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,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Beijing Hospital of Traditional Chinese Medicine,*,首都医科大学附属,北京中医医院,急诊科,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,低钠血症诊断思路,目录,低钠血症的临床意义,低钠血症的诊断思路,低钠血症的治疗原则,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,目录,低钠血症的临床意义,低钠血症的诊断思路,低钠血症的治疗原则,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的临床意义,钠,:,机体血液渗透压的主要决定因子,,调节细胞外液容积,,影响血压及组织器官灌注。,体内钠总量,ECF,血压,组织器官灌注,低钠血症的临床意义,常见的电解质紊乱:,15%,的住院患者,尤其是重症监护室:,丧失自主行为能力;,水钠平衡调节能力下降,老年人,神经科病人,昏迷,插管,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的临床意义,症状及体征与血钠的水平,血钠异常主要影响,神经、胃肠道,和,神经肌肉,的功能。,血清钠,125mmol/L,,多无症状,血清钠,125mmol/L,,,GI,症状,血清钠,120mmol/L,出现,NS,症状,血清钠,110mmol/L,,抽搐、昏迷,发生速度、年龄,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的临床意义,中枢神经系统,轻度:冷漠,头痛,昏睡,中度:兴奋,运动失调,混乱,定向力障碍,,精神异常,重度:木僵,昏迷,假性延髓麻痹,死亡,胃肠道,厌食,恶心,呕吐,肌肉运动系统,肌肉痉挛,腱反射减弱,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,目录,低钠血症的临床意义,低钠血症的诊断思路,低钠血症的治疗原则,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,血钠,135mmol/L,低钠血症,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,1.,血浆渗透压,2.,细胞外液状态,3.,尿钠(尿渗透压),Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,1.,血浆渗透压,=,2,血钠(,mmol/L,),+,血糖(,mmol/L,),+,血尿素氮(,mmol/L,),正常值:,270-290 mmol/L,高渗,移位性,低钠血症,等渗,假性,低钠血症,低渗,有意义,的低钠血症,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,高渗性低钠血症:钠以外的其他溶质导致血,浆渗透压升高,最为常见的原因:,高血糖;,血液中甘露醇浓度升高,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,大量甘露醇充盈膀胱,血液中甘露醇水平显著升高,血液高渗状态,细胞内液向细胞外间隙移动,血钠水平降低,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,等渗性:假性低钠血症。,最为常见的原因:,血浆中固相成分增加;,检测方法。,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,血浆中固相成分增加,:,高血脂;,高蛋白血症,(多发性骨髓瘤;大量使用丙种球蛋白);,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,检测方法:间接离子特异性电极法,(特点:血液标本需要稀释后才能进行测定),病例,A,患者,A,的,1ml,血浆中含:,930,l,水及,70,l,固体,水中,Na,+,=150mmol/L,固相,Na,+,=0mmol/L,采用,1,:,10,稀释的标本测定钠浓度,=1500.93/10=13.95mmol/L,血钠浓度,=13.9510=140mmol/L,病例,B,患者,B,的,1ml,血浆中含:,800,l,水及,200,l,固体,水中,Na,+,=150mmol/L,固相,Na,+,=0mmol/L,采用,1,:,10,稀释的标本测定钠浓度,=1500.8/10=12mmol/L,血钠浓度,=1210=120mmol/L,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,低渗性低钠血症:,2.,评估细胞外液状态:,低容量性(总水,总钠);,等容量性(总水,总钠,-,);,高容量性(总水,总钠)。,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,细胞外液容量状态的判断:,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,3.,测定尿钠水平:,判断钠丢失的途径(未使用利尿药物的情况下):,尿钠,20mmol/L,肾脏排钠;,尿钠,20mmol/L,肾外途径,(胃肠道、第三间隙)。,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,低钠血症的诊断思路,Beijing Hospital of Traditional Chinese Medicine 2020/6/22,谢谢!,
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