水和电解质代谢紊乱课件

,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,(Disturbances of water and electrolyte balance),水和电解质代谢紊乱,(Disturbances of water and ele,水和电解质代谢紊乱,钾代谢,及钾代谢障碍,正常水与电解质平衡,一,、,体液的容量和分布,二,、,体液的电解质,三、,体液的渗透压和水的交换,四、体液容量和渗透压的调节,五、,水和钠的生理功能,水、钠代谢紊乱,水中毒,水 肿,高渗性,低渗性,等渗性,脱水,水过多,水和电解质代谢紊乱钾代谢正常水与电解质平衡 一、体液的容量和,正常水与电解质平衡,正常水与电解质平衡,体液,(body fluid),体内的水和溶解于其中的物质,电解质、低分子有机化合物以及蛋白质等,体液(body fluid)体内的水和溶解于其中的物质电解质,(Water and electrolytes balance),水与电解质平衡,体液的容量,(volume),化学成分,(composition),渗透压,(osmotic pressure),分布,(distribution),相对恒定,(Water and electrolytes balanc,一、体液的容量和分布,(Volume and,distribution of body fluid),一、体液的容量和分布(Volume and,The Composition of the Human Body,Body fluids/Total body water,60% of the body weight,The Composition of the Human B,Total body water (TBW) 60%,细胞内液,I,ntra,c,ellular,f,luid (ICF),40,细胞外液,E,xtra,c,ellular,f,luid (ECF),组织间隙,15,组织液,Interstitial fluid(ISF),血浆,5%,Plasma,跨细胞液（,transcellular fluid,）,Total body water (TBW) 60,影响体液容量的因素,年龄、性别、胖瘦,影响体液容量的因素 年龄、性别、胖瘦,二、体液的电解质,(Electrolyte in body fluid),ECF:,Na,+,、,Cl,-,、,HCO,3,-,ICF:,K,+,、,Mg,2 +,、,HPO,4,2-,Pr,-,二、体液的电解质 (Electrolyte in body,血,Na,140,mmol/L,血,Cl,104,mmol/L,血,HCO,3,24,mmol/L,平均正常值,血Na 140 mmol/L平均正常值,Cations and Anions in Body Fluids,Figure 27.2,Cations and Anions in Body Flu,体液的电解质成分（带电数目）,体液呈电中性,2,4,体液的电解质成分（带电数目） 体液呈电中性24,三、体液的渗透压 和水的交换,(Osmotic pressure of body fluid and water movement),三、体液的渗透压 和水的,(,一,),体液的渗透压,(Osmotic pressure of body fluid),溶液所具有的吸引和保留水分子的能力，其大小与溶液中所含溶质颗粒数目成正比而与溶质的分子量半径等特性无关。,(一)体液的渗透压(Osmotic pressure o,高渗,等渗,低渗,280310 mmol/L(mOsm/L),血浆渗透压,晶体渗透压,：晶体物质离子（主要是电解质）引起的渗透压,。,胶体渗透压,：血浆中蛋白质所产生的渗透压，虽仅占血浆总渗透压的0.5%，但对于维持血管内外液体的交换和血容量具有十分重要的,作用,。,高渗等渗低渗280310 mmol/L(mOsm/L)血浆,(,二,),水的交换,(Water movement ),细胞内外,血管内外,机体内外,(二) 水的交换(Water movement ) 细胞,1. Water movement between outside-inside of cell,Water, oxygen and carbon dioxide can move freely, but electrolytes and proteins not.,Cell membrane: Semipermeable,1. Water movement between outs,Aquaporins (AQPs),A family of small, hydrophobic proteins forming water-selective channels,(AQP0-12),Cells with aquaporins,Cells without aquaporins,embedded in the cell membrane,The plumbing system for cells,Aquaporins (AQPs) A family of,The Nobel Prize in Chemistry 2003,Peter Agre Roderick MacKinnon,The Nobel Prize in Chemistry 2,2. Water movement between outside-inside of capillary,Water, glucose, oxygen, carbon dioxide and electrolytes,can pass freely,through the capillary wall.,Proteins,are confined to,the intravascular space.,2. Water movement between outs,capillary,venule,Filtration,+,+,+,+,+,+,+,+,Hydrostatic pressure-IVF,e.g. 30 mm Hg,Hydrostatic pressure-ISF,e.g. 2 mm Hg,+,+,+,+,+,Diffusion,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,+,x,x,x,x,x,x,x,x,x,x,x,x,x,x,x,Cell wastes,Osmosis,Osmotic pressure-ISF,e.g. 3 mm Hg,Osmotic pressure-blood,e.g. 25 mm Hg,+,+,+,+,+,+,+,+,+,+,+,ICF,+,+,+,+,Active transport,p,p,p,p,p,p,p,+,x,solute, e.g. Na,+, glucose,waste, e.g. urea,p,protein,capillaryvenuleFiltration+,Daily intake:2,500ml,Minimum water output:,1,500ml,850ml,500ml,150ml,Daily output:2,500ml,3.,Water movement between outside-inside of body,Daily intake:2,500mlMinimum wa,四、体液容量和渗透压的调节,(Regulation of body fluid,volume and,osmotic pressure,),四、体液容量和渗透压的调节(Regulation of bo,1.,渴感,(thirst),渴中枢,ECF,渗透压,血容量,1.渴感(thirst) 渴中枢ECF渗透压血容量,2.,抗利尿激素,(antidiuretic hormone , ADH),ECF,渗透压,有效循环血量,渗透压感受器,ADH,肾,重吸收水,ECF,量渗透压,容量感受器,压力感受器,其它,ADH,提高肾远曲小管和集合管对水的通透性,2.抗利尿激素ECF渗透压有效循环血量渗透压感受器,水和电解质代谢紊乱课件,3.,醛固酮,(aldosterone),有效循环血量,醛固酮,肾重吸收,Na,+,H,2,O,ECF,量,低血,Na,+,高血,K,+,保,Na+,排,K+,醛固酮提高肾远曲小管和集合管对,Na+,的重吸收,3.醛固酮(aldosterone)有效循环血量醛固酮,近球小体,出球小动脉,入球小动脉,致密斑,近球细胞,系膜细胞,近球小体出球小动脉入球小动脉致密斑近球细胞系膜细胞,肾素,-,血管紧张素,-,醛固酮（,RAAS,）系统,肾素-血管紧张素-醛固酮（RAAS）系统,4.,心房肽,(atriopeptin),心房钠尿肽（,ANP,）,血容量,ANP,减少肾素分泌,抑制醛固酮分泌,对抗血管紧张素的缩血管效应,拮抗醛固酮的滞钠作用,拮抗,RAAS,系统,高盐饮食,提高心房压,兴奋心房牵张感受,器,利尿、利钠、扩血管,4.心房肽(atriopeptin)心房钠尿肽（ANP）血容,5.,水通道蛋白,(aquaporin, AQP),是一组构成水通道和水通透有关的细胞膜转运蛋白。,分 类,分 布,功 能,5.水通道蛋白(aquaporin, AQP) 是一组构,总结,机体通过,ADH,、口渴中枢、,RAAS,、,ANP,及,AQP,的调节维持维持体液渗透压和体液容量的稳定,总结 机体通过ADH、口渴中枢、RAAS、,五、,水和钠的生理功能,(Physiologic function of water and sodium),五、水和钠的生理功能(Physiologic functio,(,一,),水的生理功能,(Function of body water),运输养料和代谢物质,调节、维持体温恒定,润滑作用,结合水的作用,(一)水的生理功能(Function of body wa,Function of body water,Function of body water,(,二,),钠的生理功能,(,Physiologic function of sodium),维持体液的渗透压和酸碱平衡,参与细胞动作电位的形成,(二)钠的生理功能(Physiologic functio,骨（,40%,）,ECF,（,50%,）,130150mmol/L,(,血钠）,ICF,（,10%,）,10mmol/L,体钠分布,: 40-50mmol/kg,骨（40%）ECF （50%） 130150mmol/L(,钠的平衡,Na,+,食盐,消化道,血,肾排出,消化液,细胞间液,汗液,多吃多排,少吃少排,不吃不排,钠的平衡Na+食盐消化道血肾排出消化液细胞间液汗液多吃多排,(Disturbances of water and sodium metabolism),第一节 水、钠代谢紊乱,(Disturbances of water and so,血钠水平,体液容量,等容量,水、钠代谢紊乱的分类与命名,Classification and Termination of Disturbances of Water and Sodium Metabolism,正常血钠,（等渗）,(130-150mmol/L),低钠血症,（低渗）,高钠血症,（高渗）,(150mmol/L),低容量,（脱水）,高容量,水中毒,盐中毒,水肿,血钠水平体液容量 等容量 水、钠代谢紊乱的分类与命名,脱水,(dehydration),高渗性,低渗性,等渗性,水过多,(water excess),水 肿,水中毒,类型,（,Classification,）,(,据体液的渗透压来分,),脱水(dehydration),一、脱水,(Dehydration),体液容量减少,(2%),，并出现一系列功能代谢变化的病理过程。,Mild,Moderate,Severe,一、脱水(Dehydration) 体液,Dehydration signs:,Dehydration signs:,1.,概念,(concept),低容量性高钠血症,(hypovolemic hypernatremia),(,一,),高渗性脱水,(hypertonic dehydration),water loss,sodium loss,serumNa,+, 150 mmol/L,plasma,osmotic pressure,310 mmol/L,1.概念(concept) 低容量性高钠血症 (hypov,2.,原因,(causes),(1)入量不足,(,d,ecrease of intake),(2)丢失过多,(,l,ost from ECF),水源断绝,丧失口渴感,进食困难,大量,出汗,尿崩症和渗透性利尿,呼吸道蒸发,2.原因 (causes) (1)入量不足(decrease,脱水，,失水多于失盐，,使细胞外渗透压升高，细胞内液进入细胞外，导致,细胞内液减少为主,。,3.,病理生理学变化*,血,浆,组织间液,细 胞,内 液,脱水，失水多于失盐，使细胞外渗透压升高，细胞内液进入细,细胞内,液减少,高渗性脱 水,口渴中枢细胞内脱水,细胞外液渗透压,细胞内液进入细胞外,严重脑细胞脱水,ADH,尿量,比重高,CNS,功,能障碍,汗腺,分泌,体温升高,(,脱水热,),4.,临床表现,*,口 渴,脱水热,(dehydration fever),因,皮肤蒸发水减少引起的体温上升。,脱水热 (dehydration fever),5,防治的病理生理基础,(pathophysiological basis of prevention and treatment),及时补水,适当补钠,适当补钾,5防治的病理生理基础(pathophysiological,病例,1,女性，,62,岁，因进食即呕吐,10,天而入院。近,20,天尿少色深，明显消瘦，卧床不起。体检：发育正常，营养差，精神恍惚，嗜睡，皮肤干燥松弛，眼窝深陷；呈重度脱水征。呼吸,17,次,/min,，血压,120/70kPa,，诊断为幽门梗阻。,检验结果：血球分析：平均红细胞体积,MCV72fL,、红细胞压积,HCT 0.56L/L,，其余正常。,血液生化检验：血糖,5.0mmol/L,、尿素,7.6mmol/L,，,K,+,3.61mmol/L,、,Na,+,158mmol/L,、,Cl,-,90mmol/L,、,pH7.50,、,BE+8.0/mmol/L,、,HCO,3,-,45mmol/L,、,AG26.4mmol/L,。,病例 1女性，62岁，因进食即呕吐10天而入院。近20天尿少,1.,概念,(concept),低容量性低钠血症,(,hypovolemic hyponatremia,),(,二,),低渗性脱水,(Hypotonic dehydration),sodium loss,water loss,serumNa,+, 130 mmol/L,plasma,osmotic pressure ,280 mmol/L,1.概念(concept) 低容量性低钠血症 (hypov,2.,原因,(causes),钠平衡调节：,多吃多排，少吃少排，不吃不排,丢失过多,(,l,ost from ECF),肾性失钠,(r,enal losses),胃肠道丢失,(g,astrointestinal losses),皮肤丢失,(s,kin losses),液体积聚在第三间隙,(accumulate,in third space),2.原因 (causes) 钠平衡调节：丢失过多(lost,脱水，,只补水而未补盐,，使细胞外渗透压降低，细胞外液进入细胞内，导致,细胞外液减少为主,。,血,浆,3.,病理生理学变化*,组织间液,细 胞,内 液,脱水，只补水而未补盐，使细胞外渗透压降低，细胞外液进入细胞,细胞外,液减少,低渗性脱 水,血容量减少,细胞外液渗透压,细胞外液进入细胞内,组织间液减少,脱水貌,醛固酮,ADH,早期尿量不,4.,临床表现*,休克、急性肾衰,尿钠, ,细胞外低渗性脱 水血容量减少细胞外液渗透压 细,脱水貌：,因组织间液量减少，临床 上出现皮肤弹性减退、眼 窝下陷，婴幼儿囟门凹陷 等体征。,脱水貌：因组织间液量减少，临床,5,防治的病理生理基础,(pathophysiological basis of prevention and treatment),补等渗液以恢复细胞外液容量,治疗休克,5防治的病理生理基础(pathophysiological,病例,2,8,岁女孩，严重腹泻,4,天，表情淡漠，对问题反应支离破碎，皮肤弹性下降，眼球下陷。,脉搏,144,次,/min,，血压,13.06/8.00kPa (90/60mmHg),，呼吸深，,26,次,/mim,，红细胞压积,58%,，两肺（,-,），腹软无压痛，血浆,pH7.13,，,PaCO,2,2.40kPa(18mmHg),病例28岁女孩，严重腹泻4天，表情淡漠，对问题反应支离破碎，,1.,概念,(concept),(,三,),等渗性脱水,(Isotonic dehydration),sodium loss,water loss,serumNa,+, 130,150 mmol/L,plasma,osmotic pressure 280,310 mmol/L,1.概念(concept) (三) 等渗性脱水(Isoto,2.,原因,(causes),丢失,等渗液,(,l,ost isotonic fluid),胃肠道丢失,(g,astrointestinal losses),肾性失钠,(r,enal losses),皮肤丢失,(s,kin losses),液体积聚在第三间隙,(accumulate,in third space),2.原因 (causes) 丢失等渗液(lost isoto,3.,影响,(effects),ECF,渗透压正常，血,Na,+,正常,醛固酮,、,ADH,分泌, 尿量,ECF,减少 血容量组织液量,ICF,变化不明显,(1),血浆渗透压和血钠的变化？,(2),容量的变化？脱水的主要部位？,(3),激素水平的变化？,ECF渗透压正常，血Na+正常醛固酮、ADH分泌,高渗性 低渗性 等渗性,脱水热 外周循环衰竭,正常水平,三种脱水容量变动比较,高渗性,二、水过多,(Water excess),体液容量增多,Excess of body water,二、水过多(Water excess)体液容量增多Exc,1.,概念,(concept),高容量性低钠血症,(hypervolemic hyponatremia),(,一,),水中毒,(water intoxication),低渗性液体在体内潴留的病理过程,serumNa,+, 130 mmol/L,plasma osmotic pressure,回流,(1)血管内外液体交换异常(imbalance of exc,毛细血管流体静压增高,(increased capillary hydrostatic pressure),右心衰竭,全身性水肿,左心衰竭,肺水肿,孕晚期,下肢及足部水肿,毛细血管流体静压增高(increased capillary,Experimental Pulmonary Edema in Rabbits,Normal,after diuretics treatment,pulmonary edema,Cutted lung tissue,pulmonary edema,pulmonary,edema,Left heart failure,Right heart failure,(caused by COPD),Chronic obstructive pulmonary disease,Experimental Pulmonary Edema i,血浆胶体渗透压降低,(decreased plasma colloid osmotic pressure),摄入,Protein malnutrition,Hepatic disease (inadequate albumin synthesis ),Renal disease (protein loss in urine),Chronic debilitating diseases,分解代谢,丢失,合成,低蛋白血症,（,Hypoproteinemia),血浆胶体渗透压降低(decreased plasma c,微血管壁通透性增高,(,increased capillary permeability),淋巴回流障碍,(,lymphatic obstruction),Inflammation or allergy, leakage of abnormally large quantities of proteins from capillaries,Malignant obstruction of lymphatic structures,Surgical removal of lymph nodes,Blockage by infection, e.g. in filariasis,微血管壁通透性增高(increased capillar,丝虫病,丝虫病,象皮腿,Elephantiasis,象皮腿Elephantiasis,(2),体内外液体交换平衡失调,(imbalance of exchange between intra- and extra-body fluid),(2) 体内外液体交换平衡失调(imbalance of e,肾小球滤出钠、水,9999.5,肾小管重吸收,6570,近曲小管吸收,0.51,排出体外,钠水潴留,Na,+,and water are retained by the kidney.,肾小球滤出钠、水 钠水潴留Na+ and water a,GFR,Reabsorption of sodium and water,Reabsorption of sodium and water,Reabsorption of sodium and water,Reabsorption of sodium and water,GFR,GFR,GFR,N,N,N,N,Balance,Glomerular-tubular imalance,The renal retention of sodium and water,GFRReabsorption of sodium and,(,decreased glomerular filtration rate,),滤过面积,有效循环血量,（,1,）肾小球滤过率下降,(decreased glomerular filtrati,（,2,）肾小管重吸收增加,(,Increased tubular reabsorption),心房钠尿肽（,ANP,）分泌减少,远曲小管和集合管重吸收,(,醛固酮、,ADH,),近曲小管重吸收,（肾小球滤过分数增加）,（2）肾小管重吸收增加(Increased tubular,Efferent arteriole,Efferent arteriole,有效循环血量减少,出球小动脉收缩入球小动脉收缩,GFR,相对增高,滤过分数,肾小球滤过率,肾血浆流量,（,FF,）,血浆从肾小球滤出增多,管周血管中胶体渗透压相对增高/,血流量减少，流体静压相对降低,近曲小管重吸收钠水增多,有效循环血量减少出球小动脉收缩入球小动脉收缩GFR相对增高,(characteristics and effects of edema),3.,水肿的特点及 对机体的影响,(characteristics and effects,（,1,）水肿液的性状,（1）水肿液的性状,（,2,）水肿的皮肤特点,显性水肿,（,frank edema),又称凹陷性水肿,(pitting edema),隐性水肿,（,recessive edema),（2）水肿的皮肤特点 显性水肿（frank edema),（,3,）全身性水肿的分布特点,心性水肿,（,cardiac edema,),首先出现于低垂部，内踝、胫前区水肿,肾性水肿,（,renal edema,）,首先表现为眼睑或面部水肿,肝性水肿,（,hepatic edema),腹水为主,（3）全身性水肿的分布特点 心性水肿（cardiac ed,Distribution of edema fluid,Generalized edema,Distribution of edema fluid,Pathogenesis,Cardiac edema,Affected by gravity,The swelling of the ankles,Increased capillary hydrostatic pressure,ADH and aldosterone-induced retention of sodium and water,Decreased GFR due to decrease in cardiac output and effective arterial blood volume,Renal edema,The swelling of eyelids and face,Decrease in GFR,The retention of sodium and water,Hepatic edema,Ascites,Increased portal venous pressure,Overflow of hepatic lymph,The decreased effective circulating blood volume and hypoalbuminemia,Distribution of edema fluid G,（,4,）,水肿对机体的影响,有利作用：,“,安全阀,”,稀释毒素,运送抗体,不利影响：,细胞营养障碍,水肿对器官组织功能活动的影响,（4）水肿对机体的影响 有利作用：,