grams Eg:a mole of NaCl:58 grams(Na,23;Cl,35)An Equivalent of an ion=its atomic weight expressed in grams divided by the valence.Eg:Ca+1 millimole equals 2 milliequivalents Osmole refers to the actual number of osmotically active particals present in solution.1mmol NaCl,2mOsm;1mmol Na2SO4,3 mOs;1 mmol glucose,1mOsm.In each compartment the total number of osmotically active particles is 290 to 310 mOsm.The effective osmotic pressure depends on those substances that fail to pass through the pores of the semipermeable membrane.Such as sodium,glucose.The cell membranes are completely permeable to water.Any condition that alters the effective osmotic pressure in either compartment causes redistribution of water between the compartments.1体液平衡和渗透压的调节 神经-内分泌系统渗透压：下丘脑下丘脑-垂体后叶-抗利尿激素系统（敏感而弱）血容量：肾素-醛固酮系统（强）共同作用于肾共同作用于肾二.酸碱平衡的维持血液缓冲 HCO3-/H2CO3肺：CO2肾:排出固定酸、保留碱性物质 Case:男，42岁。柴油烧伤60%，2-3度休克期平稳，伤后第3天行气管切开，四肢削痂生物敷料覆盖、并行悬浮床治疗术后4天：有一过性烦躁，嗜睡术后5天：昏迷，Na 158,Cl 119 血糖：704mg%BUN82,Cr3.36 进量 出量术后第1天 5250 4370术后第2天 5250 4670术后第3天 6560 3950术后第4天 5270 4800 结果：抢救抢救3天，死亡！天，死亡！每天生理需要量每天生理需要量5%氯化钠溶液氯化钠溶液500ml5-10%葡萄糖溶液葡萄糖溶液1500-2000ml10%氯化钾溶液氯化钾溶液30ml第二节 体液代谢的失调容量：等渗性体液的减少或增多浓度：水分增加或减少，渗透压改变成分：钠以外的其他离子改变 先细胞外液，再细胞内液1水和钠的代谢紊乱（一）Isotonic dehydration (二)hypotonic dehydration (三)hypertonic dehydrationIsotonic dehydration病因：消化液急性丧失、体液丧失在软组织或感染区临床表现：一般症状；血容量不足症状（口渴不显）诊断：病史，临床表现 Hb 尿比重 血气分析治疗：病因治疗 补含钠的等渗液 见尿补钾（40ml/h）Hypotonic dehydration 继发性或慢性Na+135mmol/L病因：1.2.3.4.临床表现：一般症状；血容量不足症状；神经症状诊断：病史，临床表现 尿比重(1.010)Hb 血气分 析 Na+135mmol/L治疗：病因治疗 补含钠的高渗液、纠酸 见尿补钾（40ml/h）Hypertonic dehydration 原发性Na+150mmol/L病因：1.2.临床表现：口渴；一般症状；血容量不足症状、精神症状诊断：病史，临床表现 Hb 尿比重 血气分析 Na+150mmol/L治疗：病因治疗 补含钠的低渗液或补水 见尿补钾（40ml/h）所有治疗切记：公式作参考补丧失量的一半观察，复查实验室检查最重要补生理需要量，注意治疗过程中的继续丧失见尿补钾血容量不足时可先补胶体纠正酸中毒水中毒：自学二.体内钾的异常2%细胞外液 重要！3.5-5.5mmol/LHypokalemiaHyperkalemia 3K2Na,1HHypokalemia 原因:进少出多,移入胞内 临床表现:肌肉兴奋性,伴随缺水缺钠时的症状被掩盖,碱中度的症状 治疗:逐步补充!Hyperkalemia 原因:进多出少,移出胞内 临床表现:肌肉兴奋性,治疗:1.停用 2.移入细胞 3.对抗心率失常 体内钙镁磷的异常 自学为主 要考试第三节 酸碱平衡的失调 代谢性酸中毒 代谢性碱中毒 呼吸性酸中毒 呼吸性碱中毒