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,*,Water and electrolyte disorders,一、水、电解质代谢的生理基础,(一)体液,1.体液及其分布,Intracellular fluid,Total (ICF)40%,(60%)interstitial fluid 15%,extracellular fluid plasma 5%,(ECF)20%transcellular fluid 2%,(,透细胞液),2.体液中主要电解质及其分布,extracellular fluid:,Na,+,、Cl,-,、HCO,3,-,intracellular fluid：,K,+,、HPO,4,2,-,在,Na,+,-,K,+,-,ATPase,作用下，细胞内外,Na,+,、,K,+,保持不对等分布,。,3.,Osmotic pressure of body fluid,(,plasma),Positive ion:151mmol/L,Negative ion:139mmol/L total 280-310mmol/L,Nonelectrolyte:10mmol/L (678.3kpa),Plasma colloidal osmotic pressure:,3.72kpa(28mmHg),（二）,movement,of water and electrolytes,1.plasma interstitial fluid,capillary protein,2.intra-and extra-cellular fluid,proteins and positive ion:permeability,water and negative ion:permeability,(water movement balance of osmotic pressure),R,B,C,3.,Balance of body water and sodium,drink,1200ml,water intake food,1000ml,(2000-2500ml),oxidation,300ml,balance,of water urine,1200-1500ml,water loss skin,500ml,(2000-2500ml),respiration,350ml,feces,150ml,Balance Intake/d 100-200mmol (digestive tract),of sodium Loss/d 100-200mmol (urinary system),ECF:50%,Distribution,ICF:10%,of sodium,骨基质:40%(正常血清钠:,130-150mmol),(,三),Regulation of osmotic pressure and volume,Hypertonic thirst,of ECF,1.body water ADH ;aldosterone,sodium thirst,Ang ADH,body volume,aldosterone,receptor of volume,ADH,2.body water,sodium ADH,reabsorption of sodium,3.blood volume ANP aldosterone(ADS),tension,4.others ADH,pain,Figure:regulation of ADH secretion,osmotic pressure R,pressure R,ADH,volume R,heart,二、,water and sodium disorders,hypertonic hypertonic,dehydration isotonic water excess isotonic,hypotonic hypotonic,(一),细胞外液容量不足,(,extracellular fluid deficit),1.,Hypotonic dehydration,sodium loss water loss,serum sodium 130mmol/L,plasma osmotic pressure,280mOsm/L,1)cause and Pathogenesis,excessive loss of water and sodium replaced with water only.,vomiting,diarrhea;burn;diuretics;,Addison,s disease (ADS );,chronic renal failure;renal tubular acidosis,2)adaptive response and effect on body,movement of body fluid,ECF ICF cellular swelling,Blood volume,Extracellular fluid,Shock dehydrated signs edema of brain and lung,urinary alteration,urine specific urine,volume gravity Na,+,-,early ADH,or,stage ADS,late ADH,stage ADS,-,(,注：经肾失钠的低渗性脱水，尿钠不减少,),3),principles of treatment,treating primary disease,0.9%NaCl,2.,hypertonic dehydration,water loss sodium loss,serum sodium 150mmol/L,plasma osmotic pressure310mOsm/L,1)cause and pathogenesis,lack of water(desert;sea),intake,to drink inability(coma;baby),lung:hyperpnea(hypoxia;acidosis),skin:fever;hyperthyroidism;sweat;,exposure to hot environment,loss digestive tract:vomiting;diarrhea;,baby diarrhea(Na,+,:60mmol/L),kidney:diabetes(ketosis);,diabetes insipidus,diuretic(mannitol;hypertonic glucose),2),effect on body,hypertonic of ECF thirst,movement of the body fluid,ICF ECF cell dehydration,Brain dehydration,Sleepiness subarachnoid space bleeding,Dehydration of sweat glands,dehydrated fever,dehydration of heat,regulating center,urinary alteration,urine specific urine,volume gravity Na,+,-,early ADH,stage ADS,late ADH,stage ADS,-,3)principles of treatment,先水，后盐；补水大于补钠。,病例,1,：患者，男性，,40,岁，吐、泻伴发热、口渴、尿少,4,天入院。,体格检查：体温,38.2,，血压,110/80mmHg,，汗少，皮肤黏膜干燥。,实验室检查：血,Na+155mmol/L,，血浆渗透压,320mOsm/L,，尿比重,1.020,。,给予,5%,葡萄糖溶液,2500ml/d,和抗生素，,2,天后体温、尿量正常，口不渴，眼窝凹陷，皮肤弹性明显降低，无力，肠鸣音减弱，腹壁反射消失。浅表静脉萎陷，脉搏,110,次,/,分，血压,72/50mmHg,，血,Na,+,120mmol/L,，血浆渗透压,255,mOsm,/L,，血,K,+,3.0mmol/L,，尿比重,1.010,，尿钠,8mmol/L,。,3.isotonic dehydration,water loss,sodium loss,serum sodium,=,130-150mmol/L,plasma osmotic pressure:280-310mOsm/L,1)cause and pathogenesis,vomiting;diarrhea;gastrointestinal suction;,biliary fistula;intestinal fistula,ascitic fluid;pleural effusion,2),effects on body,slight thirst,blood volume dehydrated signs;BP,urinary alteration,urine specific urine,volume gravity Na,+,-,early ADH,stage ADS,late ADH,stage ADS,-,3)principles of treatment,补偏低渗液；先补0.9%,NaCl,病例,2,：,患者，女性，,38,岁，因减肥连续服用泻药一周，现感虚弱乏力，偶有直立性眩晕而入院。,体格检查：体温,36.7,，血压从入院时的,110/60mmHg,很快降至,80/50mmHg,，心率,100,次,/,分，皮肤弹性差，黏膜干燥，尿量,120ml/24h,。,实验室检查：血,Na,+,140mmol/L,，血浆渗透压,295mOsm/L,，尿比重,1.038,，尿钠,6mmol/L,。,(二),细胞外液容量过多,(,extracellular fluid excess),1.water intoxication,water intake ,total sodium,;ECF ,ICF ;,hyponatremia;Serum sodium 130mmol/L,1)cause,excessive water intake,renal loss (acute renal failure;,acute congestive heart failure),2)effects on body,brain cells swelling,water moves into cells,pulmonary edema,3)principles of treatment,diuresis,病例,3,：患者，女性，因外伤急救误输异型血,200ml,后，出现黄疸和无尿。,体格检查：体温,37,，脉搏,80,次,/,分，呼吸,80,次,/,分，血压从入院时的,110/60mmHg,很快降至,80/50mmHg,。神志模糊，表情淡漠，皮肤黏膜干燥、黄染，静脉塌陷。,实验室检查：血清尿素氮,15.0mmol/L,，非蛋白氮,57.12mmol/L,，血,K,+,6.7mmol/L,。,入院后急速输入,5%,10%,葡萄糖溶液,1500ml,，生理盐水,500ml,后，当晚做血液透析，透析中血压上升并稳定在,110,140/70mmHg,，透析后查尿素氮为,9.46 mmol/L,，非蛋白氮,44.3mmol/L,，血,K,+,5.7mmol/L,。,患者,5,天内一直无尿，并逐渐出现明显气喘、心慌、不能平卧，嗜睡、呕吐、头痛、精神错乱症状。查体发现，心率,120,次,/,分，两肺布满湿罗音。血,Na,+,120mmol/L,，血浆渗透压,230mOsm/L,，红细胞比容,32%,。,2.,Edema,interstitial fluid,fluid in the