小儿补液英文修.pptx

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1、LastlessonEmphasisEtiology(in/ex/no)Pathogenesis(4+ex/b/v/no)ClinicalmanifestationDiagnosisDifferentialDiagnosis(p/d/n)Treatment Predisposing(4)第1页/共72页DiagnosisNot difficultAccording to clinical manifestation,laboratory tests and character of stool.+InfectiousOrNoninfectiousDehydrationDegreeandqual

2、ityElectrolytedisturbancesAndDisturbanceofacid-basebalance第2页/共72页 Severity clinical signs of dehydrationmildmoderatesevereWater lossBy weightSpirit SkinMocous Anterior fontanel and eye ballTearUrine outputPeripheral circulation50ml/kg 5%Slightly dispiritedslightly agitatedSlightly drySlightly drySl

3、ightlydepressedNormalSlightly reducednormal50100ml/kg5%10%DispiritedAgitatedDry,paleVery dry depressedReducedLittle or No Little cool100120ml/kg10%Extremely dispiritedapathy,hypnody,comaGray mottledParched depressed greatlyNoNo urine outputCool,weak pulse,shockDehydration第3页/共72页DehydrationSamepropo

4、rtionlossP IFCPIFCElectrolytelossmoreP hypotonic,IF+C hypertonicCellexpansionSevereEasytoshockP:plasma,IF:interstitialfluid,C:cellIsotonicPIFCWaterlossmoreP hypertonicIF+C hypotonicCellhydrationMildThirstyAcutediarrheaaftervomitinggreatlyHypotonicHypertonicNa+:130150mmol/LNa+:150mmol/L第4页/共72页Electr

5、olytedisturbanceDiarrheacomplicatedhyponatremia&hypernatremia hypokalemiahypocalcemiahypomagnesemia第5页/共72页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 hypokalemia.Clinic

6、almanifestation:electrolytedisorderHypokalemia第6页/共72页depressedTension of skeletal muscle，tendon reflex，even respiratory muscle weakness Tension of smooth muscl ,abdominal extension,intestinal sound or disappearMyocardium excitability ,arrhythmia,ECG:T-wave is low or inversion,U-wave occurs,prolonge

7、d P-R interval and Q-T interval,ST section descending.BaseosishypokalemiaK+(potassium)3.5mmol/L (normal:3.55.5 mmol/L)Clinicalmanifestation:nerveandmuscularexcitability第7页/共72页 Ca2+1.75mmol/L(7mg/dl);Mg2+0.6mmol/L(1.5mg/dl).Symptoms usually occur after dehydration and acidosis resolved,or fluid repl

8、acement.Clinical manifestation:thrill,tetany,convulsion.If convulsion hasnt relieved after supplement calcium,pay attention to hypomagnesemia.hypocalcemia&hypomagnesemia第8页/共72页CaseexampleAn8monthboyhaddiarrheaandvomitedfor3days,urinestreamreduced,irritability.PE:Pulserate150/min,weightlosswas10%,bl

9、oodpressure65/40mmHg,skincolorshowedgreyandskinturgorlookedliketents.Mucousmembraneswereverydry;eyeballwassunkengreatly,anteriorfontaneldepressedgreatly.Abdomendistended,bowelsounddiminished.Questions:1.Whatisthediagnosis?2.Howtoadministerthefluidtherapy?第9页/共72页Answer 1 (diagnosis)Acute diarrhea se

10、vere dehydration hypokalemia第10页/共72页第11页/共72页Neonate.80%Olderchildren.65%Adult.60%featuresofbodyfluidbalanceinchildrenTheyoungerThelargerproportionofbodywaterTotalbodywater(bybodymass)-amountofbodyfluid第12页/共72页featuresofbodyfluidbalanceinchildrenTheyoungerThelargerproportionofextracellularwaterInt

11、racellularBodyfluidExtracellularInterstitialfluidPlasmaLymphfluidSecretoryjuice-distribution of body fluid第13页/共72页P6%IF37%IC35%IF20%IF10%15%IF25%IC40%P5%P5%P5%IC40%IC40%45%Neonate78%1y70%2y14y65%Adult55%60%featuresofbodyfluidbalanceinchildrenP:plasmaIF:interstitialfluidIC:intracellular-distribution

12、 of body fluid in different ages(by BW)第14页/共72页featuresofbodyfluidbalanceinchildren-water requirement Requiring more water Regulating function poorly Easy water metabolism disturbance第15页/共72页Duetogrowquickly,need0.5%3%waterforgrowth.Insensiblewaterloss:2timesmorethanadult.Fluidexchangeofdigestivet

13、ractquicker.Watermetabolismhigher:infant1/2bytotalfluidadult1/7bytotalfluid.Regulatingfunctionofwatermetabolismpoorly:kidney,lung.features of body fluid balance in children-water requirement第16页/共72页SimilarwithadultExtracellular:Na+,Cl-,Hco3-Intracellular:K+,Mg,Hpo4=,proteinFeaturesofneonate(Several

14、daysafterbirth):CompositionofbodyfluidParticularlyinpreterminfantK+,Cl-,P,lacticacidNa+,Ca+,Hco3-FunctionofexcludingH+Acidosis第17页/共72页Acid-basebalanceandadjust-twoconceptAcid-basebalanceAcidityandalkalinityAnion-cationbalanceAnionandcation第18页/共72页CompensationofadjusthaslimitAcid-basebalanceandadju

15、st-bodyliquidnBuffersystemnlung：exhaleofstoreCO2(respiratory)nkidney:excludeH+andstoreNa+(metabolic)NaHCO3/H2CO3Na2HPO4/NaH2PO4BuffersystemofplasmaproteinAdjust HCO3-NaHCO3/H2CO3=20:1第19页/共72页 PH：7.4(7.357.45)PaCO2：40(3445)mmHg SB：24(2227)mmol/L BE：-3+3mmol/L CO2CP：22(1827)mmol/LAcid-baseindexBloodg

16、asanalysis（normal）第20页/共72页Compensation&decompensationAcid-basebalancedisorderrespiratoryacidosisrespiratoryalkalosismetabolicacidosismetabolicalkalosis第21页/共72页Dispirited,dysphoria,drowsiness,comaHypernea (Kussmauls breathing)，exhalation coolExpiratory gas smells ketoneCherry lipsNausea,vomitMetabo

17、licacidosis-clinicalmanifestationMild:breathfrequencyslightlySevere:occur:第22页/共72页TocurewaterandelectrolytedisturbanceRecoverandmaintainbloodvolume,osmoticpressure,Acidity,alkalinityandelectrolyteNormalphysiologicalfunctionFluidtherapyPurpose第23页/共72页oralintravenousFluidtherapyMethodpreventiondehyd

18、ration:Ricesoupaddsaltsolute（1/3）Milddehydration:ORS。Mild/moderatedehydration:ORSmild:ORS：5080ml/kgmoderate:ORS：80100ml/kgSeveredehydrationorvomitinganddiarrhea intravenous第24页/共72页NaCl：3.5gNaHCO3(Sodiumcitrate)：2.5g(2.9g)KCl：1.5gGS：20goralrehydrationsalts（ORS）Na+90mmol，+20mmol，Cl80mmol，HCO3 30mmolA

19、dd water to 1000ml 2/3 isotonic,Total osmotic pressure:220mmolCan be diluted in Children第25页/共72页口服补液盐 Oral rehydration salt(ORS)Oral rehydration salt(ORS)WHO2002WHO2002年推荐的低渗透压ORSORS配方成分 含量 (克)NaCl 2.6NaCl 2.6枸橼酸钠 2.92.9KCl 1.5KCl 1.5葡萄糖 13.513.5水 1000ml1000ml该配方中各种电解质浓度为：NaNa+75mmol/L75mmol/L，K K+

20、20 20mmol/Lmmol/L，C1C1-65 mmol/L65 mmol/L，枸橼酸根 10mmol/L10mmol/L，葡萄糖75m75m mol/Lmol/L。总渗透压为245 mOsm/L245 mOsm/Lsodium citrate could instead by NaHCO3第26页/共72页Na+-GStransportinSmallintestineNa+GScarrierenterocyteBrushborderintracellularintercellularbloodNa+GSNa+GStransportpromoteNa+、H2Oabsorb Na+(pump

21、)intercellularspace(Cl-)OP H2OintobloodMechanisms of ORS第27页/共72页CharacteristicsofORS-Advantages Osmoticpressuresimilarwithplasma(2/3 tonicity)2/3 tonicity)CorrectlossesbyproperconcentrationofNa+、K+、Cl-ChildreneasilyacceptthetastesCorrectmetabolicacidosisbysodiumcitratePromoteNa+andH2Oabsorptionby2%

22、GS第28页/共72页CharacteristicsofORS-disadvantages Liquidtonicityhigher(2/3)CannotbeusedasthemaintenancemediaNa+concentrationisrelativelyhighertoneonatesandinfants(properdiluted).第29页/共72页ORS：Ricesoup500ml+salt1.75gFriedricenoodles25g+salt1.75g+water500ml(Cooking23min)GNS:Whitesugar10g+salt1.75g+water500

23、ml(boil)Simplepreparationathome第30页/共72页Severe dehydration intravenous第31页/共72页Osmoticpressureofplasma(OPP)OPP=(crystal+colloid)osmoticpressureNa+142Cation:K+5(mmol)Ca+2.5Mg+1.5HCO3-27Anion:Cl-103(mmol)HPO4=1SO4=0.5Organo-anion19.5151mmol/L151mmol/LOPPrange：280320mOsm/LConcentrationofelectrolyteandc

24、alculation第32页/共72页Osmoticpressure,osmol（OSM）Dissolve1mmolsoluteinto100mlwater:1mOsm.100ml water1mmol1mOsmConcentrationofelectrolyteandcalculation第33页/共72页Tononelectrolyte 1mmolGS1mOsm2mOsm1mmolNacllToelectrolyte1mmolCacl23mOsmConcentrationofelectrolyteandcalculation第34页/共72页Na:Cl=3:2（inplasma）Fluid

25、isotonicIsotonicliquid:osmoticpressuresimilarwithplasmaSodiumisotonic:Isotonic:150mmolsodiumin1000mltonicity:75mmolsodiumin1000ml2/3tonicity:100mmolsodiumin1000ml1/3tonicity:50mmolsodiumin1000ml第35页/共72页Liquidsolutioncommonlyused5%GS10%GS0.9%NaCl10%NaClRinger5%NaHCO311.2%NaL10%KClMixturenonelectroly

26、te solutionelectrolyte solutionglucose enter the body by oxidation change into water and CO2 for energy and water without tension 第36页/共72页Percentageconcentration: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 Concentrat

27、ionofelectrolyteandcalculationPercentageconcentrationofsolute（%）10Molecularweight(atomicweight)0.91058.5=154mmol/L 第37页/共72页10%NaCl：1ml=1.7mmol5%NaHCO3：1ml=0.6mmol11.2%NaL：1ml=1mmol10%KCl：1ml=1.34mmolCalculation第38页/共72页TheelementandsimpledispensinginthecommonlymixedsolutionSolutioncompositionratiod

28、ispensing(ml)NS10%GS1.4%NB10%GS10%NaCl5%NB10%KCl2:1isotonicsolution.2150030471:1solution(1/2tonicity)11500202:3:1solution(1/2tonicity)23150015244:3:2solution(2/3tonicity)43250020331:2solution(1/3tonicity)12500151:4solution(1/5tonicity)145009dailyrequirementrequirement(1/3tonic)1450097.5第39页/共72页常用溶液

29、成分常用溶液成分溶溶 液液 每每100ml100ml含含 NaClNaCl 电解质渗透压电解质渗透压 血血 浆浆 （142142：103103）3 3：2 300mmol/L2 300mmol/L 0.9%0.9%氯化钠氯化钠 0.9g 11 0.9g 11 等张等张5%5%或或10%10%葡萄糖葡萄糖 5 5或或10g10g 5%5%碳酸氢钠碳酸氢钠 5g 3.55g 3.5张张1.4%1.4%碳酸氢钠碳酸氢钠 1.4g 1.4g 等张等张10%10%氯化钾氯化钾 10g 8.910g 8.9张张第40页/共72页溶溶 液液 每每100ml100ml含含 NaClNaCl 电解质电解质111

30、1含钠液含钠液 50ml,50ml 11 1/250ml,50ml 11 1/2张张1212含钠液含钠液 35ml,65ml 11 1/335ml,65ml 11 1/3张张1414含钠液含钠液 20ml,80ml 11 1/520ml,80ml 11 1/5张张2121含钠液含钠液 65ml,35ml 32 65ml,35ml 32 等张等张231231含钠液含钠液 33ml,50ml33ml,50ml 17ml 32 1/2 17ml 32 1/2张张432432含钠液含钠液 45ml,33ml 32 2/345ml,33ml 32 2/3张张 22ml22ml续续 表表第41页/共72页

31、Watersupplement&correctacidosisAccumulativelosses-lossesfromonsettopre-treatmentongoinglosses-continuinglossesduringtreatmentdailyrequirement-tomaintainbasicallyphysiologicalfunctionAmount,compositionandtime第42页/共72页The first day fluid infusion：DehydrationFluidreplacement=losses(Accumulation+ongoing

32、+daily)Accumulationongoing daily total amount (ml/Kg)mild501030608090120moderate5010010306080120150Severe10012010306080150180Accumulation:accumulationlossesOngoing:OngoinglossesOngoinglossesdaily:PhysiologicalrequirementPhysiologicalrequirement第43页/共72页 Severity clinical signs of dehydrationmildmode

33、ratesevereWater lossBy weightSpirit SkinMocous Anterior fontanel and eye ballTearUrine outputPeripheral circulation50ml/kg 5%Slightly dispiritedslightly agitatedSlightly drySlightly drySlightlydepressedNormalSlightly reducednormal50100ml/kg5%10%DispiritedAgitatedDry,paleVery dry depressedReducedLitt

34、le or No Little cool100120ml/kg10%Extremely dispiritedapathy,hypnody,comaGray mottledParched depressed greatlyNoNo urine outputCool,weak pulse,shockDehydration第44页/共72页AccumulationAccumulationlosseslossesamountmild：50ml/kgmoderate:50100ml/kgsevere：100120ml/kgWatersupplement-1:accumulationlossesAmoun

35、t,compositionandspeed:-accordingtothedegreeandqualityofdehydration第45页/共72页compositionisotonic：1/2tonicity(1:1)hypotonic：2/3tonicity(4:3:1)Hypertonic:1/31/5tonicity(1/3 tonicity)speedPrinciple:fastslowsevere：bolus of isotonic fluid 2:1 isotonic:20ml/kg(300ml)in301h(rapidlyexpand)others：812h(810ml/（k

36、gh）ivWatersupplement-1:accumulationlossesAccumulationAccumulationlosseslossesDehydration:第46页/共72页OngoingOngoinglosseslossesamount1/21/3tonicity(1:1)speed1216hafterstage-1In24h,steadyspeed 5ml/（kgh）1040ml/kg.dcompositionWatersupplement-2:ongoinglosses第47页/共72页dailydailyrequirementrequirementamount1/

37、31/5tonicity(Physical main medium)speedIn24h,steadyspeedAccompanywithstage-26080ml/kg.d（includingoral）compositionWatersupplement-3:dailyrequirement第48页/共72页To master three principlesThe volum of rehydration-AmountDeficit fluid=(percentage of dehydration)(body weight in Kg)The type of fluid-Compositi

38、onIsotonic dehydration1/2 tonicity solutionHypotonic dehydration2/3 tonicity solutionHypertonic dehydration1/3 tonicity solutionThe speed of liquid-Time：four steps第49页/共72页four steps(for fluid and electrolyte deficits)Step 1.Expanding volume:restoration of circulation emergency,within 30 min to 1 ho

39、ur 20ml/kg,2:1(isotonic)sodium solution Step 2.supplement lost body liquid:first 810 hours 810ml/h half of total loss volume 2:3:1 solution(1/2 tonicity)第50页/共72页Step 3.maintenance rehydration:-another half loss -next 16 hours 5ml/(kg.h)physical demand:6080ml/kg 4:1 solution(1/31/2 tonicity)Step 4.r

40、epair of potassium deficit four steps第51页/共72页mild：correctetiologicalfactorModerat&severe：Alkalinesolutionrequirement(mmol)(40 CO2CP Vol%)2.2 =(22-CO2CP mmol/L)0.7 kg=BE 0.3 kg 0.7 kgvUsuallyusethedosehalvedfirstandthanaccordingtobloodgasanalysesCorrectacidosis=第52页/共72页Emergency:Per-elevate5mmolHCO

41、3-5mmol/L(10%CO2-CP)needalkalinesolution:3mmol/kg5%NaHco35ml/kgor1.4%NaHco320ml/kgCorrectacidosis第53页/共72页Supplementpotassium:10%KCLu mildhypokalemia：200300mg/（kgd）23ml/（kgd）oraluseverhypokalemia：300450mg/（kgd）34.5ml/kg.d10%KClivdrip第54页/共72页SupplementafterurineorurinationbeforecomingdiagnosesIntrav

42、enousconcentration68h/d（intravenous）Time：keep46dayinterdiction：directlyintravenous，becauseheartstop！Supplementpotassium principle：第55页/共72页SupplementCalciumandMagnesiumConvulsionemerged：10%CalciumGluconate10ml+25%Glucose10mlIVIfconvulsionhasntrelievedaftersupplementcalcium,give25%Mg.Sulfas0.20.4ml/k

43、gdeeplyIMQ6hbecareful（Calcium）:HR 10%Fluid requirement at post operationor heart failure第60页/共72页 heart failure or heart post operation Control the solution by intravascular injection Volume include:maintenance fluid in vascular；medicine and dilution；rinse solution for the vascular tubule；gastric tu

44、be or food-intake。第61页/共72页Fluid requirement at post operation Include potassium glucose and sodium 1/41/5 tension 10%GS 500ml 10%NaCl 10ml 10%KCl 15ml (9.5%GS、0.19%NaCl、0.29%KCl)第62页/共72页An8monthboyhaddiarrheaandvomitedfor3days,urinestreamreduced,irritability.PE:Pulserate150/min,weightlosswas10%,bl

45、oodpressure65/40mmHg,skincolorshowedgreyandskinturgorlookedliketents.Mucousmembraneswereverydry;eyeballwassunkengreatly,anteriorfontaneldepressedgreatly.Abdomenextended,bowelsounddiminished.Answerquestion2Howtoadministerthefluidtherapy?第63页/共72页The first day fluid infusion：DehydrationFluidreplacemen

46、t=losses(Accumulation+ongoing+daily)Accumulationongoing daily total amount (ml/Kg)mild501030608090120moderate5010010306080120150Severe10012010306080150180Accumulation:accumulationlossesOngoing:OngoinglossesOngoinglossesdaily:PhysiologicalrequirementPhysiologicalrequirement第64页/共72页Step1：Plansuppleme

47、ntaryfluid.Firstbodyweightiscalculatedbyformulaofgrowthanddevelopmentsection.(6+80.25=8kg)2:1sodium:20ml8=160mlfinishedintravenouslywithin30min.第65页/共72页Step2：Acuteloss bealwaysisotonicdehydration,sowechoose：2:3:1(2:glucose,3:sodium,1:1.4%bicarbonate)thatbelongto1/2tonicity.Repairofwaterandsodiumdef

48、icitsfirst8-10hours8-10ml/(kgh)halfoftotallossvolume(1608)ml/2=640ml.第66页/共72页Step3.：4:1sodiumbetakennext16hours5ml/(kgh)80ml/kg8kg=640ml(anotherhalf)第67页/共72页Step4：Potassiumsupplement8kg0.4g=3.2g/d.Thatmeansabout10%potassiumchloridesolution32mlwillbeusedbyintravenousinfusion.Noticesupplementpotassiumwhenurinestreammustbeseen;meanwhile,beawareofconcentration(0.3%)speedandtimeofit.第68页/共72页第69页/共72页第70页/共72页第71页/共72页感谢您的观看。第72页/共72页