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in surgical patients
外科病人水电解质失衡
Machu Picchu
Who were the Barber-Surgeons
?
Did you notice my coif (hat)?
I am a member of the guild
of Barber-Surgeons.
I trained for 7 years before starting
work.
以手工为主的医疗工作被称之为外科学
The land marks in the history of surgery
in the past century (1840’s)
Anesthesia 麻醉
Antisepsis and asepsis 抗菌和无菌
Stanch bleeding 止血
Transfusion 输血
Modern surgery
•Micro-surgery
•Interventional
radiology
•Molecular biology
•Minimal invasive
medicine
UFO
Without water
without life
Three important factors
for homeostasis
Fluid 体液
intra-cellular 40%
extra-cellular 20%
Electrolyte 电解质
positive ion (+) Na+ K+ Mg2+
negative ion (-) Cl- HCO3- HPO42-
Osmotic pressure ( OP ) 渗透压
maintain the in/out side of the cells fluid volume
There is a direct ratio between electrolyte concentration and OP
Distribution and amount
of body fluid
70kg Man Body weight %
3,500ml Plasma Total extracellular
volume 20
10,500 intresticial (Plasma 5
Fluid Int. Fluid 15
renin aldosterone
kidney
angiotensin
lung
Adrenal
cortex
Angiotensin II
Contrast
vessels Renin – angiotensin-aldosterone
system
Metabolic imbalance of body fluid
Volume disorders with sodium
Potassium imbalance
Calcium (omitted)
Magnesium (omitted)
Phosphorus (omitted)
1)Volume disorders with sodium
Isotonic dehydration
等渗性缺水
Hypotonic dehydration
低渗性缺水
Hypertonic dehydration
高渗性缺水
1、Isotonic dehydration
(acute or mixture dehydration)
Etiology
1)acute loss of digestive
fluids (sever vomiting,
diarrhea or digestive
fistula)
2)water depletion in the
water Na+ area of infection or
tissue(sever infection,
gut obstruction and
burn)
dehydration = sodium loss
serum Na+ & OP are normal
Menifastation
1)common feature of dehydration
(anorexia, nausea, fatigue, sunken eyes,
poor skin elasticity)
2)water loss accounts for 5% BW, may
result in shock, 6-7% in sever shock
3)acid-base imbalance
Diagnosis
The history of acute and massive
depletion of body fluid
Hypovolemic pictures clinically
Lab. exams:concentrated blood
(RBC ↑ HCT ↑ and Hb ↑)
serum Na+&Cl- normal
urine specific gravity↑
Treatment
Etiological therapy
Infusion:balanced solution or NS 1
Rehydration: 2
1、 On degree of dehydration 3
features
mild:thirsty,2-4% lost
water Na+
middle:extreme thirsty,
4- 6% lost
water lose > sodium lose sever:mind disorders,
Serum Na+,OP 、cellular dehydration over 6% lost
Diagnosis
Disease history
Clinical manifestation
Specific gravity of urine increased
RBC、HB、HCT↑
Serum sodium >150mmol/L
Managements
Primary disease therapy
Oral or intravenous supplements:
5%G.S or hypotonic saline (0.45%)
Every 1% dehydration of BW add 400-
500ml
Under the serum Na+ value to treat the case
Maintain the physiologic requirement
2)Potassium imbalance
Hypokalemia (<3.5mmol/L)
Hyperkalemia ( ommited )
Hypokalemia
Etiology
-Insufficient eating for a long time;
-over excretion of potassium (e.g diuretic
drugs)
-inadequately supplement of K+
-extensive lose of K+ from digestive tract
- K+ transfer to inside of cells ( e.g alkalosis,
massive transfusion of Glucose or Insulin)
Clinical features
Myasthenia (muscle contractility↓) :limb mus.、
respiratory mus. 、heart (conduction block ,arrhythmia)
Digestive symptoms: nausea, vomiting, bloating,
paralytic ileus;
CNS: Irritability, drowsiness, unconsciousness,
coma
Abnormal ECG : lower T wave and lower ST
segment, or Q-T intervel prolongation; and U wave;
Alkalosis related to hypokalemia :
Mechanism :
1、the cellular exchange between k+ and Na+ H+
increases (3 k+ out of cell, 2 Na+ 1 H+ into cell)
2、 in renal distal tubule the exchange of k+ and
Na+↓; but Na+ and H+↑;
that resulted in hydrogen ion decreased in serum
Treatment
Etiological thetapy
Principles for potassium supplement
-amount:based on the degree of K+ lose
usually 40-80mmol/d(3-6g),
-velocity:< 20mmol/h (1.5g /500ml )
-standard :10% potassium chloride
-indication:urine 40ml/h
-time: normally it needs 3-5 days to recover
Acid-base imbalance
Normal physiology
Respiratory acidosis (omitted)
Respiratory alkalosis (omitted)
Metabolic acidosis
Metabolic alkalosis (omitted)
Normal physiology for acid-base balance
Buffer system: HCO3-/H2CO3=20:1
Lung: inspiration of O2 & Expiration of
co2
Kidney :
re-sorption Na+, HCO3-
secretion H+and acidized urine
The most important buffering
HCO3-/H2CO3=20:1
Calculate formula :
PH=PK+log* [HCO3-]/[H2CO3]
=6.10+log27/1.35
=6.10+log20
= 7.40
PH is depended on the ratio of [HCO3-]/[H2CO3]
* Logarithm
Metabolic acidosis 代谢性酸中毒
the most common kind of
acid-base imbalances
clinically
Etiology
Excessive bicarbonate losses:digestive juice contains
rich HCO3-(small intestine、pancreas and bile )
Increased production of hydrogen ion:
shock, diabetes and drugs (Hydrochloric acid,Chloride)
Renal dysfunction:
decreased discharge of H+ of renal distal
convoluted tubule;
and decreased re-absorption of HCO3- in proximal
convoluted tubule;
Clinical manifestations
Fast deep breathing (40-50/min.)
Cheeks flushing、quick HR
Tendon reflexes weakened and mental
alteration
Concomitant dehydration or
shock(hypotension)
Diagnosis
Disease history;
Clinical pictures;
Gas analysis: PH、HCO3-、BE (base
excess);
Treatment
Etiological treatment (underlying diseases :e.g
shock , intestinal fistula);
Supplement of body fluid and improve
microcirculation( based on the degree of
dehydration);
When HCO3- <10mmol/L, sodium bicarbonate
is required under guide of gas analysis
The formula :
NaHCO3(ml)=[normal val. HCO3--measured val]
× BW × 0.4×20÷12
For example
A male patient , BW 70kg,with metabolic acidosis,
measured serum HCO3-was 10mmol/L. The needed
amount of HCO3-was calculated as follows:
NaHCO3(ml)=[24-10] ×70 × 0.4×20÷12
=14 ×70 ×0.4 ×20÷12
=7840÷12 =653ml
Half of the calculated volume(≈320) given to the patient
within 12 h. According to the gas analysis to determine
if the rest should be transfused to him again.
Summary
There is a direct ratio (正比)between electrolyte
concentration and OP
Different type of dehydration with sodium is
depended on the lost amount of water and
electrolyte
Hypokalemia is a common complication in critical
cases
Metabolic acidosis is the commonest disorder of
acid-base imbalance clinically
Questions for this chapter
1.What are the three factors to regulate
homeostasis of our body?
2.What is the etiology of metabolic acidosis and
how to diagnose and treat it?
3.What kind of acid-base imbalance will occur in
hypokalemia? Why ?
4.Definition of the three types of dehydration
with sodium?