液体疗法精选课件.ppt

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1、关于液体疗法第一页，本课件共有99页概要概要胎儿-新生儿转化与正常新生儿水电解质平衡影响因素常见的电解质紊乱和处理第二页，本课件共有99页体液的分区体液的分区 细胞内液(ICF)血管内液(IVF)总体液(TBW)淋巴液细胞外液(ECF)间质液(ISF)第三页，本课件共有99页胎儿胎儿-新生儿过渡新生儿过渡 水生水生（寄生）（寄生）陆生陆生（独立生存）（独立生存）第四页，本课件共有99页提塔利克提塔利克是距今三亿七千五百万年前的鱼类，但同是距今三亿七千五百万年前的鱼类，但同时拥有两生类的原始特征，是时拥有两生类的原始特征，是水中动物爬上陆地生水中动物爬上陆地生活时的过渡物种活时的过渡物种。第五页

2、，本课件共有99页从水生到陆地生活花费了上亿年的时间进化。从水生到陆地生活花费了上亿年的时间进化。第六页，本课件共有99页胎儿胎儿-新生儿过渡新生儿过渡 水生水生（寄生）（寄生）陆生陆生（独立生存）（独立生存）第七页，本课件共有99页Total Body Water(TBW)Content and Fluid Distribution between Intracellular(ICF)and Extracellular(ECF)Fluid Compartments in Humans from the First Trimester until 9 Months of AgeBody Wat

3、er Content(%)FETUS NEWBORNAge(months)%100 90 80 70 60 50 40 30 20 10 0第八页，本课件共有99页Electrolyte Composition of Fluid Compartments:阳离子阳离子第九页，本课件共有99页Electrolyte Composition of Fluid Compartments:阴离子阴离子第十页，本课件共有99页(mEq/L)Electrolyte Composition of Fluid Compartments:阳离子阳离子(mEq/L)(mEq/kg H2O)第十一页，本课件共有99

4、页(mEq/L)Electrolyte Composition of Fluid Compartments:阴离子阴离子(mEq/L)(mEq/kg H2O)第十二页，本课件共有99页Postnatal changes in body weight,extracellular fluid volume and sodium balance Shaffer and Weismann;Clin Perinatol 19:233,1992Body weight-expressed in%of birth weight Extracellular Fluid Volume-estimated by t

5、he bromide dilution methodSodium Balance-calculated as the difference between sodium intake and urinary sodium excretion第十三页，本课件共有99页水平衡水平衡 出入水量的动态平衡入量：肠道外液体的摄入、药物和输液、血液制品、口服摄入、内生水等；出量：不显性失水、尿量、大便、胃肠道丢失、出汗，化验抽血、意外失血、生长所需水量等第十四页，本课件共有99页新生儿生理需水量新生儿生理需水量 是保持机体水平衡所必需的，是正常和患病新生儿所共同需要的。在疾病情况下另有不同的需要。不显性失

6、水+排尿+粪便失水+生长需要所需水量-氧化代谢的内生水量,以保证出入水量的平衡（零平衡）。旺盛生长发育中的新生儿呈正平衡，为生成新组织保留水和其它物质第十五页，本课件共有99页不显性失水（不显性失水（IWL）指弥散到指弥散到皮肤皮肤和和呼吸道表面呼吸道表面而蒸发丢失的水量而蒸发丢失的水量。新生儿代谢旺盛，所需热量相对较多，而且体表面积与体重的比值大，不显性失水量相对较多。在一般室温、湿度和基础情况下，为20-40ml/kg，其中通过肺(13)和皮肤蒸发(2/3)。不同胎龄体重新生儿之间差异很大。不显性失水中不含盐。第十六页，本课件共有99页影响不显性失水量的因素：影响不显性失水量的因素：（1）

7、胎龄：胎龄、出生体重愈小，按体重计算不显形失水愈多。（2）呼吸：呼吸增快可增加2030%甚至更多。（3）体温：每升高1度约增加10-30%或0.5ml/kg/h，代谢率增加10%。（4）环境温度:环境温度高于适中温度，可增加数倍。第十七页，本课件共有99页（5）光疗或辐射台应用：可增加40190%（6）活动：可增加30%以上。（7）环境湿度：湿度愈大，IWL愈小。（8）呼吸机治疗：呼吸机治疗时，IWL减少。（9）皮肤屏障损害：如腹裂等。第十八页，本课件共有99页第十九页，本课件共有99页Mean Insensible Water Loss Through the Skin in AGA Inf

8、ants in a Relative Ambient Humidity of 50%Postnatal Age(days)Transepidermal Water Loss(mL/kg/day)Hammarlund et al;A Paed Scand 72:721,1983;Sedin;Current Topics in Neonatology;WB Saunders Co,p 50,1995第二十页，本课件共有99页Transepidermal Water Loss during the First Week of Life in Infants Born at 25-27 Weeks m

9、L/dayDay of LifeRelative Ambient HumidityRelative Ambient HumidityHammarlund et al;A Paed Scand 72:721,1983;Sedin;Current Topics in Neonatology;WB Saunders Co,p 50,1995第二十一页，本课件共有99页Transepidermal Water Loss in Relation to Gestational Age at Birth and During the First Month of Life in AGA InfantsTra

10、nsepidermal Water Loss(g/m2/h)Gestational Age(weeks)Postnatal Age(days)Postnatal Age(days)Hammarlund et al;A Paed Scand 72:721,1983;Sedin;Current Topics in Neonatology;WB Saunders Co,p 50,1995第二十二页，本课件共有99页粪便失水粪便失水 新生儿消化道的液体交换快，在腹泻时，体液丢失迅速，比儿童更容易出现水、电解质失衡。新生儿排便量为510ml/kg.第二十三页，本课件共有99页肾脏发育和功能的变化肾脏发育

11、和功能的变化 出生时足月新生儿的肾小球滤过率（GFR）低仅为成人的25，早产儿更低。出生早期肾脏尿液的浓缩和稀释功能均较差，但随生长逐步成熟。相对而言浓缩更差。第二十四页，本课件共有99页肾脏的浓缩和稀释肾脏的浓缩和稀释正常成人可稀释尿液达501200mOsm/L新生儿出生一周后可达成人水平。但肾小球滤过率低排水能力仍有限。第二十五页，本课件共有99页新生儿肾脏浓缩能力差，早产儿最大到600mOsm/kgH2O，足月儿800mOsm/kgH2O。排泄同量溶质所需水量较成人为多。入水不足或失水过多，易于超过肾脏浓缩能力，发生代谢产物潴留和高渗性脱水。第二十六页，本课件共有99页生理需水总量的计算

12、生理需水总量的计算 头几天正常足月新生儿生理需水量失水途径液量（ml/kg）不显性失水内生水尿丢失粪便失水10允许的负水平衡10液量20+10+50-10-10=60205-1020-50第二十七页，本课件共有99页Assessment of FE statusHistoryHistory:babys F&E status partially reflects moms F&E status(Excessive use of oxytocin,hypotonic IV fluid hyponatremia)Physical ExaminationPhysical Examination:Wei

13、ght:reflects TBW but not intravascular volume(eg.Long term paralysis and peritonitis incr BW and incr IF but decreased intravascular volume.Moral:a puffy baby may or may not have adequate fluid where it counts in his blood vessels)第二十八页，本课件共有99页Assessment of FE statusPhysical examination(Contd)Skin/

14、Mucosa:Altered skin turgor,sunken AF,dry mucosa,edema etc are not sensitive indicators in babiesCardiovascular:Tachycardia too much(ECF excess in CHF)or too little ECF(hypovolemia)Delayed capillary refill low cardiac outputHepatomegaly can occur with ECF excessBP changes very lateUrine output第二十九页，本

15、课件共有99页Assessment of FE status Lab evaluationLab evaluationSerum electrolytes and plasma osmolarityUrine electrolytes,specific gravity(not very useful if the baby is on diuretics-lasix etc),FENaBlood urea,serum creatinine(values in the first few days reflect moms values,not babys)ABG(low pH and bica

16、rb may indicate poor perfusion)第三十页，本课件共有99页体液平衡的临床监测和评估指标体液平衡的临床监测和评估指标1体重的变化 初生第一周，任何体重的变化都代表液体的变化。体液占体重的百分比随新生儿的成熟而变化。2红细胞压积3血清渗透压、电解质和蛋白质浓度4尿流率、尿渗透压、尿比重、尿电解质、血尿素氮和肌酐。5)心血管评估 监测中心静脉压、心输出量等6临床体征第三十一页，本课件共有99页脱水时的液体复苏（水疗）第三十二页，本课件共有99页感染性休克的液体复苏感染性休克的液体复苏第三十三页，本课件共有99页第三十四页，本课件共有99页早期液体复苏适当的终点定为HR

17、140 160 次/分MBP 45 mmHg尿量 0.5 ml/kg/hrCVP=8 12 mmHgHCT 30%ScvO2 70%第三十五页，本课件共有99页围手术期的液体管理“干”（限制）和“湿”（开放）的争论仍将继续液体治疗的主要目标是维持足够的组织灌注补液策略的应用取决于外科手术类型和病人的基本情况传统晶体液和胶体液输注的观念需要更新扩充血容量：胶体液效率更高补充细胞外液：必须使用晶体溶液限制晶体入液量（避免超量输注）对择期手术的患者有益避免过度补液，就能避免很多不必要的并发症第三十六页，本课件共有99页水肿时的液量管理和药物应用第三十七页，本课件共有99页Diuretics in N

18、eonatesFurosemide(2)1.Administration A.Bolus:-1-2 mg/kg/dose iv Q12-24 hours(oral dosage is usually higher due to poor bio-availability)-Maximum dose:16 mg/kg/day for neonates on ECMOB.Continuous Infusion:-0.01-0.05 mg/kg/hour,titrate dosage to desired clinical effect-Continuous infusion has several

19、 advantages over bolus administration including+decreased dosage requirements+decreased adverse effects+improved diuretic response2.Tolerance:Decreased effectiveness over time primarily due to activation of compensatory homeostatic mechanisms and changes in tubular electrolyte concentration.-Combina

20、tion of furosemide with a thiazide diuretic-Administration via continuous infusion第三十八页，本课件共有99页Diuretics in NeonatesFurosemide(3)Indications-Fluid retention without evidence for decreased effective circulating blood volume(hypotension)-Congestive heart failure(congenital heart disease with left-to-

21、right shunting;left outflow tract obstruction to decrease afterload;cardiomyopathy)-Acute renal insufficiency-Chronic lung disease:Recent metaanalysis concluded that chronic administration of Lasix cannot be recommended in preterm neonates with CLD due to the lack of appropriately designed and power

22、ed clinical trials looking at outcome measures other than changes in pulmonary physiology(Cochrane Database;2000).Theoretical benefits:+Decreases total body sodium and thus extracellular volume+Direct inhibition of the upregulated pulmonary Na-K-2 Cl co-transporter-In an attempt to decrease cerebros

23、pinal fluid production in certain cases of obstructive hydrocephalus(in combination with acetazolamide)第三十九页，本课件共有99页Diuretics in NeonatesFurosemide(4)Side Effects:-Hyponatremia,hypokalemia,hypochloremia,volume contraction-Growth failure due to contraction alkalosis-Enhanced urinary calcium losses(n

24、ephrocalcinosis;nephrolithiasis)-Osteopenia,bone fractures-Ototoxicity:+concurrent aminoglycoside administration may increase the risk of ototoxicity+slow infusion decreases the risk of ototoxicity-Displacement of bilirubin from albumin binding第四十页，本课件共有99页Diuretics in NeonatesFurosemide(5)Electroly

25、te Losses:-Sodium and chloride losses are readily reflected in the electrolyte panel-The potentially severe decrease in total body potassium usually goes undetected (2%of the total body potassium is outside the cells)-The excess chloride loss results in bicarbonate retention and metabolic alkalosis-

26、In neonates with CLD,the metabolic alkalosis may go undetected as CO2 is being retained by the patient to compensate for the metabolic alkalosis.The increase in CO2 may inappropriately trigger an increase in ventilatory support and a vicious cycle may develop:the respiratory compensation(CO2 retenti

27、on)is being treated instead of addressing the primary acid-base derangement(metabolic alkalosis).第四十一页，本课件共有99页Diuretics in NeonatesFurosemide(6)Replacement of Electrolyte Losses:-Potassium chloride supplementation should be initiated early(3-8 mEq/Kg/day)-If seCl remains 3 weeks of age,4-week treat

28、ment with thiazide and spironolactone improved lung compliance and reduced the need for Lasix-Thiazide and spironolactone administration decreased the risk of death and tended to facilitate extubation after 8 weeks in preterm infants without steroid,bronchodilators or theophylline treatment-Little o

29、r no evidence to support any benefit of diuretic administration on need for ventilatory support,length of hospital stay or long-term outcome.Conclusion:-Acute and chronic administration of distal diuretics improves pulmonary mechanics第四十四页，本课件共有99页Diuretics in NeonatesCombination of DiureticsFurosem

30、ide and Thiazide Diuretics:-Attenuates the development of tolerance-No clear evidence of attenuation of side effects of Lasix administration unless the dose can be decreasedThiazide and Spironolactone:-Chronic administration of this combination improved lung compliance and reduced the use of Lasix i

31、n preterm neonates with CLD(Brion,Cochrane Library,2002)Furosemide and Dopamine:-May be synergistic(Tulassay and Seri 1986;Acta Paediatr Scand 75:420)Methylxanthines and Dopamine:-May be synergistic(Bell et al 1998;Int Care Med 24:1099)第四十五页，本课件共有99页Renal Effects of Dopamine in the Preterm Renal Eff

32、ects of Dopamine in the Preterm NeonateNeonateSUMMARYSUMMARY1.Renal hemodynamic effects of dopamine:Increases in total renal blood flow;Increases in renal medullary blood flow;Increases in glomerular filtration rate.2.Direct renal tubular effects of dopamine:Increases in renal sodium,phosphorous,and

33、 free water excretion and decreases concentrating capacity.第四十六页，本课件共有99页Renal Effects of Dopamine in the Preterm Renal Effects of Dopamine in the Preterm NeonateNeonateSUMMARYSUMMARY1.Renal hemodynamic effects of dopamine:Increases in total renal blood flow;Increases in renal medullary blood flow;I

34、ncreases in glomerular filtration rate.2.Direct renal tubular effects of dopamine:Increases in renal sodium,phosphorous,and free water excretion and decreases concentrating capacity.第四十七页，本课件共有99页水肿的肾脏替代治疗水肿的肾脏替代治疗 CRRT第四十八页，本课件共有99页新生儿常见的电解质紊乱新生儿常见的电解质紊乱第四十九页，本课件共有99页热能、水、电解质需要量热量kcal/Kg.d水ml/kg.dN

35、a+mmol/kg.dK+mmol/kg.d早产儿120120-1802-31-2足月儿120100-1601-21-2第五十页，本课件共有99页第五十一页，本课件共有99页主要离子分子量主要离子分子量Na：23K：39Ca：40CL：351ml10%Nacl=1.7mmolNa；1ml3%NaCl=0.51mmolNa1ml10%KCl=1.3mmolK1ml10%葡萄糖酸钙=0.23mmolCa1ml5%NaHCO3=0.6mmolHCO3-第五十二页，本课件共有99页Common lytes problemsSodium:Hypo(130 mEq/L;worry if 150 mEq/L

36、;worry if 150)Potassium:Hypo(3.5 mEq/L;worry if 6 mEq/L(non-hemolyzed)(worry if 6.5 or if ECG changes)第五十三页，本课件共有99页第五十四页，本课件共有99页问题低钠（体积单位体积单位）少钠（质量单位质量单位）？钠与水的关系：水肿，脱水，高钠，低纳渗漏综合征时的液体管理：又有水肿同时存在有效循环容量不足？如何解决此类矛盾（监测和处理）？特殊情况的液体管理：围手术期，体重过重（水肿）或过轻（营养不良）时计算液量或药物计量的体重标准是什么（实际体重还是预期体重）？为什么？第五十五页，本课件共有99

37、页问题如何处理液量限制和营养供给的矛盾？对液体敏感的靶器官有哪些？重危阶段（心肺脑功能不稳定）和平稳增长阶段的液体管理有何不同？什么是以液量控制为主导的液量管理和以营养为主导的液量管理？举例说明！第五十六页，本课件共有99页Increased Risk of Chronic Lung Disease in Preterm Neonates with Increased Fluid Intake Retrospective StudiesExcessive hydration increases risk of CLD Brown et al 1978,J Pediatr;Tooley 1979

38、,J PediatrIncreased total,crystalloid and colloid fluid administration during the first 24 hours of life results in1)a weight gain over the first 4 days 2)a higher incidence of a hemodynamically significant PDA 3)a higher incidence of CLD Van Marter et al 1990,J Pediatr第五十七页，本课件共有99页问题 什么就第三间质液？电解质紊

39、乱对离子电活动的影响如何？心电、脑电、肌电、平滑肌电活动离子过高过低对机体功能影响有何不同？什么是以功能结局为目标的的处理原则？第五十八页，本课件共有99页Management of F&EGoal:Allow initial loss of ECT over first week(as reflected by wt loss),while maintaining normal intravascular volume and tonicity(as reflected by HR,UOP,lytes,pH).Subsequently,maintain water and electroly

40、te balance,including requirements for body growth.Individualize approach(no“cook book”is good enough!)Target management（目标化管理或处理目标化管理或处理）第五十九页，本课件共有99页一）钠一）钠 生理需要量约为23mEq/kg.d血清钠低于130mmol/L,为低钠血症高于150mmol/L为高钠血症。早产儿由于肾脏发育和功能的不成熟，既易出现低钠血症，又易出现高钠血症。抗利尿激素和醛固酮在新生儿期起作用第六十页，本课件共有99页1 1、低钠血症低钠血症第六十一页，本课件共有

41、99页常见导致低钠血症原因常见导致低钠血症原因（1）母亲低血钠:母亲分娩时应用大量的低盐溶液，或滥用利尿剂或导泻剂等（2）生后早期低血钠可偶发于急性肾盂肾炎或尿路梗阻之后，以及失盐性的先天性肾上腺皮质功能增生症。（3）肾脏对钠的重吸收功能不成熟(早产儿)第六十二页，本课件共有99页（4）摄入不足：如纯母乳喂养或足月儿配方奶粉含钠不足（5）胃肠道丢失过多（6）补液过多（7）ADH增多致水潴留（SIADH）第六十三页，本课件共有99页 Sodium balance in the newbornPreterm infants may need 4-5mEq/kg of sodium per day

42、to offset high renal lossesIncreased urinary sodium losseshypoxia respiratory distress hyperbilirubinemia ATN polycythemia increased fluid and salt intake diuretics.第六十四页，本课件共有99页 低钠血症的后果低钠血症的后果 低钠血症和水储留可增加新生儿呼吸系统疾病的发生率和严重程度。慢性低钠血症可伴骨骼和组织生长发育迟缓。低钠血症最严重的后果是累及中枢神经系统。取决于血清钠下降的速度、幅度和时间。急性低钠血症可导致脑水肿。第六十五

43、页，本课件共有99页 处理处理 急性水潴留和低钠血症一旦发生，必须限制入液量。可引起惊厥的重度低钠血症（血钠低于120mmol/L）可通过输注3氯化钠先提高血钠至125mmol/L，然后在2448小时内逐渐使血钠恢复正常。慢性低钠血症应缓慢纠正，需4872小时。第六十六页，本课件共有99页如水潴留是由于压力感受器所致的ADH分泌增多，可用增强心肌收缩的药物或扩容以纠正低血压。对SIDAH应以限制入液量为主。（除非血清Na125mmol/L,再于24-48小时内缓慢纠正。第七十二页，本课件共有99页如4小时后测Na128则Na=（135-128）30.6=12.6mmolNa生理需要量=2mmo

44、l/kg3=6mmol总需要10%NaCl=（12.6+6）1.7=10.9ml总液量=1603=480ml24小时入第七十三页，本课件共有99页2 2、高钠血症高钠血症第七十四页，本课件共有99页高钠血症原因高钠血症原因（1）单纯水缺乏 在新生儿较为常见，尤其是胎龄小于28周的未成熟儿有大量的不显性失水，当水摄入不足时可引起高钠、高钾、高糖和高渗综合征。第七十五页，本课件共有99页（2）单纯钠过多或盐中毒 较为少见，见于喂以稀释不当的口服补液盐或配方奶时，或由于复苏时碳酸氢钠应用过多。第七十六页，本课件共有99页（3）低张液体丢失过多或补液不够 为最常见的原因，常见于腹泻补液不足或存在呕吐、

45、甘露醇、高血糖等渗透性利尿时，此时体内总钠量减少，但总水量减少更多。第七十七页，本课件共有99页高钠血症后果高钠血症后果由于钠不能自主通过细胞膜，高钠血症时不易发生休克。血钠大于160mmol/L时可引起脑细胞脱水、脑血管撕裂或脑血栓形成，患儿可出现激惹、尖叫、嗜睡、昏迷、肌张力增高和惊厥等症状。第七十八页，本课件共有99页处理处理 （1）严重脱水和休克时，不论血清钠高低，均应首先扩容。（2）缺水量（L）=（实际值-140）/140kg0.6第七十九页，本课件共有99页（3）纠正血钠的速度比溶液张力的选择更为重要，过分迅速的水化和降低血钠浓度可引起脑细胞水肿和永久性的CNS后遗症。降低血钠的最

46、大安全速率为每小时降低0.51mmol/L。第八十页，本课件共有99页第八十一页，本课件共有99页二）钾二）钾 新生儿生后10天内，血钾可高达57mmol/L，故传统的观点是生后两天进行液疗可不补钾。新生儿钾生理需要量为12mmol/Kg/d。新生儿期，尤其是病理新生儿，钾的补充较难掌握。第八十二页，本课件共有99页Potassium stuffPotassium is mostly intracellular:blood levels do not usually indicate total-body potassiumpH affects K+:0.1 pH change=0.3-0.6

47、 K+change(More acid,more K;less acid,less K)ECG affected by both HypoK and HyperK:ECG affected by both HypoK and HyperK:Hypok:flat T,prolonged QT,U wavesHyperK:peaked T waves,widened QRS,bradycardia,tachycardia,SVT,V tach,V fib第八十三页，本课件共有99页Hypo-and Hyper-KHypokalemia:Leads to arrhythmias,ileus,leth

48、argyDue to chronic diuretic use,NG drainageTreat by giving more potassium slowlyHyperkalemia:Increased K release from cells following IVH,asphyxia,trauma,IV hemolysisDecreased K excretion with renal failure,CAHMedication error very common第八十四页，本课件共有99页1 1、低钾血症、低钾血症 第八十五页，本课件共有99页1 1）病因）病因 （1）钾摄入不足（2

49、）钾丢失过多a.经肾脏丢失b.经消化道丢失（3）钾在细胞内外分布异常a.碱中毒：持续呕吐致大量胃酸丢失致代谢性碱中毒；通气过度致呼吸性碱中毒b.胰岛素增多，糖原合成需要钾。以上均导致细胞摄取钾增加而致低血钾。第八十六页，本课件共有99页2 2）临床表现）临床表现 主要表现为神经、肌肉和心脏症状。第八十七页，本课件共有99页3 3）心电图表现）心电图表现 T波增宽、低平、倒置，出现U波，同一导联中U波大于或等于T波。QT间期延长，ST下降，后期P波增高。房性或室性早搏，室速、室扑或室颤、阿斯综合征，以致发生心脏停搏。第八十八页，本课件共有99页4 4）处理）处理 （1）治疗原发病（2）纠正碱中毒

50、（3）补充钾盐a.见尿补钾b.10kcl23ml/kg/d,缓慢静滴。浓度不超过0.3%。c.因细胞内钾恢复较慢，需持续补给46天。第八十九页，本课件共有99页第九十页，本课件共有99页2 2、高钾血症、高钾血症 新生儿出生37天后，血清钾大于5.5mmol/L为高钾血症。第九十一页，本课件共有99页1 1）病因）病因 （1）钾摄入过多 交换输血时使用ACD（储血稳定剂）血；大剂量青霉素钾盐静脉注射。（2）肾脏排钾功能障碍 急性肾功衰、血容量减少引起脱水和休克、21羟化酶缺乏、潴钾利尿剂应用等。（3）钾在细胞内外分布异常 酸中毒、组织分解代谢亢进、严重组织损伤、坏死、胰岛素缺乏等。第九十二页，