13小兒補(bǔ)液英文修

FluidTherapyThefirstaffiliatedhospitalSUNYAT-SENuniversity

Prof.WangHuishen

王慧深LastlessonEmphasisEtiology(in/ex/no)

Pathogenesis(4+ex/b/v/no)ClinicalmanifestationDiagnosis

DifferentialDiagnosis(p/d/n)Treatment

Predisposing(4)DiagnosisNotdifficultAccordingtoclinicalmanifestation,laboratorytestsandcharacterofstool.++InfectiousOrNoninfectiousDehydrationDegreeandquality

ElectrolytedisturbancesAndDisturbanceofacid-basebalance

SeverityclinicalsignsofdehydrationmildmoderatesevereWaterlossByweightSpiritSkinMocousAnteriorfontanelandeyeballTearUrineoutputPeripheralcirculation＜50ml/kg＜5%SlightlydispiritedslightlyagitatedSlightlydrySlightlydrySlightlydepressedNormalSlightlyreducednormal50～100ml/kg5%～10%DispiritedAgitatedDry,paleVerydrydepressedReducedLittleorNoLittlecool100～120ml/kg＞10%Extremelydispiritedapathy,hypnody,comaGraymottledParcheddepressedgreatlyNoNourineoutputCool,weakpulse,shockDehydrationDehydration

SameproportionlossPIFCPIFCElectrolytelossmorePhypotonic,IF+ChypertonicCellexpansionSevereEasytoshockP:plasma,IF:interstitialfluid,C:cellIsotonicPIFCWaterlossmorePhypertonicIF+ChypotonicCellhydrationMildThirsty

AcutediarrheaaftervomitinggreatlyHypotonic

Hypertonic

Na+:130～150mmol/LNa+:

<130mmol/LNa+:

>150mmol/LElectrolytedisturbanceDiarrheacomplicatedhyponatremia&hypernatremia

hypokalemiahypocalcemiahypomagnesemiaK+(potassium)<3.5mmol/L(normal:3.5～5.5mmol/L)causes：

Excessivelosses:vomit,diarrhea.Inadequateintake.Renalfunctionofkeepingkalium,itcontinuesexcludingkaliumwhenwithhypokalemia.Clinicalmanifestation:electrolytedisorderHypokalemiadepressedTensionofskeletalmuscle，tendonreflex，

evenrespiratorymuscleweaknessTensionofsmoothmuscl,abdominalextension,intestinalsoundordisappearMyocardiumexcitability,arrhythmia,ECG:T-waveisloworinversion,U-waveoccurs,prolongedP-RintervalandQ-Tinterval,STsectiondescending.BaseosishypokalemiaK+(potassium)<3.5mmol/L(normal:3.5～5.5mmol/L)Clinicalmanifestation:nerveandmuscularexcitabilityCa2+﹤1.75mmol/L(7mg/dl);Mg2+﹤0.6mmol/L(1.5mg/dl).Symptomsusuallyoccurafterdehydrationandacidosisresolved,orfluidreplacement.Clinicalmanifestation:thrill,tetany,convulsion.Ifconvulsionhasn’trelievedaftersupplementcalcium,payattentiontohypomagnesemia.hypocalcemia&hypomagnesemiaCaseexampleAn8–monthboyhaddiarrheaandvomitedfor3days,urinestreamreduced,irritability.PE:Pulserate150/min,weightlosswas10%,bloodpressure65/40mmHg,skincolorshowedgreyandskinturgorlookedliketents.Mucousmembraneswereverydry;eyeballwassunkengreatly,anteriorfontaneldepressedgreatly.Abdomendistended,bowelsounddiminished.

Questions:1.Whatisthediagnosis?2.Howtoadministerthefluidtherapy?Answer1(diagnosis)

AcutediarrheaseveredehydrationhypokalemiaFluidTherapyNeonate……………...80%Olderchildren………..65%Adult…..60%

featuresofbodyfluidbalanceinchildren

TheyoungerThelargerproportionofbodywaterTotalbodywater(bybodymass)----amountofbodyfluid

featuresofbodyfluidbalanceinchildrenTheyoungerThelargerproportionofextracellularwaterIntracellularBodyfluidExtracellularInterstitialfluidPlasmaLymphfluidSecretoryjuice----distributionofbodyfluidP6%IF37%IC35%IF20%IF10%~15%IF25%IC40%P5%P5%P5%IC40%IC40%~45%Neonate78%

~1y70%2y~14y65%Adult55%~60%

featuresofbodyfluidbalanceinchildren

P:plasmaIF:interstitialfluidIC:intracellular----distributionofbodyfluidindifferentages(byBW)featuresofbodyfluidbalanceinchildren----waterrequirement

RequiringmorewaterRegulatingfunctionpoorlyEasywatermetabolismdisturbanceDuetogrowquickly,need0.5%~3%waterforgrowth.Insensiblewaterloss:2timesmorethanadult.Fluidexchangeofdigestivetractquicker.Watermetabolismhigher:infant1/2bytotalfluidadult1/7bytotalfluid.Regulatingfunctionofwatermetabolismpoorly:kidney,lung.featuresofbodyfluidbalance

inchildren----waterrequirementSimilarwithadultExtracellular:Na+,Cl-,Hco3-Intracellular:K+,Mg,Hpo4=,proteinFeaturesofneonate(Severaldaysafterbirth):CompositionofbodyfluidParticularlyinpreterminfantK+,Cl-,P,lacticacidNa+,Ca++,Hco3-FunctionofexcludingH+Acidosis

Acid-basebalanceandadjust----twoconceptAcid-basebalanceAcidityandalkalinityAnion-cationbalanceAnionandcationCompensationofadjusthaslimitAcid-basebalanceandadjust----bodyliquidBuffersystemlung：exhaleofstoreCO2(respiratory)kidney:excludeH+andstoreNa+(metabolic)NaHCO3/H2CO3Na2HPO4/NaH2PO4BuffersystemofplasmaproteinAdjust

HCO3-

NaHCO3/H2CO3=20:1

PH：7.4(7.35~7.45)PaCO2：40(34~45)mmHgSB：24(22~27)mmol/LBE：-3~+3mmol/LCO2CP：22(18~27)mmol/LAcid-baseindexBloodgasanalysis〔normal〕Compensation&decompensationAcid-basebalancedisorderrespiratoryacidosisrespiratoryalkalosismetabolicacidosismetabolicalkalosisDispirited,dysphoria,drowsiness,comaHypernea(Kussmaulsbreathing)，exhalationcoolExpiratorygassmellsketoneCherrylipsNausea,vomitMetabolicacidosis--clinicalmanifestationMild:breathfrequencyslightlySevere:occur:TocurewaterandelectrolytedisturbanceRecoverandmaintainbloodvolume,osmoticpressure,Acidity,alkalinityandelectrolyteNormalphysiologicalfunctionFluidtherapyPurposeoralintravenousFluidtherapyMethodpreventiondehydration:Ricesoupaddsaltsolute〔1/3〕Milddehydration:ORS。Mild/moderatedehydration:ORS——mild:ORS：50～80ml/kg——moderate:ORS：80～100ml/kgSeveredehydrationorvomitinganddiarrhea——intravenousNaCl：3.5gNaHCO3(Sodiumcitrate)：2.5g(2.9g)KCl：1.5gGS：20goralrehydrationsalts〔ORS〕Na+90mmol／Ｌ，Ｋ+20mmol／Ｌ，Cl－80mmol／Ｌ，HCO3－30mmol／ＬAddwaterto1000ml2/3isotonic,Totalosmoticpressure:220mmol／ＬCanbedilutedinChildren口服補(bǔ)液鹽Oralrehydrationsalt(ORS)WHO2002年推薦的低滲透壓ORS配方

成分 含量(克) NaCl2.6枸櫞酸鈉

2.9KCl1.5葡萄糖13.5水1000ml該配方中各種電解質(zhì)濃度為：Na+75mmol/L，K+20mmol/L，C1-65mmol/L，枸櫞酸根10mmol/L，葡萄糖75m

mol/L?？倽B透壓為245mOsm/LsodiumcitratecouldinsteadbyNaHCO3Na+--GStransportinSmallintestineNa+–GScarrierenterocyteBrushborderintracellularintercellularbloodNa+GSNa+GStransportpromoteNa+、H2OabsorbNa+(pump)intercellularspace(Cl-)OPH2OintobloodMechanismsofORSCharacteristicsofORS

---Advantages

Osmoticpressuresimilarwithplasma(2/3tonicity)CorrectlossesbyproperconcentrationofNa+

、K+

、Cl-ChildreneasilyacceptthetastesCorrectmetabolicacidosisbysodiumcitratePromoteNa+andH2Oabsorptionby2%GS

CharacteristicsofORS

---disadvantages

Liquidtonicityhigher(2/3)CannotbeusedasthemaintenancemediaNa+concentrationisrelativelyhighertoneonatesandinfants(properdiluted).ORS：

Ricesoup500ml+salt1.75gFriedricenoodles25g+salt1.75g+water500ml(Cooking2－3min)GNS:Whitesugar10g+salt1.75g+water500ml(boil)SimplepreparationathomeSeveredehydration

intravenousOsmoticpressureofplasma(OPP)

OPP=(crystal+colloid)osmoticpressure

Na+142Cation:K+5(mmol)Ca++2.5Mg++1.5

HCO3-27Anion:Cl-103(mmol)HPO4=1SO4=0.5Organo-anion19.5151mmol/L151mmol/LOPPrange：280－320mOsm/LConcentrationofelectrolyteandcalculationOsmoticpressure,osmol〔OSM〕Dissolve1mmolsoluteinto100mlwater:1mOsm.100mlwater1mmol1mOsmConcentrationofelectrolyteandcalculationTononelectrolyte

1mmolGS1mOsm2mOsm1mmolNaclToelectrolyte1mmolCacl23mOsmConcentrationofelectrolyteandcalculationNa:Cl=3:2〔inplasma〕

FluidisotonicIsotonicliquid:osmoticpressuresimilarwithplasmaSodiumisotonic:Isotonic:150mmolsodiumin1000ml?tonicity:75mmolsodiumin1000ml2/3tonicity:100mmolsodiumin1000ml1/3tonicity:50mmolsodiumin1000mlLiquidsolutioncommonlyused5%GS10%GS0.9%NaCl10%NaClRinger5%NaHCO311.2%NaL10%KClMixturenonelectrolytesolutionelectrolytesolutionglucoseenterthebodybyoxidationchangeintowaterandCO2forenergyandwaterwithouttensionPercentageconcentration:5%GS、10%NaClMolar(mol,grammolecularweight),mmol

1molNaCl=23+35.5=58.5gMolarity(mol/L)

calculation：mol/L=

e.g.0.9%NaCl==0.154mol/L

ConcentrationofelectrolyteandcalculationPercentageconcentrationofsolute〔%〕10Molecularweight(atomicweight)0.9×1058.5=154mmol/L

10%NaCl：1ml=1.7mmol5%NaHCO3：1ml=0.6mmol11.2%NaL：1ml=1mmol10%KCl：1ml=1.34mmolCalculationTheelementandsimpledispensing

inthecommonlymixedsolution

Solutioncompositionratiodispensing

(ml)

NS10%GS1.4%NB10%GS10%NaCl5%NB10%KCl

2:1isotonicsolution.2150030471:1solution(1/2tonicity)11500202:3:1solution(1/2tonicity)2315001524

4:3:2solution

(2/3tonicity)4325002033

1:2solution(1/3tonicity)1250015

1:4solution(1/5tonicity)145009

dailyrequirement(1/3tonic)1450097.5常用溶液成分溶液每100ml含Na∶Cl電解質(zhì)滲透壓血漿〔142：103〕3：2300mmol/L①0.9%氯化鈉0.9g1∶1等張②5%或10%葡萄糖5或10g③5%碳酸氫鈉5g3.5張④1.4%碳酸氫鈉1.4g等張⑤10%氯化鉀10g8.9張溶液每100ml含Na∶Cl

電解質(zhì)1∶1含鈉液①50ml,②50ml1∶11/2張1∶2含鈉液①35ml,②65ml1∶11/3張1∶4含鈉液①20ml,②80ml1∶11/5張2∶1含鈉液①65ml,④35ml3∶2等張2∶3∶1含鈉液①33ml,②50ml④17ml3∶21/2張4∶3∶2含鈉液①45ml,②33ml3∶22/3張④22ml續(xù)表Watersupplement&correctacidosis

Accumulativelosses

---lossesfromonsettopre-treatment

ongoinglosses

---continuinglossesduringtreatment

dailyrequirement

---tomaintainbasicallyphysiologicalfunctionAmount,compositionandtimeThefirstdayfluidinfusion：Dehydration

Fluidreplacement=losses(Accumulation+ongoing+daily)

Accumulation

ongoingdailytotalamount

(ml/Kg)mild5010~3060~8090~120moderate50~10010~3060~80120~150Severe100~12010~3060~80150~180

Accumulation:accumulationlossesOngoing:Ongoinglossesdaily:Physiologicalrequirement

SeverityclinicalsignsofdehydrationmildmoderatesevereWaterlossByweightSpiritSkinMocousAnteriorfontanelandeyeballTearUrineoutputPeripheralcirculation＜50ml/kg＜5%SlightlydispiritedslightlyagitatedSlightlydrySlightlydrySlightlydepressedNormalSlightlyreducednormal50～100ml/kg5%～10%DispiritedAgitatedDry,paleVerydrydepressedReducedLittleorNoLittlecool100～120ml/kg＞10%Extremelydispiritedapathy,hypnody,comaGraymottledParcheddepressedgreatlyNoNourineoutputCool,weakpulse,shockDehydrationAccumulationlossesamountmild：50ml/kgmoderate:50~100ml/kgsevere：100~120ml/kgWatersupplement-1:

accumulationlossesAmount,compositionandspeed:

---accordingtothedegreeandqualityofdehydrationcompositionisotonic：1/2tonicity(1:1)hypotonic：2/3tonicity(4:3:1)Hypertonic:1/3~1/5tonicity

(1/3tonicity)speedPrinciple:fastslowsevere：bolusofisotonicfluid2:1isotonic:20ml/kg(<300ml)in30’~1h(rapidlyexpand)others：8~12h(8～10ml/〔kg·h〕ivWatersupplement-1:

accumulationlossesAccumulationlossesDehydration:Ongoinglossesamount1/2~1/3tonicity(1:1)speed12~16hafterstage-1In24h,steadyspeed5ml/〔kg·h〕10~40ml/kg.dcompositionWatersupplement-2:

ongoinglossesdailyrequirementamount1/3~1/5tonicity(Physicalmainmedium)speedIn24h,steadyspeedAccompanywithstage-260~80ml/kg.d〔includingoral〕compositionWatersupplement-3:dailyrequirementTomasterthreeprinciplesThevolumofrehydration-AmountDeficitfluid=(percentageofdehydration)×(bodyweightinKg)Thetypeoffluid-CompositionIsotonicdehydration——1/2tonicitysolutionHypotonicdehydration——2/3tonicitysolutionHypertonicdehydration——1/3tonicitysolutionThespeedofliquid-Time：fourstepsfoursteps

(forfluidandelectrolytedeficits)Step1.Expandingvolume:

restorationofcirculation–emergency,within30minto1hour20ml/kg,2:1(isotonic)sodiumsolutionStep2.supplementlostbodyliquid:

first8~10hours8~10ml/hhalfoftotallossvolume2:3:1solution(1/2tonicity)Step3.maintenancerehydration:-anotherhalfloss-next16hours5ml/(kg.h)

physicaldemand:60~80ml/kg4:1solution(1/3~1/2tonicity)Step4.repairofpotassiumdeficitfoursteps

mild：correctetiologicalfactorModerat&severe：Alkalinesolutionrequirement(mmol)(40–CO2CPVol%)

2.2

=(22-CO2CPmmol/L)0.7kg=

BE0.3kg0.7kgUsuallyusethedosehalvedfirstandthanaccordingtobloodgasanalysesCorrectacidosis=Emergency:Per-elevate5mmolHCO3-5mmol/L(10%CO2-CP)needalkalinesolution:3mmol/kg

5%NaHco35ml/kgor1.4%NaHco320ml/kg

CorrectacidosisSupplementpotassium:10%KCL

mildhypokalemia：200~300mg/〔kg·d〕

2~3ml/〔kg·d〕oralseverhypokalemia：300~450mg/〔kg·d〕

3~4.5ml/kg.d10%KClivdripSupplementafterurineorurinationbeforecomingdiagnosesIntravenousconcentration<0.3%inthesolutespeed：>6~8h/d〔intravenous〕Time：keep4～6dayinterdiction：directlyintravenous，becauseheartstop！

Supplementpotassium

principle：SupplementCalciumandMagnesiumConvulsionemerged：10%CalciumGluconate10ml+25%Glucose10mlIVIfconvulsionhasn’trelievedaftersupplementcalcium,——give25%Mg.Sulfas0.2~0.4ml/kgdeeplyIMQ6hbecareful〔Calcium〕:HR<80time/minute，stop！Don’tleakoutvesselIntervaloftheDigitalisDon’tinjectionwithsubcutaneousandintramuscularfirstfastthenslow

PrinciplesofTherapyfirstthickthenthinsupplementpotassiumwhenhavingurineadjustanytimeandmonitorOngoinglossesanddailyrequirement

dailyrequirement

60~80ml/kg(1/3~1/5tonicity)Ongoinglossesfollowthehowmuchofthelostintheanytime(1/2~1/3tonicity)12~24HequalthespeedivdripTocontinuethesupplementpotassiumandcorrectacidosisTheseconddayfluidinfusion：Neonate:toreducetheliquidandelectrolytesproperly.Severemalnutrition：toreducethewateramountproperly,withlowspeed,2/3~1/2tonicsupplement10%GSand/orplasmaNotesoperationday2ml/kg/hthefirstday*4ml/kg/h——(thefirst10kg)4ml/kg/h——(thesecond10kg)2ml/kg/h*heartfailure/breathingmachineutilization:3ml/kg/h

puttoopenwarmcasing,thevolume>10%Fluidrequirementatpostoperation

orheart

failure

heartfailureorheartpostoperation

Controlthesolutionbyintravascularinjection

Volumeinclude:

—maintenancefluidinvascular；

—medicineanddilution；

—rinsesolutionforthevasculartubule；

—gastrictubeorfood-intake。Fluidrequirementatpostoperation

Includepotassiumglucoseandsodium1/4~1/5tension

10%GS500ml10%NaCl10ml10%KCl15ml(9.5%GS、0.19%NaCl、0.29%KCl)

An8–monthboy