高低血鈉病患之診治與照護 - areahp.org.tw

1 100 XI100 10 30 PM1:30 CKD ? ? ? ? ? ? ? ? ? .. 500cc (Normal Saline) ? (1/)()1) (NaCl) (dii)2) (Sodium concentration, Na) 154 mmol/L3) (Sodium Equilibrium, Na+) 154 mEq/L4) (Osmolality) 308 mosm/KgH2Og25) (Isotonic solution)A Ans: (2/) (/) ? 1000cc 9 NaCl 9 NaCl =Na(23)+Cl( )= 9000 (~154) mmoles9000 ( 54)mmoles 1 (Liter, l) =154mmol/L NaCl Na++Cl 1 Na+ Cl Na+ Cl 154mmol/L 154 NaClNormal SalineNa+154 mmol/LNa+154 mEq/L/q/ =308mmol (Particles) q/Osm 308 mmos/Kg H2O 308 mosm/KgH2O 500cc 5% (5% Glucose solution) 5% ?

2 (3/)()1)5% (Glucose) 278mmol/L278mmol/L2)5% (Equilibrium) 278E/L 278mEq/L3)5% (Osmolality) 278 mosm/KgH2O4) (Isotonic solution)()ABAns: B (4/) (/) 5% ? 1000cc 5%Glucose = 50 glucose 50 =C6H12O6= 180 50 =50,000mg/180= (~278)l(~278) mmoles 1 (Liter, l) =278mmol/L 1 5% glucose solution=278mmol/L 5% =278mmol (Particles) Glucose 278 mmol/LOsm 278 mmos/Kg H2O(Particles) Osmolality =278 mosm/KgH2O (5/) (/) (Osmosis)? Osmolality (mosm/kg H2O) Osmolarity(mosm/Lsolution) Osmolarity(mosm/L solution) Omsotic pressure (mmHg) and Osmolarity y = CRT :1 msom/L= mmHg (Body fluid) (y) 300 mosm/L Guyton 10th eds (Osmosis) (5/) (/) (Isotonic solution)?

3 Solution)? (Hypertonic solution)? (Hypotonic solution)? ? 09%NaClsolution(Normalsaline) NaClsolution (Normal saline) 5% Glucose water saline 25%Glucosewater/0 45%saline Glucose saline Ringer solution Lactate Ringer solution 3%saline 3% saline 10% Glucose water (5/) (/) ( ) ( ) (Osmosis) ?Jv=LpS(Pc-Pi)- ( c- i) Starling Force GlomerularhydrostaticGlomerular Colloid c 3% saline hydrostatic pressure(60 mm Hg)Colloid osmoticPressure(32 mm Hg) Bowman s capsule pressure (18mm Hg) PhysiologicalRegulationPhysiological Regulation (Homeostasis) (Balance) (Cti ) (Compensation) (Steady State) (Overloading) (Injury) (Degeneration) (Apaptosis) (Failure) ()

4 Hyper- Hypo- BR BR R BRBR BRBB BR R BB Hyper Hypo ? R B mosm/L300 NaCl mosm/L300200 2001000 ICFECF mosm/L300200 NaCl 2001000 mosm/L300 NaCl 0 10 20 30 40 L2001000 ICFECF0 10 20 30 40 L3002001000 ICFECF0 10 20 30 40 L0 10 20 30 40 L0 (/) (1/4)

5 600 Osm/Kg /g 10 mEq/L (/) (2/4) (Abdominalsequestration) (Abdominal sequestration) (/) (3/4) (/) (4/4) RingerLactate Ringer Lactate Colloid De tranDextran 135 150 meq/l (I id )0 97%/d (Incidence): (Prevalence): (Anderson & , Ann Intern Med.)

6 1985) Prevalence in general hospitalNa<135meq/l:15 20%Na<135 meq/l: 15 20%Na<130 meq/l: 3 6%/lNa<125 meq/l: 1 3% Hospital acquired: 40 66% 130mEq/L Posm Posm UNa Hypovolemichyponatremia Hypovolemichyponatremia (UNa > 40 mEq/L) (UNa < 20 mEq/L)

7 Evolemichyponatremia (UNa>40mEq/L Evolemichyponatremia (UNa> 40 mEq/L UNa < 20 mEq/L) SIADH SIADH Hypovolemichyponatremia Hypovolemichyponatremia (UNa > 40 mEq/L) (UNa < 20 mEq/L) ( <24 ) ( >48()( ) 125 130mEq/L 24 24 12 mEq/L Central Pontine ll Myelinolysis = x x 125 PNa 3%NaCl(513mEq/L) 3% NaCl(513 mEq/L) 3%NaCl 24 24 Furisemide Osmotic demyelination syndrome New England Journal of MedicineConsequence of rapid correction for hyponatremia.))

8 Osmotic demyelination syndrome (ODS) / Central pontine myelinolysis (CPM) Flaccid paralysis, dysarthria, and dysphagiaHi hbidi&li High morbidity & mortality Rapid or over correction sudden osmotic shrinkage of brain cellsT2 weightedMRIscan T2 weighted MRI scan Patchy areas of signal change within the ponsAndrew Waclawik, 160mEq/L Uosm 300 800 Osm/Kg Uosm>800 Osm/Kg > 800 Osm/Kg Uosm < 100 Osm/Kg Pit i Pitressin Uosm UNa Uosm UNa = x x (PNa/140)

9 1 q/ 1 0mEq/L/h 5% % DDAVP Thiazide ADH ThankyouforyourattentionThank you for your attentio