液體療法(英文版)

Fluidtherapy

ThecharacteristicoffluidbalanceagefluidplasmaISFICFnewborn78637351y70525402-14ys6552040adult605540Fluid=ICF+ECF(plasma+ISF)ComponentECF(PlasmaISF)Na+(90%)K+Ca+Mg++CL-HCO3-protein

ICFK+(78%)Ca+Mg++Na+HCO3-HPO4-CL-

Watermetabolism

ageWaterrequirment(ml/kg)<1y120-1601-3ys100-1404-9ys70-11010-14ys50-90NeedmorewaterWaterexchangerateinchildrenis3-4timeshigherthaninadultsTheintoleranceofhydropeniaisworsethanadults.Soit’seasyforthemtoarisedehydrationTherenalfunctionisimmature.It’seasytoarisewaterelectrolytedisturbancesWaterandelectrolytedisturbancesDehydrationMetabolicacidosisHypokalemiaHypocalcemiaHypomagnesemiaDehydration

mild3-5%lossofbodyweight

30～50ml/kgmoderate5-10%lossofbodyweight

50～100ml/kgsevere>10%lossofbodyweight

100～120ml/kgHowtoevaluatetheseverityofdehydrationDryskinandmucosaPoorskinturgor(elasticity)DepressedanteriorfontanelSunkeneyesocketsSingsofshock:tachycardia,thinandthreadypulse,hypotension,hypothermia,pallor,coolextremities,delayedcapillaryrefiling,oliguriasymptomMinimalornodehydration(<3%lossofbodyweight)mildormoderatedehydration(<3%lossofbodyweight)severedehydration(<3%lossofbodyweight)MentalstatusWell;alertNormal;fatiguedorrestless;irritableApathetic;lethargic;unconsciousthirstDrinksnormally;mightrefuseliquidsThirsty;eagertodrinkDrinkspoorly;unabletodrinkHeartratenormalNormaltoincreaseTachycardia;withbradycadiainmostseverecasesQualityofpulsesNormalNormaltodecreaseWeak;thready;orimpalpableBreathingnormalNormal;fastdeepeyesnormalSlightlysunkenDeeplysunkentearspresentdecreasedabsentMouthandtonguemoistdryparchedSkinfoldInstantrecoilRecoilin<2secRecoilin>2secCapillaryrefillnormalprolongedProlonged;minimalextremitieswarmcoolCold;mottled;cyanoticUrineoutputNormaltodecreaseddecreasedminimalType:accordingtotheosmolarity

Isotonicdehydration:[Na+]130～150mmol/LHypertonicdehydration:[Na+]>150mmol/LHypotonicdehydration:[Na+]<130mmol/LIsotonicdehydrationWaterlossisinproportiontoelectrolyte[Na+]=130～150mmol/LECFCommoninclinicHypotonicdehydrationMoresoluteislostthanwater[Na+]＜130mmol/L

ECFICFosmoticpressurelow

cerebrocellularedemaShock,NSsymptomscommoninmalnutritionHypertonicdehydrationMorewaterislostthansolute[Na+]＞150mmol/L

ECFICFosmoticpressurehighThirsty,

polydypsia,

irritation,

NSsymptomscerebrocellular

dehydrationIsotonicNa≈H2OHypotonicNa+>H2OHypertonicH2O>Na+consciousnessdrowsinessdrowsinesscomaIrritableconvulsionurinedecreaseNdecreaseSkinelasticitybadworseOKBPlowshockNNa(mmol/L)130-150<130>150summaryHypokalemia[K+]<3.5mmol/L(3.5-5.5mmol/L)ReasonsPoorintakeLossbyvomitinganddiarrheaOutputincreasefromrenalTransferintocellwhenacidosisrecoveryGlycogensynthesisDistributionisunnormal:familialperiodicparalysisCentralnervoussystem:lassitudeSkeletalmuscle:weakness,hypotonia,paralysisSmoothmuscle:abdominaldistention,absentperistalsisHeart:Arrhythmia,tachcardia,dullheartsoundsECG:

depressedSTsegment,prolongedQ-Tinterval,flatorinvertedTwaves,prominentUwaveAlkalosisManifestationsTreatmentNourinenosupplement[K+]<0.3%，ivSpeed<0.3mmol/kg.hDoseMild:3-4mmol/Kg.d(220-300mg/kg.d)(10%KCL2-3ml/kg.d)Severe:4-6mmol/Kg.d(300-450mg/kg.d)

(10%KCL3-4.5ml/kg.d)Acid-basedisturbance

CommonindexPH7.35～7.45HCO3-22～27mmol/LPaCO24.4～6.25kPa（34～45mmHg）AG（aniongap）8～16mmol/LAcidosisManifestationsrespirationirritable,comanausea,vomitingcherrylips,ketonflavourBloodgas:PH,HCO3－↓,CO2CP↓,BEnegative

degrees:mild13-18mmol／Lmoderate

9-13mmol／Lsevere

<9mmol／LTreatmentDealwithprimarydiseaseCalculate（PH<7.3）HCO3（mmol）＝（-BE）×0.3×Wt（kg）5％SB（ml）＝（-BE）×0.5×Wt（kg）Add?amountinthefirsttimeWithoutbloodgas，increase[HCO3－]5mmol/L1.4%NaHCO31ml/Lelevate[HCO3－]1mmol/L5%NaHCO33.6tonic1.4%NaHCO3isotonic5%SB+5%(10%)GS=1.4%SB12.5isotonicCommonsolutionNon-electrolytesolution5%G.S10%G.SElectrolytesolution0.9%NaClSodiumbicarbonate1.4%SB(isotonic)5%SB(3.6tonic)10%KCl(8.9tonic)Mixedsolutions5%10%G.S0.9%NaCl1.4%NaHCO32:1(isotonic)213:2:1(1/2tonic)3213:4:2(2/3tonic)3426:2:1(1/3tonic)6214:1(1/5tonic)41OralrehydrationtherapyaccordingtothemechanismofabsorptionofNa+andglucosecoupledtransportinintestineIndicationsmild/moderatedehydrationNoseverevomittingNoabdominaldistentionOralRehydrationSalts(ORS)

NaCl2.6g(3.5)Natriumcitricum2.9gKCL1.5gG.S13.5g(20)Water1000ml1/2tonic(2/3)

245mOsm/LIntravenousfluidtherapyIndicationsModerateorseveredehydrationSeverevomittingNotrelievedbyoraltherapyPrinciple

Rapid-slowNa-GSK-urineCal-convulsionKeypointsAmountoffluidKindoffluidInfusionrateFluidtherapy1stdayPreexistinglossesOngoingabnormallossesNormalrequirementsPreexistinglossesTheamountoffluidMild30-50ml/kgModerate50-100ml/kgSevere100-120ml/kgKindoffluidsHypotonic2/3tonicIsotonic1/2tonicHypertonic1/3-1/5tonic

withoutbloodgas,maybeisotonicInfusingrate8-10ml/kg.h(8-12h)Severedehydration/shock:2:120ml/kg，0.5-1hrivdrip（thisvolumebelongstocumulatedlost）Ongoingabnormallosses

AccordingtostoolsVolume:estimate30ml/kgSolution:1/3～1/2tonicSpeed:5ml/kg.h(12-16h)NormalrequirementsVolume60ml-80/kgWtfluidrequirement~10Kg100ml/kg11~20Kg1000+50ml/kgforeachkgabove10kg>20kg1500+20ml/kgforeachkgabove20kgSolution:1/4～1/5tonicSpeed:5ml/kg.hTrytodrinkTotalvolumeinthewholedayMild:90－120ml/kgModerate:120－150ml/kgSevere:150－180ml/kgvolume（ml/kg）tonicvolume(ml/kg)tonic(ml/kg)tonicmild5090～120moderate50～100120～150severe100～120150～1808～12h（8～10ml/kg/hr）12～16h(5ml/kg/hr）total(ml/kg)hypo2/3Isotonic1/2hyper1/310～401/3～1/260～801/51stdCumulativeloss

Furtherloss

PhysiologicalneedvolumeCase1Subject:Male,1y,Wt10kgHistory:diarrheafor2daysvomitingfor1daywaterystool>10times/dnourinefor8hrs

Object

PE：apthy，marblingskin,depressedfontanelle，sunkeneyesockets,dryCherry-lips,coldlimbs,CRT4’’Labs：pH7.15，PaCO230mmHgCO2-CP13mmol/L，BE-18mmol/L,K+2.6mmol/L,Na+140mmol/LAssessmentAcutediarrheaSeveredehydrationandshockIsotonicHypokalemiaMetabolicacidosisPlanVolume

：10×180ml=1800mlSolution

：1/2tonic5％SB(ml)

=(-BE)×0.5×BW

=18×0.5×10=90ml

=1.4％SB300ml10％KCL:3×10=30mlSolution2：3：1NS600ml25％GS900ml31.4％SB300ml1Step20ml/kg(isotonic):200mlNS，in0.5hRemainderin20～24hCumulatedlost:120×10=1200ml,120