⽔・Na代謝異常 輸液 考え⽅ - nishikawaclinic.com

1 6 2015/10/161 Na Water & Electrolyte 6 2015 OVERVIEW 0 20 LNaCl 0 500mEqK0 500mEqH0 200mEqCa 0 30gP0 30g 60% Na 140 day 6 2015/10/162 NaCl10g/ NaCl10g/ L 100mEq 100mEq ICFECF 70kg28L14L11L3L (TBW)42L 11L 3L (ICF)28L (ECF)14L2/31/3 3 Osmolality 360 mg/dl == 20 mOsm/Lmg/dl x 10mOsm/L360 x 10180= 6 2015/10/163 OsmolalityECF=2Na + += 2x140+ += 290 mOsm/LICF=290 effective osmole(Na, , ) Glucose Urea Tonicity (Osmolality) (Tonicity)TOTALOSMOLALITY =+INEFFECTIVEOSMOLALITY2 (Na) +Glucose(mg/dl)18 EFFECTIVEOSMOLALITY(TONICITY)BUN(mg/dl) ) 2) Na, : ECF.

2 TBW 3) + 6 2015/10/164 ICFECFGlu 90Na 140urea 14urea 14290 290 Na ECF ICF ICFECFGluWater313 313 (Hypertonicity)350 Glucose 140gICFECFGlu 90Na 140urea 14urea 14290 290 Na ECF ICF 250 ICFECFGluWater277 277 (Hypotonicity)Water120 Osmolality 2(Na) 2(Na+K)Glucose Tonicity 2(Na) 2(Na+K) Glucose Ureatonicity urea Summary 6 2015/10/165 tonicity ECF = ICF ECF = ICF = skin turgor = JVD, (D5W) (NS) /2 (1/2NS) IV 1 L of NSICFECF tonicity ECF 750ml 250ml 1 6 2015/10/1661 L of D5 WICFECF free water TBW 80ml2 5% free water solute-free water 1 L of 1/2NS500ml NS ECF500ml water 1/3 ECF 2/3 ICFICFECF half-normal saline3 1 L of 5% salineICFECF tonicity ICF ECF 4 5% 6 2015/10/167 iso-oncotic albumin 18-24 1 L of 5% albuminICF ECF"crystalloid and colloidcontraversy" 5 5% Oncotic pressureAlbumin( ).

3 ECFICFKNaGluUreaUreaUreaNaGlu Crystalloid 2-5 Colloid , AIDS 6 2015/10/168 ICF ICF D5W IVICF ICF skin turgor ECF NS IV ECF sign of vol. NSor ECF or Excess disorder K K K Na Na HCO3- HCO3- Na ADH (osmoregulation) Edema 4-5 L ECF NS (isotonic fluid) D5W 15 L Na Na , Special thanks to Washy.

4 6 2015/10/169 Na Na<130mEq/l Na Na free water Na Na Na 140mEq/lNaNaNaNaNaNaNa NaNaNaNaNaNaNa Volume regulation vs Osmoregulation Na Na Na Na 6 2015/10/1610 Na ECF volumedepletion Na Na Na Na 135145 5% Na V2 2000mlNaCl5g = 86meqK 60 meq 800kcalGlucose200 gwater 1000mlNa 40 meq/LK30meq/L100g/L 10% Glucose1 L NSWaterK 60meqGlucose200g+ +NaCl 6 2015/10/1611isotonic hypertonic hypotonic3%salineNS1/2 NS1/3 - 1/4 NSD5W = + 24 Start Hx & PELab 6 hr 12 - 24 hrPELab 48 - 72 hrPELab 6 2015/10/1612 (tonicity) PNa140mEq/LNaNaNaNaNaNaNaNaNaNaUNa+ UK140mEq/L NS (free water) Na 6 2015/10/1613 Hx , , , PE 4 Na 3-5 (L)(%) 2-44-6>65-1010-15>15 Dehydration (free water)

5 Volume depletion Na 6 2015/10/1614 ICFECF Posm (tonicity) Na ICFECF Posm (tonicity) Na ICFECF (pure water) Posm (tonicity) Na 6 2015/10/1615 2000ml1500ml500ml 4 4 4 or V2 Na Na ECF volumedepletion Na Na 135145 5% Na dehydration D5W + free water D5W 6 2015/10/1616 6 2015 CASE STUDY 28 BP120/60, P 90/min C BUN 32, Cr , Na 138, K , Cl 98.

6 TP Na 140mEq/l 6 2015/10/1617 Heat cramp Na 4kg 4L 2 78 3 . BP110/70 mmHg 100/min, C RR 20/min Na125, K , Cl 87, Na Na Na 125mEq/l 6 2015/10/1618 400 600 800 100012001400 mOsm/kgGlucose 350 35-40 mOsm/L 35 - 40 x 15 = 525 - 600 mOsm/LNormal range 2 Na Na Na Na ADH ( Na Volume 3 78 51kg BP120/50 HR96/min Af, CVP skin turgor EJV Na160,K , Cl 130, BUN35, Cr.)

7 6 2015/10/1619 Na Na Na 160mEq/l volume depletion 3 Na Na Na D5W) 1 Na Na Na Na 6 2015/10/1620 ECFECFECFECF Na Na Na ECFECF Na volume depletion V2 Na ECF volumedepletion Na Na Na Na 135145 5% Na 3 70 3 2 BP164/94, 96/min, T CR 24/min, SpO290% Serum.

8 Na140, K , Cl 108, HCO325 BUN 24mg/dl, Cr mg/dl 6 2015/10/1621 70 3 2 BP164/94, 96/min,RR24/min, C,SpO290% Serum:Na140, K , Cl 108, HCO325 BUN 24mg/dl, Cr mg/dl =Na Na 70 -1 20mgIV 12 36 Nrs crackle BP150/92, P 96/min, T C, RR 20/min Serum:Na145, K , Cl 108, HCO325 BUN 32mg/dl, Cr mg/dl Urine: 2L/24hr Na 50mEq/L K 20mEq/L 300mOsm/L (=Na) UNa+UK=70mEq/L Na( ) NS 2L D5W1L 6 2015/10/1622 SIADH (free water) 2L free water 1 LNSNS Free water 74 10 8kg Na124,K , Cl 88, BUN33, Cr , TP , Alb , Glu 112, TCho 473 U/A SG , ,prot(3+), glu (-), 1-4/hpf, WBC 1-4/hpf, Na Na 124mEq/L (isotonic fluid) NaNaNaNaNaNaNaNaNaNaNaNaNaNaD5W (free water)

9 6 2015/10/1623 46 46 BP 110/70 mmHg Pulse 90/min, Temp C RR 20/min Finger-Nose test WBC 8500/ l, Hb g/dl, Ht , pl l Na 117, K , Cl 81, BUN 6mg/dl, Cr , ABG: pH , ,pH ,prot(-),glucose(-) 6 2015/10/1624 Step1: Na Step 2: Na Euvolemic hypotonic hyponatremia vs SIADH very low 80ml/hr IV Na Na V2 Na ECF volumedepletion Na Na Na Na 135145 5% Na 5 6 6 2015/10/1625 2015 2015 REVIEW Na Na Na Na Na Na Na NaCl10g/ NaCl10g/ 1%70%20%5-8% 150L/ 6 2015/10/1626Na Volume regulation

10 RAA ANP NaCl ECF Na ECF Na Na Na Na Sodium retention RAA ANP NaCl ECF Na ECF Na Na (ECF )Na Na Water diuresis Posm ADH Posm Posm 6 2015/10/1627 AntidiuresisPosm ADH 70%20%5-8% 1% ADH ADH ADH Posm280 (Na135mEq/l) ADH Posm290 (Na140mEq/l) 6 2015/10/1628 Na Na Posm ADH Inappropriate ADH Na Posm ADH SSRI Na SIADH free water Na Posm ADH 140mEq/lWt60kgwater load140mEq/l 6 2015/10/1629 Na ADH Na 140mEq/l120 mEq/lwater load ADH Primary polydipsia free water Na 140mEq/l125mEq/lwater load140mEq/l ADH Na 140mEq/lNaNaNaNaNaNaNa