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Fluid and Electrolyte Management of the Surgical Patient

Fluid and Electrolyte Management of the Surgical Patient. References: 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.

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Fluid and Electrolyte Management of the Surgical Patient

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  1. Fluid and Electrolyte Management of the Surgical Patient References: 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.

  2. 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%

  3. 题外话 • 我的学、教经历 • 我的困惑 • 我的体会

  4. Interstitial fluid: Functioning components (90%) Nonfunctioning components(10%) connective tissue water and transcellular water, which includes cerebrospinal and joint fluids.

  5. 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)

  6. 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.

  7. 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.

  8. 体液平衡和渗透压的调节—— 神经-内分泌系统 • 渗透压：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

  9. 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

  10. 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

  11. 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

  12. 结果： 抢救3天，死亡！！

  13. 每天生理需要量 5%氯化钠溶液500ml 5-10%葡萄糖溶液1500-2000ml 10%氯化钾溶液30ml

  14. 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

  15. 水和钠的代谢紊乱 • （一）Isotonic dehydration • (二) hypotonic dehydration • (三) hypertonic dehydration

  16. Isotonic 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）

  17. 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）

  18. 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）

  19. 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

  20. 水中毒：自学

  21. 二.体内钾的异常 2%细胞外液 重要！ 3.5-5.5mmol/L Hypokalemia Hyperkalemia 3K 2Na ,1H

  22. Hypokalemia • 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!

  23. 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

  24. 体内钙镁磷的异常 • 自学为主 • 要考试

  25. 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

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