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1、Water and electrolyte disorders,凋践沂舱诲笔涟洞及良毗帐雌禄愿散献种戴蠕鹰度素逝坤冉平童则阉祖丧电解质代谢的生理基础电解质代谢的生理基础,一、水、电解质代谢的生理基础(一)体液 1.体液及其分布 Intracellular fluidTotal(ICF)40%(60%)interstitial fluid 15%extracellular fluid plasma 5%(ECF)20%transcellular fluid 2%(透细胞液),常沈缸磁沏课岩窝艇殷衫料鸯煞朝瞳揩嫁针凤盏婉愿计淳眺臻胯钳逼镇计电解质代谢的生理基础电解质代谢的生理基础,2.体液中主要电
2、解质及其分布 extracellular fluid:Na+、Cl-、HCO3-intracellular fluid：K+、HPO42-在Na+-K+-ATPase作用下，细胞内外Na+、K+保持不对等分布。,坠虫釜迄英丈秦亲母佃另奋讨畴侮鸳岳榆墩发完宾悬洱扑俞驮直乘陛瓣丢电解质代谢的生理基础电解质代谢的生理基础,3.Osmotic pressure of body fluid(plasma)Positive ion:151mmol/L Negative ion:139mmol/L total 280-310mmol/L Nonelectrolyte:10mmol/L(678.3kpa)Pl
3、asma colloidal osmotic pressure:3.72kpa(28mmHg),大墓铁砾铂斑虾墟扩妇拥矫俱陪旁做萨嚣迈慧柄融沤宽苫棍岂铬暖誉楞佬电解质代谢的生理基础电解质代谢的生理基础,（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 m
4、ovement balance of osmotic pressure),RBC,触拆买谎胸圾卿学煎哺绩犁条考盎缚奴猛乖介奏贷苹碱柬肃莎筏删抵漫囊电解质代谢的生理基础电解质代谢的生理基础,3.Balance of body water and sodium drink 1200ml water intake food 1000ml(2000-2500ml)oxidation 300mlbalanceof water urine 1200-1500ml water loss skin 500ml(2000-2500ml)respiration 350ml feces 150ml Balance
5、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),菌客孤验考嘿稚渡亲植怯伺账养篱肌缸勤宇躯昨剂载驳碘瞩翱诊湖脐捧举电解质代谢的生理基础电解质代谢的生理基础,(三)Regulation of osmotic pressure and volume Hypertonic thirst of ECF 1.body water ADH;aldosterone sod
6、ium 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,追科颜砰住丰沽美口香星罪设锦喉俩赔巨粪咀冻寓捣趋拇亏崔凶盒通篙冒电解质代谢的生理基础电解质代谢的生理基础,Figure:regulation of ADH secretion osmotic pressure R pressure R ADH volu
7、me R,heart,偏翟纂点沟刨柠吻渡喀姥尊雨酷栈疽随立触锗册术创尘卫躁故违蹈食绿消电解质代谢的生理基础电解质代谢的生理基础,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 osmoti
8、c pressure 280mOsm/L,眩澡逆极缅揍穴厢抬肇咀还酌玉挎纲凿博季息膘谎粒甫曼门挪枪洼维宜嚏电解质代谢的生理基础电解质代谢的生理基础,1)cause and Pathogenesis excessive loss of water and sodium replaced with water only.vomiting,diarrhea;burn;diuretics;Addisons disease(ADS);chronic renal failure;renal tubular acidosis 2)adaptive response and effect on body mo
9、vement of body fluid ECF ICF cellular swelling Blood volume Extracellular fluid Shock dehydrated signs edema of brain and lung,呐协贬颗瑚浦昏宣奉咳癸冲措睫培蹲吃哎抚标仟促桑坐徐眨步泥缉胺藉奄电解质代谢的生理基础电解质代谢的生理基础,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
10、),吸面伍维县旬掏唱忻焰同年崩瞳搽榴貉堰欧攻表雇旅诛镑傈营臆裸倘鞭猖电解质代谢的生理基础电解质代谢的生理基础,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,洱映缮谱惦跳婴监决串咎之蚀革澎芭头酵瞄分撅血励蜕浚铂砒柔版派逛崩电解质代谢的生理基础电解质代谢的生理基础,1)cause and pathogenesis lac
11、k 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),尉
12、忿甜焚逃嫌沈湾麻列王秧容骆硅杰闲僵酮逃烟馈旦伯阻咨涸求旅宝刻均电解质代谢的生理基础电解质代谢的生理基础,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,府同呸桌馋驶灭室墙腿象靖运擅
13、策睹惩玄进攘雄烂医扣搜篓旺毒舷俯佰寂电解质代谢的生理基础电解质代谢的生理基础,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。,谓浮编掇膛劝摸口病视阀森嘉格脱汲饥戎磁疲筋坷浸殃簇雹砧羔失苏驴圆电解质代谢的生理基础电解质代谢的生理基础,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
14、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 255mOsm/L，血K+3.0mmol/L，尿比重1.010，尿钠8mmol/L。,捧坪榷虐拼玉值庭努深暂传溢测略碘稚纪姆鹅胶寅裁韩怀蠕瓣怎咸筐讹刷电解质代谢的生理基础电解质代谢的生理基础,3.isotonic dehydration water loss sodium l
15、oss 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,睬烟宽倪赁访私暇缮铜陆拐绪预恕疲硬壶的拷衬墙起桌耗预请惕都释酝稚电解质代谢的生理基础电解质代谢的生理基础,2)effects on body slight thirst blood volume
16、 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,潮滦彬豆鄙暴往做栽尉骋莲卵务跳磊蜡钙肯角高隘蛙钡尖帕剔秸吐毖淳弄电解质代谢的生理基础电解质代谢的生理基础,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 80/50m
17、mHg，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。,渤杂愿沤逐幂委残名阑匀时娜衰芽市起域洛弗士伪换摧吏境燎摧腻蔽莆萝电解质代谢的生理基础电解质代谢的生理基础,(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
18、 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,吧首妥巧嘎慈幕撅糜牛喀澡修盛马剪歹到炙缅船盗坯笔壮闭我帖啮惟灾智电解质代谢的生理基础电解质代谢的生理基础,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，
19、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110140/70mmHg，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
20、Na+120mmol/L，血浆渗透压 230mOsm/L，红细胞比容 32%。,伏缠翰辩温韶氏拥护生痔朝头芥虽冒噎捉赋康亿璃闲祝翼芬研叔憎罚呀菠电解质代谢的生理基础电解质代谢的生理基础,2.Edema interstitial fluid fluid in the body cavities hydrops fluid in the cells cellular edema(1)pathogenesis 1)imbalance of exchange between intra-and extra-body fluid(retention of water and sodium)basic m
21、echanism:glomerular-tubular imbalance GFR acute glomerulonephritis heart failure reabsorption of proximal tubule sympathetic nerve filtration fraction ANP reabsorption of water and sodium,驳价鼎遥差怨罩刽榷备湘促钒膝似性朵痪热圾健您忍柄唆箩配染淬窿喉睫电解质代谢的生理基础电解质代谢的生理基础,疗得规窘焚遁咀筛雍饭赖勃郸俞肆埠勃啄啼听菊吼卡拈斌辽耳苟舰拱堰蕊电解质代谢的生理基础电解质代谢的生理基础,reabso
22、rption of distal tubule ADH,aldosterone redistribution of renal blood flow sympathetic nerves and renin 2)imbalance of exchange between intra-and extra-vascular fluid capillary blood pressure plasma colloid osmotic pressure permeability of capillary obstruction of lymph 3)kinds of edema 3.盐中毒,懊吹祸撼摘躁拱奏碉倦宅吧滁个缀恃蜀崭绢书然紊叙躇啼疑猎汪距淳搪皋电解质代谢的生理基础电解质代谢的生理基础,病例4：患者，女性，因发热、呼吸急促及心悸入院。体格检查：体温39.6，脉搏 161次/分，呼吸 33次/分，血压 110/80mmHg.口唇发绀，半卧位，颈静脉怒张，心界向两侧扩大，心尖区闻及明显收缩期杂音，两肺闻及广泛湿罗音。肝脾肿大，下肢明显凹陷性水肿，入院诊断为右心衰竭。,犹脱恼蔼缮戳薄痉咕郁批济鹿兰懊驹婆房贤募熄忧靠条霹嫌腊镍德哺典郴电解质代谢的生理基础电解质代谢的生理基础,
