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1、Fluid Therapy,The first affiliated hospital SUN YAT-SEN university Prof. Wang Huishen 王慧深,Last lesson Emphasis,Etiology (in/ex/no),Pathogenesis (4+ex/b/v/no),Clinical manifestation,Diagnosis,Differential Diagnosis (p/d/n),Treatment,Predisposing (4),Diagnosis,Not difficult According to clinical manif
2、estation, laboratory tests and character of stool.,+,+,Infectious Or Noninfectious,Dehydration Degree and quality,Electrolyte disturbances And Disturbance of acid-base balance,Severity clinical signs of dehydration,Dehydration,Dehydration,Same proportion loss,P,IF,C,P,IF,C,Electrolyte loss more,P hy
3、potonic, IF+C hypertonic,Cell expansion Severe Easy to shock,P: plasma, IF: interstitial fluid, C: cell,Isotonic,P,IF,C,Water loss more,P hypertonic IF+C hypotonic,Cell hydration Mild Thirsty,Acute diarrhea after vomiting greatly,Hypotonic,Hypertonic,Na+ :130150mmol/L,Na+: 130mmol/L,Na+: 150mmol/L,E
4、lectrolyte disturbance,Diarrhea complicated,hyponatremia & hypernatremia hypokalemia hypocalcemia hypomagnesemia,K+ (potassium)3.5mmol/L (normal: 3.55.5 mmol/L) causes： Excessive losses: vomit, diarrhea. Inadequate intake. Renal function of keeping kalium ,it continues excluding kalium when with hyp
5、okalemia.,Clinical manifestation: electrolyte disorder Hypokalemia,depressed Tension of skeletal muscle ，tendon reflex， even respiratory muscle weakness Tension of smooth muscl , abdominal extension, intestinal sound or disappear Myocardium excitability , arrhythmia, ECG: T-wave is low or inversion,
6、 U-wave occurs, prolonged P-R interval and Q-T interval, ST section descending. Baseosis,hypokalemia K+ (potassium)3.5mmol/L (normal: 3.55.5 mmol/L),Clinical manifestation: nerve and muscular excitability,Ca2+1.75mmol/L (7mg/dl) ; Mg2+0.6mmol/L (1.5mg/dl). Symptoms usually occur after dehydration an
7、d acidosis resolved, or fluid replacement. Clinical manifestation: thrill, tetany, convulsion. If convulsion hasnt relieved after supplement calcium, pay attention to hypomagnesemia.,hypocalcemia & hypomagnesemia,Case example,An 8 month boy had diarrhea and vomited for 3 days, urine stream reduced,
8、irritability. PE: Pulse rate 150/min, weight loss was 10%, blood pressure 65/40mmHg, skin color showed grey and skin turgor looked like tents. Mucous membranes were very dry; eye ball was sunken greatly, anterior fontanel depressed greatly. Abdomen distended, bowel sound diminished. Questions: 1.Wha
9、t is the diagnosis? 2.How to administer the fluid therapy?,Answer 1 (diagnosis),Acute diarrhea severe dehydration hypokalemia,Fluid Therapy,Neonate. 80% Older children65% Adult60%,features of body fluid balance in children,The younger,The larger proportion of body water,Total body water (by body mas
10、s),-amount of body fluid,features of body fluid balance in children,The younger,The larger proportion of extracellular water,Intracellular,Body fluid,Extracellular,Interstitial fluid Plasma Lymph fluid Secretory juice,-distribution of body fluid,P 6%,IF 37%,IC 35%,IF 20%,IF 10% 15%,IF 25%,IC 40%,P 5
11、%,P 5%,P 5%,IC 40%,IC 40%45%,Neonate 78%,1y 70%,2y14y 65%,Adult 55%60%,features of body fluid balance in children,P: plasma IF: interstitial fluid IC: intracellular,-distribution of body fluid in different ages (by BW),features of body fluid balance in children,-water requirement,Requiring more wate
12、r Regulating function poorly Easy water metabolism disturbance,Due to grow quickly, need 0.5%3% water for growth. Insensible water loss : 2 times more than adult. Fluid exchange of digestive tract quicker. Water metabolism higher: infant 1/2 by total fluid adult 1/7 by total fluid. Regulating functi
13、on of water metabolism poorly: kidney, lung.,features of body fluid balance in children,-water requirement,Similar with adult,Extracellular: Na+, Cl-, Hco3-,Intracellular: K+, Mg, Hpo4=, protein,Features of neonate (Several days after birth) :,Composition of body fluid,Particularly in preterm infant
14、,K+, Cl-, P, lactic acid,Na+, Ca+, Hco3-,Function of excluding H+,Acidosis,Acid-base balance and adjust -two concept,Acid-base balance Acidity and alkalinity Anion-cation balance Anion and cation,Compensation of adjust has limit,Acid-base balance and adjust -body liquid,Buffer system lung ：exhale of
15、 store CO2 (respiratory) kidney: exclude H+ and store Na+ (metabolic),NaHCO3/H2CO3 Na2HPO4/NaH2PO4 Buffer system of plasma protein,Adjust HCO3-,NaHCO3/H2CO3=20:1,PH：7.4 (7.357.45) PaCO2：40 (3445) mmHg SB：24 (2227) mmol/L BE：-3 +3 mmol/L CO2CP：22 (1827) mmol/L,Acid-base index,Blood gas analysis（norma
16、l ）,Compensation & decompensation,Acid-base balance disorder,respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis,Dispirited, dysphoria, drowsiness, coma Hypernea (Kussmauls breathing)，exhalation cool Expiratory gas smells ketone Cherry lips Nausea, vomit,Metabolic acidosis-clinical manifestation,Mild: breath frequency slightly S
