小兒補(bǔ)液英文修

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

2、+ex/b/v/no),Clinical manifestation,Diagnosis,DifferentialDiagnosis(p/d/n),Treatment,Predisposing(4),Diagnosis,Not difficultAccording to clinical manifestation, laboratory tests and character of stool.,+,+,,Infectiou

3、s OrNoninfectious,,Dehydration Degree and quality,Electrolyte disturbancesAndDisturbance of acid-base balance,Severity clinical signs of dehydration,Dehydration,Dehydration,Same proportion loss,P,IF,C,

4、P,IF,C,Electrolyte lossmore,P hypotonic,IF+C hypertonic,,Cell expansionSevereEasy to shock,P: plasma, IF: interstitial fluid, C: cell,Isotonic,,,P,IF,C,Water lossmore,P hypertonicIF+C hypotonic,Cell hydrati

5、onMildThirsty,,Acute diarrheaafter vomiting greatly,Hypotonic,Hypertonic,,,,,,,,,,,Na+ :130～150mmol/L,Na+: < 130mmol/L,Na+: > 150mmol/L,Electrolyte disturbance,Diarrhea complicated,hyponatremia & hypernatre

6、mia hypokalemia hypocalcemia hypomagnesemia,K+ (potassium)<3.5mmol/L (normal: 3.5～5.5 mmol/L)causes： Excessive losses: vomit, diarrhea.Inadequate intake.Renal function of keeping kalium ,it continues excl

7、uding kalium when with hypokalemia.,Clinical manifestation: electrolyte disorder Hypokalemia,,,depressedTension of skeletal muscle ，tendon reflex， even respiratory muscle weakness Tension of smooth muscl

8、 , abdominal extension, intestinal sound or disappearMyocardium excitability , arrhythmia, ECG: T-wave is low or inversion, U-wave occurs, prolonged P-R interval and Q-T interval, ST section de

9、scending.Baseosis,hypokalemia K+ (potassium)<3.5mmol/L (normal: 3.5～5.5 mmol/L),Clinical manifestation: nerve and muscular excitability,,,,,Ca2+﹤1.75mmol/L (7mg/dl) ; Mg2

10、+﹤0.6mmol/L (1.5mg/dl).Symptoms usually occur after dehydration and acidosis resolved, or fluid replacement.Clinical manifestation: thrill, tetany, convulsion.If convulsion hasn’t relieved after supplement

11、 calcium, pay attention to hypomagnesemia.,hypocalcemia & hypomagnesemia,,Case example,An 8 – month boy had diarrhea and vomited for 3 days, urine stream reduced, irritability. PE: Pulse rate 150/min, weight

12、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

13、 sound diminished. Questions: 1.What is the diagnosis? 2.How to administer the fluid therapy?,Answer 1 (diagnosis),Acute diarrhea severe dehydration hypokalemia,Fluid Therapy,Neonate……………... 80% Older

14、 children………..65% Adult…………………..60%,features of body fluid balance in children,The younger,The larger proportion of body water,Total body water(by body mass),,,,,,----amount of body fluid,features of body fluid balance

15、 in children,,,,The younger,The larger proportion of extracellular water,,,,Intracellular,,Body fluid,Extracellular,Interstitial fluidPlasmaLymph fluidSecretory juice,,,----distribution of body fluid,P6%,IF37%,IC

16、35%,IF20%,IF10%~15%,IF25%,IC40%,P5%,P5%,P5%,IC40%,IC40%~45%,Neonate 78%,~1y 70%,2y~14y 65%,Adult 55%~60%,features of body fluid balance in children,P: plasmaIF: interstitial fluidIC: intracellular,,--

17、--distribution of body fluid in different ages (by BW),features of body fluid balance in children,,----water requirement,Requiring more water Regulating function poorly Easy water metabolism disturb

18、ance,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

19、 adult 1/7 by total fluid.Regulating function of water metabolism poorly: kidney, lung.,,,,features of body fluid balance in children,----water requir

20、ement,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,K+, Cl-, P, lactic

21、 acid,Na+, Ca++, Hco3-,Function of excluding H+,Acidosis,,,,,,,,Acid-base balance and adjust----two concept,Acid-base balance Acidity and alkalinityAnion-cation balance Anion and cation,Compensation o

22、f adjust has limit,Acid-base balance and adjust ----body liquid,Buffer system lung ：exhale of store CO2 (respiratory) kidney: exclude H+ and store Na+ (metabolic)

23、,NaHCO3/H2CO3Na2HPO4/NaH2PO4Buffer system of plasma protein,Adjust HCO3-,NaHCO3/H2CO3=20:1,,,,,,,PH：7.4 (7.35~7.45) PaCO2：40 (34~45) mmHg SB：24 (22~27) mmol/L BE：-3 ~ +3 mmol/L CO2CP：22 (18~27) mmol/L,A

24、cid-base index,Blood gas analysis（normal ）,Compensation & decompensation,Acid-base balance disorder,respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis,Dispirited, dysphoria, dro

25、wsiness, comaHypernea (Kussmauls breathing)，exhalation coolExpiratory gas smells ketoneCherry lipsNausea, vomit,Metabolic acidosis--clinical manifestation,Mild: breath frequency slightlySevere: occur:,To cure wate

26、r and electrolyte disturbance,Recover and maintain blood volume , osmotic pressure , Acidity , alkalinity and electrolyte,Normal physiological function,,,Fluid therapy Purpose,oral,intravenous,Fluid therapy Method,,p

27、revention dehydration: Rice soup add salt solute（1/3）Mild dehydration: ORS。Mild/moderate dehydration : ORS ——mild: ORS： 50～80ml/kg ——moderate: ORS：80～100ml/kgSevere dehydration or vomiting and diarrhea

28、 —— intravenous,NaCl：3.5gNaHCO3 (Sodium citrate)：2.5g (2.9g)KCl：1.5g GS：20g,oral rehydration salts （ORS）,,Na+ 90mmol／Ｌ，Ｋ+20mmol／Ｌ，Cl－80mmol／Ｌ，HCO3－ 30mmol／ＬAdd water to 1000ml 2 / 3 isotonic , Total

29、osmotic pressure: 220mmol／ＬCan be diluted in Children,口服補(bǔ)液鹽 Oral rehydration salt (ORS),WHO2002年推薦的低滲透壓ORS配方 成分 含量 (克)NaCl 2.6枸櫞酸鈉 2.9KCl

30、 1.5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- 65 mmol/L，枸櫞酸根 10mmol/L，葡萄糖75m mol/L?？倽B透壓為245 mOsm/L,,,,sodium citrate could instead by NaHCO3,Na + -- GS transpor

31、t in Small intestine,Na+–GScarrier,enterocyteBrush border,intracellular?intercellular?blood,,,Na+GS,,Na+GS,transport,,promote,Na+、H2O absorb?,Na+(pump) ?intercellular space(Cl- )?OP? ?H2O into blood,Mechanisms of OR

32、S,,Characteristics of ORS ---Advantages,Osmotic pressure similar with plasma(2/3 tonicity) Correct losses by proper concentration of Na+ 、K+ 、Cl- Children easily accept the t

33、astes Correct metabolic acidosis by sodium citrate Promote Na+ and H2O absorption by 2% GS,Characteristics of ORS ---disadvantages,Liquid tonicity higher (2 / 3) Can not be us

34、ed as the maintenance media Na+ concentration is relatively higher to neonates and infants (proper diluted) .,ORS： Rice soup 500ml+ salt 1.75g Fried rice noodles 25g + salt 1.75g + water

35、500ml (Cooking 2－3min)GNS: White sugar 10g + salt 1.75g + water 500ml (boil),Simple preparation at home,Severe dehydration,intravenous,,Osmotic pressure of plasma (OPP) OPP= (crystal + colloid) osmotic pressur

36、e,Na+ 142 Cation: K+ 5(mmol) Ca++ 2.5 Mg++ 1.5,HCO3- 27 Anion: Cl- 103 (mmol) HPO4= 1 SO4= 0.5 Organ

37、o-anion 19.5,151 mmol/L,151 mmol/L,OPP range：280－320mOsm/L,Concentration of electrolyte and calculation,Osmotic pressure, osmol（OSM） Dissolve 1mmol solute into 100ml water: 1mOsm.,100ml water,1mmol,,1mOsm,Concentrati

38、on of electrolyte and calculation,To non electrolyte,1mmolGS,,1mOsm,2mOsm,,1mmolNacl,To electrolyte,1mmolCacl2,,3mOsm,Concentration of electrolyte and calculation,Na:Cl=3:2 （in plasma）,Fluid isotonic,Isotonic liquid:

39、osmotic pressure similar with plasma Sodium isotonic:,Isotonic: 150mmol sodium in 1000ml½ tonicity: 75mmol sodium in 1000ml2/3 tonicity: 100mmol sodium in 1000ml1/3 tonicity: 50mmol sodium in 1000ml,Liquid so

40、lution commonly used,5%GS10%GS,0.9%NaCl10%NaClRinger5% NaHCO3 11.2% NaL10%KClMixture,nonelectrolyte solution,electrolyte solution,,,glucose enter the body by oxidation change into water and CO2 for energy and w

41、ater without tension,Percentage concentration: 5%GS、10%NaClMolar (mol, gram molecular weight) , mmol 1 mol NaCl=23+35.5=58.5gMolarity (mol/L) calculation：,,,,mol/L=,e.g. 0.9%NaCl=,=0.15

42、4mol/L,Concentration of electrolyte and calculation,Percentage concentration of solute（%）?10,Molecular weight (atomic weight),0.9×10,58.5,=154mmol/L,,10%NaCl： 1ml=1.7mmol5%NaHCO3：1ml=0.6mmol11.2%NaL： 1ml=1mmo

43、l10%KCl： 1ml=1.34mmol,Calculation,The element and simple dispensing in the commonly mixed solution,Solution composition ratio dispensing (ml)

44、 NS 10%GS 1.4%NB 10%GS 10%NaCl 5%NB 10%KCl 2:1 isotonic solution . 2 1 500 30 47 1:1 solution (1/2 tonicity) 1

45、 1 500 20 2:3:1 solution (1/2tonicity)2 3 1 500 15 24  4:3:2 solution (2/3tonicity)4 3 2 500

46、 20 33  1:2 solution (1/3 tonicity)1 2 500 15  1:4 solution (1/5 tonicity) 1 4 500 9  daily requirem

47、ent (1/3tonic) 1 4 500 9 7.5,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 ：2 300mmol/L ①0.9%氯

48、化鈉 0.9g 1∶1 等張②5%或10%葡萄糖 5或10g ③5%碳酸氫鈉 5g 3.5張④1.4%碳酸氫鈉 1.4g 等張⑤10%氯化鉀 10g 8.9張,,,,溶 液 每100ml含 Na∶Cl 電解質(zhì)1∶1含鈉液

49、①50ml,②50ml 1∶1 1/2張1∶2含鈉液 ①35ml,②65ml 1∶1 1/3張1∶4含鈉液 ①20ml,②80ml 1∶1 1/5張2∶1含鈉液 ①65ml,④35ml 3∶2 等張2∶3∶1含鈉液 ①33ml,②50ml ④17ml 3∶2 1/2張4∶3∶2含鈉液 ①45ml,②

50、33ml 3∶2 2/3張 ④22ml,,,續(xù) 表,,,Water supplement & correct acidosis,Accumulative losses ---losses from onset to pre-treatment ongoing losses ---continuing losses during treatment

51、 daily requirement ---to maintain basically physiological function,Amount , composition and time,The first day fluid infusion ：,Dehydration Fluid replacement=losses (Acc

52、umulation + ongoing + daily ) Accumulation ongoing daily total amount (ml/Kg) mild 50 10~30 60~80 90~120 moderate

53、 50~100 10~30 60~80 120~150 Severe 100~120 10~30 60~80 150~180,Accumulation: accumulation lossesOngoing: Ongoing lossesdaily: Physiological requirement,,Se

54、verity clinical signs of dehydration,Dehydration,,Accumulationlosses,amount,mild： 50ml/kgmoderate: 50~100ml/kgsevere： 100~120ml/kg,Water supplement-1: accumulation losses,Amount , composition and speed:

55、 --- according to the degree and quality of dehydration,composition,isotonic ： 1/2 tonicity(1:1)hypotonic：2/3 tonicity(4:3:1)Hypertonic:1/3~1/5 tonicity (1/3 tonicity),speed,Principle: f

56、ast slowsevere：bolus of isotonic fluid 2:1 isotonic : 20ml/kg(<300ml) in 30’~1h(rapidly expand) others： 8~12h (8～10ml/（kg·h） iv,Water supplement-1: accumulation losses,Accumulationlosses,,

57、Dehydration :,Ongoinglosses,amount,1/2~1/3 tonicity(1:1),speed,12~16h after stage-1 In 24h, steady speed 5ml/（kg·h）,10~40ml/kg.d,composition,Water supplement-2: ongoing losses,dailyrequirement,amount,1/3~

58、1/5 tonicity(Physical main medium),speed,In 24h, steady speedAccompany with stage-2,60~80ml/kg.d（including oral）,composition,Water supplement-3: daily requirement,To master three principles,The volum of rehydration-

59、AmountDeficit fluid=(percentage of dehydration)×(body weight in Kg)The type of fluid- CompositionIsotonic dehydration——1/2 tonicity solutionHypotonic dehydration——2/3 tonicity solutionHypertonic dehydration——1

60、/3 tonicity solutionThe speed of liquid-Time：four steps,four steps(for fluid and electrolyte deficits),Step 1. Expanding volume: restoration of circulation –emergency, within 30 min to 1 hour 20ml/kg, 2:1 (i

61、sotonic )sodium solution Step 2. supplement lost body liquid: first 8~10 hours 8~10ml/h half of total loss volume 2:3:1 solution(1/2 tonicity),Step 3. maintenance rehydration: - another half loss

62、 - next 16 hours 5ml/(kg.h) physical demand : 60~80ml/kg 4:1 solution(1/3~1/2 tonicity)Step 4. repair of potassium deficit,four steps,mild：correct etiological factorModerat & severe：Alkaline s

63、olution requirement (mmol) (40 –CO2CP Vol%)　　　 2.2 = (22 - CO2CP mmol/L) ? 0.7 ? kg=　BE ? 0.3 ? kg,,,,?0.7 ? kg,Usually use the dose halved first and than according to blood gas analyses,C

64、orrect acidosis,,=,Emergency :Per-elevate 5mmol HCO3- 5mmol/L(10% CO2-CP)need alkaline solution: 3mmol/kg 5%NaHco3 5ml/kg or 1.4% NaHco320ml/kg,Correct acidosis,,Supplement potass

65、ium: 10%KCL,mild hypokalemia：200~300mg/（kg·d） 2~3ml/（kg·d）oral sever hypokalemia：300~450mg/（kg·d） 3~4.5ml/kg.d 10% KCl ivdrip,Supplement after urine or urination

66、 before coming diagnoses Intravenous concentration6~8h/d（intravenous）Time：keep 4～6 day interdiction：directly intravenous， because heart stop！,Supplement potassium principle：,Supplement Calcium and Magnesium

67、,Convulsion emerged ： 10% Calcium Gluconate 10ml+25% Glucose 10ml IVIf convulsion hasn’t relieved after supplement calcium, ——give 25% Mg.Sulfas 0.2~0.4ml/kg deeply IM Q6hbe careful （Calcium ）:HR<

68、;80 time /minute ，stop！Don’t leak out vessel Interval of the Digitalis Don’t injection with subcutaneous and intramuscular,first fast then slow,Principles of Therapy,first thick then thin,supplement potassium when ha

69、ving urine,adjust any time and monitor,Ongoing losses and daily requirement daily requirement 60~80ml/kg (1/3~1/5 tonicity)Ongoing losses follow the how much of the lost in the any time ( 1/2~1/3 tonicity)12~24H