1、Fig15Body Weight40Body Weight （Female 35）PO4-Na+Na+Na +CI- CI- HCO3- HCO3- K+K+K+protein5% Body WeightNa+ K+ ATPaseInterstitial Fluid (ISF)PlasmaIntracellular Fluid (ICF)Extra cellular FluidIntracellular Fluid（ECF）（ICF）Anatomy of Body Fluids Compartments Mg2+Protein功能性功能性非功能性非功能性 Function:Taking par

2、t in modulating the balance of body fluids. Non-function: Fluids in cavity in normal status.Including cerebrospinal ,joint,pericardium and abdominal cavity fluids Definition: Pathophysiologiclly, relatively nonfunctional extra cellular fluid.Mainly for the change of quantity of functional and nonfun

3、ctional ECF. Distribution: exudates in burns; ascites; soft tissue injuries. bowel wall;peritoneum;infected lesions. Attention: not confused with the nonfunctioning components from interstitial fluid. waterwaterSemi-permeable membraneAnion and Cation as well as non-electrolyte particles Pressure lea

4、ding to the shift of water through semi-permeable membrane Definition the number of osmotically active particles or ions per unit volume. Unit : milliosmoles per liter （mOsm / L）Normal Range =290310mOsm/Lcationmmol/Lanionmmol/LNaKCaMg14252.51.5HCO3ClHPO3SO3Orgnic acidProtein2710310.560.8Total151Tota

5、l138.3 Osmotic Pressure： Crystal OP and Colloid OP Plasma Crystal OP : Na+ contributes to a major portion of OP Plasmatic Colloid OP： Plasma protein contributes a force leading to distribution of ECF Interstitial Crystal OP： Contributes to the shift of extracellular and intracellular waterPlasmaInte

6、rstitial FluidICFECFNaNa+ +Colloid OP Plasmatic proteinCrystal OPSemi-permeable membraneCrystal OPColloid OPCrystal OP Maintaining normal osmotic pressure Maintaining normal concentration & Integral dose of natrium Maintaining normal Volume (Blood-volume)posterior hypophysisA D H Distal renal tu

7、bules & collecting tubulesSensitivity： ECF Osmotic pressure 12（6 mOsm）Release of ADH Maintaining osmotic pressurehypothalamusosmotic pressure receptor Maintaining the concentration & Integral dose of natriumDistarenal tublemacular densaadrenal ortexrenin angiotoninaldosterone Increased Narea

8、bsorption & eliminating K、Decreased removing HCO3-、 acid urine Volume regulation(Blood-volume)Glomerulus paracell+adrenal cortexaldosteronerenin angiotoninAssaying CVP、AP& PAWP Volume Changes(ECF) Volume Deficit Volume Excess Concentration Changes Hyponatremia Hypernatremia Mixed volume and

9、Concentration Abnormalities ECF Deficit and Excess with Hyponatremia ECF Deficit and Excess with Hypernatremia Composition Changes Acid-base disturbances Potassium, Calcium, Magnesium abnormalities External-losses: gastrointestinal fluids due to vomiting, nasogastric suction, diarrhea, and digestive

10、 tract fistula Internal-losses :sequestration (Third Space） Soft tissue injuries and infection,burns Intra-abdominal and retroperitoneal inflammation intestinal obstruction, bowel wall,peritonitisModerateServeCNSSleepiness, apathy, slow responses, anorexia，Cessation of usual activityDecrease tendon

11、reflexes ，Anesthesia of distal extremities， Stupor，Coma GIProgressive decrease in food consumption Nausea, VomitingRefusal to eat Silent ileus and distentionCVOrthostatic hypotension Tachycardia Collapsed veins Collapsing pulseCutaneous lividityHypotensionDistant heart soundsCold extremitiesmoderate

12、serveTissue signsSoft,small tonguelongitudinal wrinkling Decreased skinAtonic musclesSunken eyes MetabolismTemperatureTemperature Etiology Clinical manifestation : Seeing Table LaboratoryIncreased RBC,WBC,PLT and plasma proteinIncreased HCTNormal serum sodium & chloridehyperbaric urine To elimin

13、ate etiologies Quality of Solution Isotonic sodium solution Lactated Ringers solution Quantity hydropenic quantity+continuous losses quantity+physiological quantity Rate and Goal To moderate BP & Pulse rate Urinary Output 30 50 ml / hr Iatrogenic Secondary to renal insufficiencyMajor operation S

14、evere traumaInfection Renal vascular constrictionIncreased ADH & Aldosterone Retention ofsodium & water Circulatory overload Basilar rales Heart failure Tissue signs Subcutaneous pitting edema Restriction of water & sodium Colloid + Diuretics Hypertonic diuresis: relieve cerebro-edema 20

15、% mannitol Continues to drink water while losing large volumes of gastrointestinal fluids. The loss of a large amount of salt, such as via sweat, and kidney. In the postoperative period when gastrointestinal losses are replaced with only 5% dextrone in water or hypotonic sodium solution. CNS signs i

16、ncreased intracranial pressure & secondary hypertension Tissue signs excessive intracellular water Digestive system: Vomiting, Nausea Shock:Progressing to oliguric renal failure promptly Asymptomatic Untill the serum sodium falls below 120 mmol/L One important exception Closed head injury, in wh

17、ich mild hyponatremia may be extremely deleterious Etiology Laboratory Serum sodium concentration 135 mmol/L Decreased urinary sodium and Hypobaric urine（ 1.010） Increased HCT and serum BUN & NPN Clinical Manifestation Clinic manifestation Serum sodium (mmol/L) NaCl deficit ( g/kg ) Mild Symptom

18、less 131135 0.5 Moderate Increased ICP (compensated) 130121 0.50.75 Severe Increased ICP (decompensated) 120 0.751.25 Eliminating etiologies Quality of solution: NS、5%GNS and or 5%Nacl TBW (liters) =Body weight ( kg )0.6 (female 0.5) Sodium deficit (mmol)= Serum sodium (standardactual)TBW Total Amou

19、nt:Half of sodium deficit + Requisite amount per day Quality: 5%sodium chloride solution (2/3) + Isotonic sodium chloride (1/3) Shock colloid: crystalloid=1:23 Convulsions or coma 5%NaCl 100 250 ml Rate of increment of sodium is 0.51mmol/L/h; and no more than 12 mmol/L within 24hs Complication: Osmo

20、tic Demyelination Syndrome(ODS). Pontine demyelination EFW: electrolyte free water Aim: Shrink the size of brain cells with hypertonic saline Na+120mmol/L having seizures. To raise the plasma Na+ by 5mmol/L during the next hour Raising Na + to 130mmol/L at 12mmol/L/h; and 12mmol/L within 24h How to

21、calculate the amount of 10NaCl per hour Raising Na + /h Kg 0.6(女女0.5)= the amount of mmol of NaCl Convulsion or Coma: PNa rise 5mmol/L in 2-3 hours No convulsion: PNa rise 150mmol/L) & HCTHyperbaric urine Clinical ManifestationExtremely thirstyHigh feverOliguria Principles -Adopting 5 GS , 0.45%

22、 NaCl , water via intestine -Half of volume deficit Requisite amount per day Measures with loss 1% body weight，infusing 400500ml supplemental quantities (ml)= actual serum sodium normal serum sodium (mmol/L)body weight (kg) 4 ECF deficit ECF excess Isotonic normal Na+ normal Na+ hypotonic hyponatriu

23、m hyponatrium hypertonic hypernatrium hypernatrium Excessive excretion: Kidney ; Digestive tract (Vomiting, Diarrhea, Gastric suction, Intestinal fistula) Less in-take: Less dietary intake ; potassium-free parenteral fluids Redistribution The transfer of extracellular potassium into cells（Alkalosis）

24、 2Na+1H+3K+CellH+HCO3- =H2O+CO22Na+1H+3K+ General: Anorexia,Nausea,Vomiting Skeletal muscles (Diminished to absent tendon reflexes, respiratory hypoventilation) Smooth muscles(Paralytic ileus ) Cardiac muscles (Hypotension) Muscular weakness Flaccid paralysis ( k + 2.5mmol / L） CNS（Serum potassium2.

25、0mmol/L） MorbusObnubilation、disorientation Cardiovascular ECG: ST segment depression, decreased T wave, Increased U wave, T 5.5mmol/L Withholding of exogenously administered potassium Correction of the underlying cause Anti- arrhythmia - 10% Calcium gluconate infused Lowering of serum potassium Tran

26、sfer potassium into cells（5% NaHCO3;11.2% Sodium lactate, GI Diuretics Cation-exchange resins (oral ; maintaining clysis) Peritoneal dialysis, or hemodialysis, hemofiltrationHyperkelamiaEKG change？Effect in 10mincalcium gluconate V.Removec causeAversilon intra-cell：InsulinNaHCO3Urinary systermurine

27、potassiumgastrointestinalDecrease oralion exchange resin, coloclysislowhemodialysisIncrease egest:MineralocorticoidNaHCO3Acetazolamideyesno Causes: acute pancreatitis;renal failure;intestinal fistula; Infusion of a vast reserve of blood;blood purification Manifestation Symptoms:numbness; tingling;Ap

28、nea; Tetany Signs: Hyperactive tendon reflexes; Chvosteks Signs Treatments:10%calcium gluconate;5%Calcium Chloride Causes: hyperparathyroidism; Bony Metastasis Manifestations: Fatigue; Vomiting Treatment: EDTA; Na2SO4;Calcitonin Causes: intaking /absorption Manifestations: Pale /excited /Fret Treatm

29、ent: 25%MgSO4 Causes: Burn/Pancreatitis Manifestations: Emotional disturbance Treatment: Glycophosphate Buffer system A weak acid or base & the salt of that acid or base Intracellular Extracellular Red cell B.Protein/H.Protein B.HCO3/H2CO3 B.Hb/HHb B2HPO4/ BH2PO4 B.HbO2/HHbO2 Anion Gap=Na+Cl-+HC

30、O3- Assumption: pre- existing potassium depletion Outcome: Intracellular (3 K)and extracellular ( 2Na+、1 H+ ) exchange Decreased Na+ and K+ exchange, Increased H+ and Na+ exchange in renal tubule Paradoxical acid urine Metabolic alkalosis is aggravated Sensible acids are excreted via the lung HCINaH

31、CO3 NaCIH2CO3 H2O CO2 Insensible acids excreted by kidney Inorganic acid anions （hydrochloric、sulfuric、hosphoric acids） with hydrogen（H+Na+ exchange） ammonium salts（H+ NH3NH4-）organic acid anions（lactic、keto、pyruvic acids） Be metabolized Some renal excretion（with high levels） BHCO3- pHpKlog H2CO3 27

32、mmol/L 6.1log 1.35mmol/L 2 0 6.1log 1 6.1 1.3 = 7.4 H HbO2+H+CO2 Hb +O2 CO2SaOSaO2 2PaOPaO2 2normalShift rightShife lefeDissociation curveDissociation curveDefects Causes Compensation BHCO3/H2CO3Retention of Diabetes, Pulmonary(Rapid) 20/1Fixed acids Starvation :increased rate (numerator)（Anion gap

33、Lactic acid, and depth of Increased Azotemia breathing Defects Causes CompensationLoss of base Diarrhea, Renal slow) : bicarbonate Small bowel , Retention of HCO3-, (Anion gap pancreatic Excretion of acid salts, normality) fistulas ammonia formation, Chloride into RBC Increased in depth & freque

34、ncy of respiration (Kussmaul breathing) Peripheral vessels dilated ，Circulatory shock, Cerise lip Decreased muscular tension & tendon reflex merged Unconsciousness Principles Therapy for basic disease Alkali treatment: dose initials 1 / 3 1 / 2 requisite amount Pre-treatment: serum K+ & Ca+

35、The amount of Alkali necessary （normal CO2-CP - serum CO2-CP） TBW（Kg） （BE3）BW（Kg） （normal SB observed SB）BW （Kg） Loss of base （mEq） Some of alkalescent solution contains HCO 3 1 gm NaHCO312 mmol HCO3 - 1ml - 11.2%NaC3H5O31 mmol HCO3 - 1ml - 3.63%THAM0.3 mmol HCO3 -De fects Causes Compensation BHCO3/

36、H2CO3Retention of Depression of Renal 20/1Acids suction with decreased rate (numerate pyloric obstruction & depth of breathint increase)Gain of base excessive intake of Renal (slow)Bicarbonate bicarbonate excretion bicarbonatePotassium, Diuretics retention of acidChloride of salts, decreased Depletion ammoniaformation Peripheral vessel constricted Mental symptoms:Delirium,Drowsiness Decreased in depth & frequency of respiration Tetany & tendon reflex accentuat