心脏术后围手术期的液体管理原则及注意点课件.ppt

心脏术后围手术期的液体管理原则及注意点Peri-operative fluid management,第三军医大学新桥医院心外科刘健,For practical consideration,most losses and gain of body fluid occur directly from the extracellular compartment,一、Body fluid compartment(体液的容量和分布）,ICF(细胞内液)占40%,Body fluid占60%,ECF(细胞外液)占20%,plasma(血浆)占5%,细胞间液占15%,*,：成人每日水分排出量(2000-2500ml)尿 1000-1500ml 大便 150ml（ICU病人一般不计）皮肤 300-600ml（平均500ml）肺 200-400ml（平均350ml）即成人每日基本生理需要量(2000-2500ml),二、Normal exchange of fluid(正常成人每日水的出入量（ml/24 h）,Sensible loss,Insensible loss,：成人每日水摄入量(2000-2500ml)饮水(oral)1000-1500ml 食物水 700ml（solid food）代谢水 300ml(water of oxidation）即基本生理需要量(2000-2500ml),Normal exchange of fluid(正常成人每日水的出入量（ml/24 h）,Sensible gain,Insensible gain,Compositional abnormalities include changes(1)acid-base balance(酸碱)(2)concentration changes of potassium(K+),calcium(Ca2+),and magnesium(Mg2+)(电解质),三、Classification of body fluid change(体液变化分类）,1、Volume change（容量）,2、Composition change（成分）,Fluid change of cardiopulmonary bypass(CPB)体外循环后的液体变化,1、An intentional hemodilution（to lower blood viscosity during hypothermia）血液稀释预充2、cardioplegia or the copious use of irrigation（accumulation of excess fluid）心脏停搏液和冲洗液的应用3、an increase of total body water（causes impaired organ function as it accumulates in tissues）体液增加,四、Effects of CPB on the function of multiple organ system(体外循环对机体的影响）,1.Total body sodium and water overload（钠水超负荷）2.Systemic inflammatory response symptom(SIRS)capillary permeability increase crystalloid and colloid partially shift to the interstitial space3.Transient myocardial dysfunction3.Pulmonary venous resistance(PVR)increase and abnormalities of gas exchange5.Stress and hormonal responses leading to fluid and electrolyte disturbances,The Starling equilibrium displaying the effect of different pressures on transcapillary membrane fluid flux adapted for the lung,CHP COP THP TOP capillary(毛细血管)interstiturm（间质）alveoli（肺泡）CHP:capillary hydrostatic pressureCOP:capillary oncotic pressure(of which 90%is dependent on serum albumin）THP:tissue hydrostatic pressureTOP:tissue oncotic pressure,1.Careful fluid administration may decrease postoperative respiratory disturbances 2.the elderly are especially prone to over-hydration,particularly as renal dysfunction is common in this age group,and that care needs to be taken in avoiding acute pulmonary oedema.3.A positive fluid balance was a common feature for those that died and death was attributed to pulmonary oedema or cardiac failure on the death certificates.4.Careful fluid challenges of colloid guided by central venous pressure,resulted in improved haemodynamics(cardiac output or central venous pressure),less postoperative morbidity and a reduction in hospital stay5.we emphasis on avoiding fluid overload and insufficient fluid therapy post-operatively,especial in the elderly.,五、Peri-operative fluid management(液体管理原则）,Factors Affecting the Amount of Fluid Administration,Preoperative cardiovascular functionAnesthetic technique and agent pharmacologyCardiopulmonary bypassPatient positionThermoregulationOperative fluid administrationDuration of surgeryOperative site,Surgical techniqueSplanchnic ischemiaIntraoperative cardiac functionCapillary permeabilityEndotoxemiaProinflammatory cytokinesSepsisAllergic/anaphylactic reactions,Qualitative Considerations in Selection of Fluid Therapy,1.Oxygen-carrying capacity2.Coagulation factors3.COP(colloid oncotic pressure)4.Tissue edema5.Electrolyte balance6.Acid-base equilibrium7.Nutrition/glucose metabolism8.Cerebral abnormalities,Oxygen-Carrying Capacity,The need to provide sufficient oxygen delivery(DO2)is expressed by the following formula:DO2=content of arterial oxygen(CaO2)x cardiac output(CO).CaO:hemoglobin level,arterial oxygen saturation(SaO2),and to a minimal extent dissolved oxygen；,术后早期需additional preload 者见于：,1.Right ventriculotomy(右室切开术)(如F4,Rastelli procedure)2.Cavopulmonary anastomosis(腔肺吻合术)(如双向Glenn,Fontan)3.Systemic to pulmonary artery shunt(如Blalock procedure)4.Operations complicated by pulmonary hypertension(如obstructed TAPVC),六、心脏术后液体管理措施：,婴幼儿术后第一日晶体液量（微泵输入）体重的第一个l0kg 2mlkgh体重的第二个10kg 1mlkgh 体重的第三个10kg 0.5mlkgh 术后第二日开始进食者总液量：4ml/kgh血浆、全血按5-10ml/kg补充，白蛋白按2.5-5ml/kg补充,注意点：,a.心衰，呼吸机应用者：2-3mlkghb.体温升高1，液体量增加10%c.置开放暖箱，液体量增加10-15d.不能脱机者术后48h（肠鸣音恢复），必须常规予胃肠营养，营养素50-100ml，4-5/日，胃管注入。因肌松剂影响肠鸣音恢复者予静脉营养。总热卡=50-100kcal/kg/day。,成人术后的液体管理：,成术后第一日晶体液按1mlkgh术后第二日总液量 2mlkgh 注：a.心衰，呼吸机应用者液体酌减 b.补液总量=继续丢失量+生理需要量 生理需要量一般不低于1500ml，以5%GS为主。c.不能脱机者术后48h（肠鸣音恢复），必须予营养素200ml，4-5/日，胃管注入。总热卡=30-50kcal/kg/day。d.肾衰少尿期补液原则 每日补液量=前一天尿量+额外丧失量+不显性失水内生水,液体成分：,1)婴幼儿输以10GS为主的含电解质的1415张混合液(NS:GS 1：3-4)例：10Gs 250ml 10NaCl 5ml 10KCl 5ml 25%MgSO3 2-3ml 2)成人输以5GS的含电解质液（其中包括极化液10GS 500ml）,婴幼儿血K维持在3.5-4.0mmol/L成人先心血K维持在4.0-4.5mmol/L成人风心血K维持在4.5-5.0mmol/L（可显著降低术后室性心律失常的发生率）,七、心脏术后电解质紊乱的纠正,钾的正常代谢（正常胞内K是胞外K的35倍）,体钾,多摄多排少摄少排不摄也排,TreatmentOral supplementation preferred unless significant symptoms presentAmount of potassium needed proportional to muscle mass and body weightEach 1 mEq/L decrease in K reflects a deficit of 150-400 m Eq in total body potassium,（一）、低血钾：血清钾35 mmol/LHypokalemia,1、一般浓度补钾(0.3%)：10%KCl 30ml+GS l000ml 2、高浓度补钾：补钾公式：成人缺K（mmol）=（4.5实测K）0.3kg 即：补K（10%KCl ml）=（4.5实测K）0.225kg 婴幼儿缺K（mmol）=（4.0实测K）0.3kg 补K（10%KCl ml）=（4.0实测K）0.225kg予KCl 2mEq，则血清钾升高0.1 mEq/L,（一）、低血钾：血清钾35 mmol/L,具体方法：成人血K+3.0 mmoIL时 10%KCl 15-20ml+GS 50ml，微泵1h泵入。血K+3.5 mmoIL时 10%KCl 10ml+GS 30-50ml，微泵1h泵入。,婴幼儿（0.2-0.3mmoIkg/h+GS 20-30 ml）血K+3.0 mmoIL时 10%KCl 0.4 mlkg+GS 20-30ml，1h泵入。血K+3.5 mmoIL时 10%KCl 0.2 mlkg+GS 10-20ml，1h泵入。(每日总量的l/6l7mEq),补钾注意点：,1)见尿补钾：尿1 mlkgh2)浓度不可高：婴幼儿10KCl 2 mlGS 10 ml，小儿以0.2-0.5mmoIkg/h速度补充，成人补钾速度10-20 mEq/h。3)选择中心静脉，速度不可过快，须微泵泵入1小时，不可静脉推注。4)每次补完20-30分钟后复查血钾，直至正常范围。5)血K维持在正常低限3.5-4.0mmol/L，呈动态下降趋势时，常意味机体缺钾，尤老年风心或洋地黄治疗者，必须补钾。6)酸中毒伴低钾，先补钾后纠酸。,1.予10%KCl 10ml，则血清钾约升高 0.6 mmol/L 2.酸中毒K+移出细胞，则高钾 机制H+-K+跨膜交换 碱中毒 K+移入细胞，则低钾 肾排K+改变 膜对K+通透性改变(K decreases 0.3-0.6 for every 0.1 increase in pH)0.1 pH0.6 mmol/L K+3.合成增加细胞外K+进入细胞内血K+分解增强细胞内K+移出细胞外血K+合成1克糖原约需0.36-0.45 mmol钾，1克蛋白质约需0.5 mmol钾。4.补血钾易，补细胞内钾难，因肠道吸收快，肾脏排泄快，进入细胞慢,*,原因causes1.Redistributionacidosisdigitalis overdoseAD hyperkalemic periodic paralysis2.Impaired potassium secretionAldosterone deficiency3.Renal failure：GFR 1,000,000 WBC 200,000,（二）、高血钾：血清钾55 mmol/LHyperkalemia,Treatment（治疗原则）1.First phase is emergency treatment to counteract the effects of hyperkalemia（葡萄糖酸钙拮抗高钾）IV Calcium2.Temporizing treatment to drive the potassium into the cells（使钾向细胞内转移）glucose plus insulinNaHCO3,（二）、高血钾：血清钾55 mmol/L,Treatment3.Therapy directed at actual removal of potassium from the body（降低体钾总量）sodium polystyrene sulfonate(Kayexalate)dialysis4.Determine and correct the underlying cause（病因治疗）,1、血清钾55 mmol/L 处理：停用钾，给利尿剂2、血清钾65 mmol/L 处理方法：1)葡萄糖胰岛素疗法(10岁，可用150ml 5)透析,1)血钙正常值1.15-1.35 mmo1/L2）正常人血钙40与蛋白结合，60游离钙，其中80离子钙一维持神经肌肉兴奋性，胞外钙是胞内钙的20,000倍。3）细胞受损，胞外Ca2+内流增加，血Ca2+降低4）胞内线粒体、肌浆网钙库Ca2+摄取减少，则细胞内Ca2+超载。,(三)、低血钙：,1)新生儿婴幼儿：10葡萄糖酸钙，0.5 mlkg次2）年长儿：10葡萄糖酸钙0.13mlkg次3）库血100 ml(补钙0.1g)：10葡萄糖酸钙1.3-2 ml4）成人：10葡萄糖酸钙 0.1-0.2mlkg次 10葡萄糖酸钙1ml含9mg Ca2+,补钙注意点：,1)最大量5 mlkg天 2)禁同时静脉用西地兰，或血浆、白蛋白、全血。3)选择中心静脉，如出现皮肤红斑，局部肿胀硬块立即停止。4)婴幼儿用GS 10-20 ml稀释后微泵泵入1h，速度过快、剂量过大，可引起心脏停搏、室速室颤等严重并发症，低钾、低氧血症或洋地黄化后尤易出现。5)低钾或刚iv过洋地黄不能立即用钙剂，以防发生严重的室性心律失常或室颤。（心脏的兴奋因子）6)婴儿补充大量钙后仍血钙不理想，可能合并低镁，应适当补镁。,1正常血镁0.7-1.15 mmo1/L儿童0.6-0.8 mmo1/L2低镁易合并低钾、低钙和碱中毒，应同时纠正。3预防低血镁：补镁0.125-0.25mmol/kg/day 即25%MgSO4(ml)0.125-0.25 ml/kg/day4严重低血镁：血镁0.5 mmo1/L 补镁0.5-1mmol/kg/day 即25%MgSO4(ml)0.5-1 ml/kg/day5单次补镁剂量：25mg/kg6予25%MgSO4 2g，则血清镁升高2 mEq/L,可降低术后房性室性心律失常的发生率。,(四)、低血镁：,A low serum Na does not tell us whether total extracellular Na is increased,decreased,or normal It only tells us that there is excess water relative to Na Most cases of hyponatremia are caused by impaired water excretion in the presence of continued water intake,(五)、低血钠（Hyponatremia）：血清钠130mmolL,1)限制水份、利尿(稀释性低钠)2)补NaCl 成人补钠量(mmol)=(140-实测Na)kg0.6 婴幼儿补钠量(mmol)=(130-实测Na)kg0.6 3)注意点：a当天补2/3量，分布在24h补液中，避免脑细胞损害。即补10NaCl(ml)=(140或130-实测Na)kg0.16b次日补1/3量c低钠常合并低钾，只要血K4.5mmol/L，就必须补钾，否则随钠泵活性的增强，可导致低钾和碱中毒的进一步加重。,(五)、低血钠：血清钠130mmolL,1)原因治疗，处理原发病和诱发因素2)纠酸：a.毫当量碳酸氢钠=0.6kgBE，一般先补充1/2量即5碳酸氢钠(ml)=kgBE3 b.THAM(不含钠的碱性溶液3.6溶液)THAM(mEq)=0.25kgBE，一般先补充1/2量,(四)、代谢性酸中毒：,1)诱因主要是低钾血症或低氯血症，而碱中毒又导致低血钾的程度更严重。代谢性碱中毒可引起低钾血症、低氯血症、低钙血症、低镁血症。2)治疗应首先纠正电解质紊乱，补充K+和Cl-，而不是补充酸性物质；同时也应补足血容量。3)严重碱中毒，可给予盐酸精氨酸（对改善细胞内碱中毒效果好，因为有机阳离子精氨酸容易进入细胞内，易引起钾离子从细胞内移出）。盐酸精氨酸(ml)=kgBE64)有症状者可给予葡萄糖酸钙iv，以及硫酸镁VD，并给予镇静剂。,(四)、代谢性碱中毒：,谢 谢！,第一讲：心脏术后围手术期的液体管理原则及注意点重点,1.成人每日基本生理需要量？2.体外循环对机体的主要影响？5条3.婴幼儿术后液体管理措施？3条4.术后血钾维持水平？婴幼儿血K维持在？mmol/L成人先心血K维持在？mmol/L成人风心血K维持在？mmol/L5.予10%KCl 10ml，则血清钾约升高？mmol/L 6.高血钾治疗原则？4条7.新生儿婴幼儿：10葡萄糖酸钙，？mlkg次 成人：10葡萄糖酸钙？mlkg次,