Part Ⅶ. Pathophysiology Of Body Fluid And Fluid Therapy
Chapter 46. Water
Total Body Water
; *78% of body weight at birth
; *55-60%
of body weight at 1year(adult level)
- adult female(55%) , adult male(60%) ; due to body fat
; *TBW(L)
= 0.61×wt(Kg) + 0.251
Fluid Compartment
; fetus
-
*ECF>ICF --> 1 세경에 adult level에 도달
- normal old child (adult level)
/
*ECF(20-25%) :
plasma5%+interstitial water 15%+transcellular water 1-3%
/ ICF(30-40%)
/ transcellular fluid(2%)
/ slowly exchangeable compartment(8-10%) : bone, connective tissue, cartilage
# ※객Transcellular Fluid
1. *GI
secretion ; ▲important
2. urine in the kidney & lower urinary tract
3. CSF
4. intraocular
5. pleural fluid
6. peritoneal fluid
7. synovial fluid
Regulation Of Body Water
; plasma osmolarity
- 285-295mOsm/KgH2O
-body내의 water amount는 feedback system(involving
+--1.osmoreceptor & voilume receptor
| 2.hypothalamus
| 3.post.pituitary
+--4.collecting duct of nephron)
에 의해 조절된다.
Inatke
; stimulated by a sensation of thirst
-
*thirst center : mid-hypothalamus
; osmolarity change
- monitored by
1. osmoreceptor in hypothalamus, pancreas, hepatic portal vein
2. baroreceptor in atria, vascular bed
3. renin-angiotensin system
; *Disorders
Of Thirst Mechanism
1. psycologic disorders
2. CNS disease
3. potassium deficiency
4. malnutrition
5. alteration in the RAS system
--> lead to incresed drinking
Excretion
# ★Obligatory
Loss Of Water
; insensible water loss - evaporation from lung and skin
; urinary excretion - urine volume to excrete solute load
; stool water losses
# urine volume and concentration regulation
1.ADH;주(neurohypophyseal-renal axis)
2.diet
3.GFR
4.state of renal tubular epithelium
5.plasma concentration of adrenal steroids
# urinary water excretion : 2 complementary mechanism에 의해 조절
1.production, storage and release into the circulation of ADH
2.renal epithelial tubular cell response to ADH
# ADH
; supraoptic nuclei에서 생산
; secretion;regulated by effective osmotic pressure of the extracellualr fluid
; ★primary action
- increse the permeability of renal collecting ducts to water
; threshold for release of ADH
-
*280mOsm/KgH2O
Pathophysiologic Conditions
# Diabetes insipidus
; central : supraoptic-osmoreceptor-hypophyseal axis이상으로 ADH분비(-)
; nephrogenic : ADH는 정상분비되나 renal collecting duct의 ADH receptor의 이상
Factors Altering ADH Release
# stimulant factors
; stressful stimuli - trauma, burn, surgery
; nicotine, prostaglandine, cholinergic & beta adrenergic drugs
; demerol, morphine, barbiturate
# inhibitory factors
; alcohol - potent inhibitor
; dephenyhydantoin(dilantin)
; glucocorticoids
Factors Altering The Renal Response To ADH
③ ADH작용 ;+- unabsorbable,osmotically active solutes in renal tubular
| lumen e.g)glucose in diabetesllitus
+- intrinsic renal condition
e.g)tubular damage due to urinary tract obstruction,
Mechanisms For Distributing Fluid Within The Body
1)ICF volume is maintained by osmotic forces operating across cell membranes
Maintenance Of The ECF Volume
; oncotic pressure
- colloid osmotic pressure
-
exerted by molecules, *primarily albumin
- produce effective osmotic gradient across capillary walls
2)plasma volume(plasma water)is maintained by a balance between filteration and
oncotic forces at the capillary level
3)interstitial fluid volume may increased by an increse in the hydroststic pressure
4)transcellularfluid
+- inflammatory bowel d's
+- early severe diarrhea
+- ileus with multiple fluid level
Osmolality Of Body Fluid
1) plasma osmorlarity증가(e.g. hyperglycemia,hyperlipidemia):ICF에서 ECF로
water shift, plasma sodium level 감소
2) pseudohyponatremia ; Tx가 필요없다.
Chapter 47. Sodium
Body Content And Distribution Of Sodium
-58mEq/Kg; 이중 30%가 non exchangeable or only slowly exchandeable
-25mEq/Kg; 43.1%가 bone에 존재
-exchangeable sodium content
+--fetus;85mEq/Kg
+--adult;40mEq/Kg
-Distribution of body sodium
+-ICF;10mEq/Kg
+-ECF;140mEq/Kg
Na-K ATPase and Mg activatedATPase system에 의해cell로부터 Na의 active
extrusion이 이루어진다.
ATPase inhibitor 1.Ca
2.ouabain(digitalis와 비슷한 작용을 나타내는 강심제)
3.cardiac glycoside
"sick cell syndrom";total body sodium change없이 ICF와 ECF사이에 sodium의
redistribution observed in the serevely ill patient
Regulation Of Sodium
Intake
Absorption
; throughout GI tract
-
*maximally in jejunum, minimally
in stomach
; *by
Na-K activated ATPase system
; augmented by aldosterone or DCA(desoxy corticosterone acetate)
Excretion
concentration of sodium in sweat;5-40 mEq/Kg
+- ;cystic fibrosis,addison d's
+- ;sodium depletion,hyperaldosteronism
Renal Regulation Of Sodium Excretion
Glomerular Filtration Of Sodium
+-ECF vol.감소 → sodium reabsorption
+-ECF vol.증가 → ANP(atrial natriuretic peptide)분비→ GFR증가→ urine Na증가
Tubular Reabsorption Of Sodium
★Fig.
47-2
+-filtered Na;2/3 is reabsorbed by proximal convoluted tubule;
| by avtive transport
+-Henle's loop(ascending limb);secondary toactive teansport of chloride;
| by countercurrent multiplier system
+-distal convoluted tubule & collecting tubule;fine regulation;by aldosterone
this is governed by the ⓐrenin-angiotensin system
ⓑpotassium balance
ⓒtrophic hormone
Factors Regulating Sodium Excretion
Renin-Angiotension System
Aldosterone
; secretion by angiotensin II
;
*promoter of sodium reabsorption
in late distal convoluted tubule and collecting duct
; increase potassium secretion
Atrial Natriuretic Peptide(ANP)
; sodium & water excretion증가
3) starling forces : rapid expansion of ECF vol.→ interstitial hydrostatic pr.증가
→ sodium reabsorption방해, urinary sodium excretion증가
Pathophysiologic Conditions
Hypernatremia
- serum Na 150meq/L 이상
Table 47-1
Hyponatremia
; serum Na 130 meq/L 이하
;
*▲common cause
- decreased nutritional sodium intake due to WIC syndrome
Table 47-2
Chapter 48. Potassium
Body Content And Distribution Of Potassium
in adult : 53 mEq/kg body weight (95%는 exchangeable)
+--intracellular potassium amount : 48 mEq/kg (89.6%)
+--extracellular potassium amount : 5.5 mEq/kg ( 이중 4mEq/kg 가 bone에 존재)
+--intracellular concentration of potassium : 150 mEq/L
+--extracellular concentration of potassium : 4-5 mEq/L
Regulation Of Potassium
# Two Mechanism
1) extrarenal mechanism
2) renal mechanism
1) Acute Loads
# absorption
; upper GI tract 에서 complete
; lower bowel lumen내에서 sodium 과 exchange
# excretion
; renal excretion
- first 4-6hr one half
; extrarenal excretion
-
*translocated into cell, primarily
in the liver & muscle
-
*more than 40%
- regulated by insulin, epinephrine enhancing potassium uptake
/ mediated through β-receptors
- aldosterone
/
increase transport of potassium to muscle
/
*primary extrarenal site : GI
tract
; acid-base balance
-
*every 0.1 unit change in blood pH
--> change 0.3-1.3mEq/L in opposite direction
2) Chronic Loads
;
*primarily regulation by kidneys
; proximal convoluted tubule 에서 filtered potassium 의 60% 이상이 재흡수된다
; Factors affecting distal nephron potassium secretion
① mineralocorticoid activity
② dietary potassium
③ acid-base status
④ distal tubular flow rate
⑤ sodium delivery to distal tubule
; aldosterone
- major role in potassium regulation
- distal tubule에서 luminal membrane의 permeability를 변경시켜 luminal Na+와 cellular K+교환
* acute potassium load때 extrarenal protective mechanism
-첫 4-6hr내에 1.1/2;kidney통해 배설
2.more than 40%;liver와 muscle내의 cell내로 이동시킴
3.some;intestine으로 secretion
-관여하는 factor
1.insuline & epinephrine;enhance K+ uptake by liver& muscle
2.aldosterone;GI tr에서 K+ 배설 증가
3.glucocorticoid
4.acid-base balance
systemic acidosis;movement of K+ out of cell
systemic alkalosis;opposite effect
pH 0.1 unit change시 0.3-1.3mEq/L의 K+이동
Pathophysiologic Conditions
Hyperkalemia
Consequence Of Hyperkalemia
-heart가 특히 hyperkalemia에 susceptible
paresthesia weakness flaccid paraysis
EKG상 ①peaked T wave
②PR interval prolong
③QRS complex widening(later)
④ventricular fibrillation
★Causes
; renal excretory impairment
-
*▲often
① acute or chronic renal failure, adrenal insufficiency, hyporeninemic hypoaldosteronism, use of potassium-sparing diuretics
② acute K+ intake
- potassium salt of penicillin
③ acute tissue breakdown
- trauma, surgery, burn, cell lysis from chemotherapy
④ transcellular redistribution of K+
- metabolic acidosis, shortly before death, severely ill patients
⑤ *succinylcholine,
digitalis overdose
# ★Pseudohyperkalemia
; RBC lysis during collection or handling of blood sample or K+ release fron platelet during clotting
Hypokalemia
Consequences Of Hypokalemia
# serum potassium 1 meq/L감소시 body potassium의 10-30%에 해당
# ★Functional
Alteration In Skeletal Muscles, Smooth Muscles, Heart
; cardiac manifestations
- ECG changes
/
*▲observable
/ prolonged QT interval & flattened T waves
; skeletal muscles
- weakness : early manifestation noted first in limb muscle
- areflexia, paralysis, death from respiratory muscle failure
; smooth muscles
- paralytic ileus, gastric dilatation
# serious neurologic symptoms
; autonomic insufficiency, orthostatic hypotension, tetany, decreased neuromuscular excitability
- weakness, decreased bowel motility
# *rhabdomyolysis
# ㉿In kidney
; vacuolar changes in tubular epithelium
-->
*if sustained, nephrosclerosis,
interstitial fibrosis
--> reduced ability to concentrate or dilute
--> polyuria, polydypsia
--> increased HCO3 reabsorption, H+ secretion
--> systemic alkalosis
# Paradoxical aciduria
; extrarenal K+ loss
--> ICF에서 ECF로 K+ shift
--> intracellular potassium is replaced by Na+, H+, dibasic aminoacids
-->
*if severe, excessive exchange of
intracellular hydrogen of renal tubular cells for sodium in distal tubule fluid
-->
*systemic alkalosis, aciduria,
with increased urinary ammonia excretion
Causes
①renal loss
ⅰ)diuretics;osmotic diuretics,carboni anhydrase inhibitor
ⅱ)tubular defect;renal tubular acidosis
ⅲ)acid-base disturbance
ⅳ)endocrinopathy;cushing SD
primary aldosteronism
thyrotoxicosis
ⅴ)diabetic ketoacidosis
ⅵ)Bartter syndrom
ⅶ)Mg deficiency
②extrarenal loss
ⅰ)from G-I
diarrhea,chronic catharsis,frequent enema,protracted vomiting,
biliary drainage,enterocutaneous fistula
ⅱ)from skin;profuse sweating
③prolonged decrease intake
Chapter 49. Chloride
Body Content And Distribution Of Chloride
: major anion of ECF ( plasma 13.6%, interstitial lymph 37.3%, connetive t's 17%,
bone 15.2%, ICF 12.4%, transcellular 4.5%)
Regulation Of Chloride
: sodium과 병행
Pathophysiologic Conditions
Hypochloremia
+--1.metabolic alkalosis
| 2.chloride loss in excess of sodium loss : vomiting,chloride diarrhea,gastric
| drainage. metabolic acidosis or K+ deficiecncy 교정할 때,urinary chloride
| loss가 Na+ loss을 exceed한다.
+--3.pretracted inadequate intake(chloride-deficient milk formula잔기간 먹일때)
-K+ deficiency시 K+ deficit correct전에 K+,Cl-를 주어야 함
-Sx;failure to thrive,muscle weakness,loss of appetite,lethargy
Hyperchloremia
: distal renal acidosis, parenteral aminoacid sol.
Anion Gap
; Na+ - [Cl- + HCO3-]
; normal : 8-16mEq/L (평균;12mEq/L)
; 임상적의의
- combined concentration of unmeasured anions such as phosphate, sulfate,protein,organic acid
; ★Normal
Anion Gap
- renal tubular acidosis
- stool loss of bicarbonates
; ★Increased
Anion Gap
- renal failure
/ due to increased phosphate & sulfate
- diabetic ketoacidosis
/ due to β-hydroxybutyrate and acetoacetate
- lactic acidosis
/ due to lactate
- hyperglycemic non-ketotic coma
/ due to unidentified organic acids
- disorders of aminoacid metabolism
/ due to various organic acids
- aministration of large amount of penicillin
- ethylene glycol ingestion
/ due to glycolate production
- methanol ingestion
/ due to formate production
- salicylate poisoning
/ due to salicylate anions
; ★Decreased
Anion Gap
- nephrotic syndrome: due to decreased s-albumin
- lithium ingestion : due to lithium as unmeasured cation
- multiple-myeloma : due to cationic protein
Chapter 50. Calcium
Body Calcium
calcium +-40%;protein bound(이중 80-90%가 albumin과 bound)
+-60%;free ionic calcium(4.8mg/dl)
Regulation Of Calcium
Regulation은 주로 G-I tr통해
- 흡수;duodenum과 proximal jejunum에서 1.25(OH)2vitD3의 작용에 의해 흡수
hypocalcemia는 parathyroid hormone release을 stimulation하여
25(OH)2vitD3를 conversion시킨다.
Intestinal Tract Absorption Of Calcium
; primary regulation of calcium
# ★Increased
Absorption
; low calcium intake
; in growing child
; pregnancy
; depletion of body calcium store
; vitamin D or PTH
; pathologic condition
- sarcoidosis, carcinomatosis, multiple myeloma
# ★Decreased
Absorption
;
*presence of phytate, oxalate,
citrate in GI tract
; complex dietary calcium
; incresed gastric motility
; reduction of bowel length
; protein depletion
Renal Calcium Excretion
excretion : glomerulus로 filtered된 non-protein-bound calcium의 99%는 tubule에 의해 재흡수 된다.
resorption +-proxiaml tubule(50-55%)---+ Na resorption과 평행
| loop of henle(20-30%) ---+
| distal convoluted tubule(10-15%)---+ independent of Na transport
+-collecting duct(2-8%) ---+
- Ca reabsorption by 1.25(OH)2vitD3
Ca reabsorption by thyrocalcitonin
- urinary Ca+ excretion
1)expansion of ECF volume
2)osmotic diuretics,furosemide,thiazide,GH,thyroid H.glucagon투여
3)metabolic acidosis
4)prolonged fasting
5)serum phosphate level
6)thyrocalcitonin
- total calcium level은 serum albumin level에 따라 변화한다.
- hypoalbuminemia시 serum total albumin level이 낮아도 symptom이 없을 수 있다.
( serum ionized calcium level이 정상이기 때문에)
- pH change
ionized Ca++ concentration 10%변동
acidosis시 Ca++ ,alkalosis시 Ca++
rapid correction or overcorrection of acidosis시
symptomatic hypocalcemia초래
- hypernatremia treatment with low potassium content
hypocalcemia초래
Pathophysiologic Conditions
Symptomatic Hypocalcemiaa(Low Ca++)
# ★원인
; vitamin D deficiency
- by nutrition deficiency, malabsorption, abnormal metabolism of vitamin D
; hypoparathyroidism
; pseudohypoparathyroidism
;
★hyperphosphatemia
;
*Mg deficiency
; acute pancreatitis
# neonate시 hypocalcemia
; hypoparathyroidism
; abnormal vit,D metabolism
; low calcium intake
; high phosphate intake
Hypercalcemia
# ★원인
; 1' or 3' hyperparathyroidism
; hyperthyroidism
; vitamin D intoxication
; immobilization
; malignancy(esp, bone metastasis)
; ★use of thiazide diuretics
; milk-alkali syndrome
; sarcoidosis
; Williams synd.
- hypersensitivity to Vit.D
;
*inadequate phosphate intake in
low-birthweight infants
# calcium loading시
1.urinary Na,K excretion
2.concentrating ability( ) polyuria,polydypsia초래
Chapter 51. Magnesium
major role in cellular enzymatic activity esp)glycolysis,ATPase stimulation
1. body content and distribution of Mg
: serum Mg;1% of body Mg;1.5-1.8mEq/L
Regulation Of Mg
Intake
+--1.vit.D
| 2.PTH
+--3.increased Na reabsorption
# decrease of Mg absorption
①calcium
②phosphate
③increased intestinal motility
Renal Excretion
# inhibition of urinary reabsorption
--> increasing urinary Mg
; expanson of ECF volume
; osmotic, thiazide, mercurial, loop diuretics
; glucagon
;
*calcium loading
;
*decreased PTH
Pathophysiologic Conditions
Hypomagnesemia
# ★원인
① malabsorption syndrom
② hypoparathyroidism
③ diuretics therapy
④ *hypercalcemia
⑤ renal tubular acidosis
⑥ *primary
aldosteronism
⑦ alcoholism
⑧ prolonged IV fluid therapy with Mg-free fluids
early or late neonatal tetany와 hypoMg과 관련있다.
# Clinical Manifestation
;
*increased neuromuscular
irritability
; tetany, severe seizure, tremor, personality changes, nausea, anorexia, abnormal cardiac rhythm & abnormal ECGs
# serum Mg level과 Sx이 늘 일치하지 않는 이유
①s-Mg level이 항상 body Mg content 반영하는것 아님
( predominatly intracellular cation)
②hypomagnesemia Sx이 Mg depletion을 일으키는 primary disease의 Sx에
비해 minor
③hypomagnesemia Sx이 hypocalcemia Sx과 complicated
# ★Severe
Hypomagnesemia이 Hypocalcemia와
공존이유
;
*interfere with PTH release &
induce skeletal resistance to PTH action
Hypermagnesemia
; >5mEq/L
; 원인
①renal disease
②Mg-containing laxative,enema,IV fluid
③neonates born of mothers who were treated with I.M of Mg sulfate for
hypertension of pre-eclampsia
④Addison's d's
; Symptoms
-
*hyporeflexia, resp. depression,
drowsiness, coma
; Treatment
-
*IV calcium
Chapter 52. Phosphorus
1. body content and distribution of phosphorus
-intracelluar phosphate;energy에 관여
2. regulation of phosphorus
1) intake & absorption
(1) diet;milk,milk product,meat
(2) 흡수;jejunum(dietary phophate의 2/3)
;①vit.D ②G.H.
;①PTH
②alkaline urine
③expansion of ECF
④hyperglycemia
⑤diuretics
(3) body reabsorption;① by PTH,1.25(OH)2vitD
② by thyrocalcitonin
3. pathophysiologic conditions
1)hyperphosphatemia
+--①hypoparathyroidism
| ②young infant
| ③excessive administration of phosphate
| ④cytotoxic drug
+--⑤reduction in GFR(25%이하)
2)hypophosphatemia
+- ①starvation
| ②protein-calorie malnutrition
| ③malabsorption syndrom
| ④intracellular shift of phosphate during diabetic ketoacidosis Tx.and
| corticosteroid administration
| ⑤urinary loss
| 1'& 3'hyperparathyroidism,renal tubular defect,ECF expansion
| diuretic administration
| ⑥vit.D deficient & vit. D resistant rickets
| ⑦inadequate intake
+- ⑧prolonged use of phosphate free fluid
* Sx ;①tissue anoxia
②increased hemolysis
③metabolic encephalopathy;irritability;paresthesia,confusion,seizure
coma
Chapter 53. Hydrogen Ion
Terminology
Normal Acid-Base Regulation
㉿Buffer Systems
; ECF
- bicarbonate-carbonic acid system
; ICF
- protein, organic phosphate
; urine
- mono & di-hydrogen phosphate
# *중탄산염
완충계 & 비중탄산염
완충계
;
H2CO3+B+Buf- --> B+HCO3
+ H+Buf
# Henderson-Hasselbalch equation
;
*bicarbonate와 carbonic acid가 20:1이
되도록 유지
Clinical Acid-Base Relationship
; 3 major components : pH, PCO2, HCO3
Pulmonary Mechanisms
resp.rate (↑) --> CO2 excretion (↑) --> PCO2 (↓) --> pH(↑)
Renal Mechanisms
; *▲important regulators of acid-base balance in normal condition
; two requirement
1) prevent loss of bicarbonate
2) excrete acid equal to daily nonvolatile acid
- two process
/ filtered bicarbonate을 proximal tibule에서 거의 reabsorption
/ distal tubule에서 phosphate & ammonia에 의해 H+ secetion하면서 HCO3흡수
# Increased H+ Ion Secretion & HCO3 Reabsorption
① increased PCO2
② decreased K+
③ reduction in effective arterial blood volume
(eg,after vomiting or hemorrhage)
④ administration of mineralocorticoids
# Decreased H+ ion secretion & HCO3 reabsorption
①decreased PCO2
②expansion of ECF volume
③inhibition of carbonic anhydrase (e.g. acetazolamide)
④cystinosis,heavy metal poisoning with damage to proximal tubule
# distal acidification 장애
① intrinsic defect ; 10 distal RTA
② 20 distal RTA;nephrocalcinosis,vit.D intoxication, amphotericin B administeration
Normal Acid-Base Balance
# ♥신생아에서 산,염기 조절이
힘든 이유
; 신장 농축 능력이 낮아서 같은 양의 용질을 배설하는데 더 많은 물이 필요
; 요를 통한 암모니움(NH4+)의 배설이 적어 효과적이지 못하다.
; 인산염을 소량밖에 배설하지 못해 적정산(titratable acid)의 배설능력이 제한되어 있다.
Disturbance Of Acid-Base Balance
★표6-2(p108)
Metabolic Acidosis
# Anion Gap
; Na+ - (HCO3 + Cl-)
# Clinical Picture
①deep rapid respiration(kussmaul breathing)
②severe acidosis에 의해 peripheral vascular resistance & cardiac ventricular function
- hypotension,pulm.edema,tissue hypoxia
# ※89 Cause(5개)
; renal cause
- proximal form of RTA
- distal form of RTA
- CRF
- low GFR in newborn
; other cause
- diabetic ketoacidosis
- salicylism
- severe diarrhea
- hyperalimentation, lactic acidosis, starvation, poisoning(methyl alcohol or ethylene glycol)
- inherited aminoaciduria (e.g. methylmalonicaciduria)
- hypoxemia, shock
Metabolic Alkalosis
# ※89 Three mechanism
① excessive loss of H+
; prolonged gastric aspiration, persistent vomiting, pyloric stenosis
② increased addition of bicarbonate to ECF fluid
; excessive administration(in milk-alkali syndrom)
; increased renal reabsorption of bicarbonate caused by
-
*profound potassium depletion
- primary hyperaldosteronism
-
*cushing syndrome
-
*bartter syndrome
- excessive intake of licorice
③contraction of the ECF volume
# hypokalemia, ECF volume depletion에 의한 경우
- refractory to treatment
- correction한 후에 Tx
# Sx
; muscle cramps, weak, tetany (ionized Ca이 metabolic alkalosis에 의해 감소시)
# Laboratory finding
① pH증가, HCO3증가, PCO2증가
② hypochloremia,hypokalemia
③ alkalized urine
㉿Potassium
depletion, volume depletion인 경우에는 다른 Lab/F ?
Respiratory Acidosis
; respiratory distress와 함께 hypoxemia가 우세한 임상증상
# ★Acute
; neuromuscular disease
- brain stem injury,G-B synd.,sedative overdose
; airway obstruction
- foreign body, severe bronchospasm, laryngeal edema
; vascular disease
- massive pulm. embolism
; other condition
- pneumothorax, pulm.edema, severe pneumonia
# ★Chronic
; pick wickian synd., poliomyelitis, COPD, kyphoscoliosis, chronic administration of sedatives
# Lab
; 1.arterial pH
2.PCO2
3.HCO3;elevated moderately
-hypercapnia로 vasodilatation초래 cerebral blood flow( ) headache & IICP
Respiratory Alkalosis
# ★원인
; hyperventilation of psychogenic origin
; overventilation of mechanically assisted ventilation
; early stage of salicylate overdosage
# Lab
; arterial pH
PCO2 ,HCO3
# 임상증세
; periorally와 extremities에 muscular irritability & paresthesia
(∵ionized calcium농도의 감소때문)
- systemic alkalosis aciduria
Clinical Assessment Of Acid-Base Disorders
Measurements
# Base excess
; 37oc, 40mmHg PCO2에서 strong acid로 whole blood를 적정하여 pH 7.4로 하는데 필요한 양(mEq/L)
# normal pH ; 7.35-7.45
# s-carbondioxide cencentration
; 25-28mEq/L
; 생후 1년간 : 20-30mEq/L
; true bicarbonate value보다 1-2mEq/L 높다.
Interpertation
Intracellular pH
6.8
[H+] X [total CO2 content in mEq/L]
PCO2 = ------------------------------------
25
pH;7.4, [H+]=40mEq/L
Cerbrospinal Fluid pH
; bicarbonate-carbonic acid buffer
; CO2는 freely diffusible하나 HCO3는 slowly change
# ♥Compenasated
Metabolic Acidosis
; 너무 빨리 교정되면, ECF pH는 정상화되나, CSF PH는 더욱 감소
Chapter 54. Fluid Therapy
- daily turnover of water
+--infant;25% of total body water
+--adult; 6% of
Determination Of Requirement
+--deficit therapy;replace loss of fluid and electrolyte resulting from illness
| maintenance therapy;replace ongoing normal and abnormal loss of fluid and
| electrolyte
+--supplement therapy;in certain disease that require specific fluid
and electrolyte
- monitoring of patient
1)physical examination
2)determine changes in body weight
3)frequent review of intake and output
4)repeated laboratory determinations;
s-electrolyte,BUN,s-creatine,blood count
Maintenance Therapy
fluid & electrolyte requirement는 metabolic rate와 직접 연관
metabolic rate에 영향을 미치는 인자
1) endogenous water production : by oxidation of carbohydrate, fat, protein
2) urinary solute excretion
3) heat production
calorie requirement & maintenance fluid & electrolyte (table 54-1)
fluid requirement(100cc/100Cal)
: insensible water loss (1/3), renal water loss(2/3)
1) insensible water loss증가
① increased activity(30%)
② fever(10 증가시 12%증가)
③ hyperventilation
④ low birth wt infant
⑤ phototherapy
2) urinary water requirement 증가
① renal concentrating ability의 감소
② ADH분비 감소
urinary water loss가 비정상적일시는 maintenance fluid는 insensible water와
urine output으로 계산
Na requirement증가
1) cystic fibrosis(d/t cutaneous loss증가)
2) salt-losing nephritis, obstructive uropathy, chronic pyelonephritis,diuretic
therapy (d/t urinary loss증가)
3) fistula, diversion, NG tube drainage, inflammatory bowel d's(d/t GI loss증가)
: 대개 isotonic or half saline으로 replacement
Na requirement 감소
1) edematous state d/t hepatic, cardiac, renal ds'
2) CRF
3) acute anuric renal failure
potassium requirement 증가
1) ongoing GI & genitourinary loss(gastric drainage,laxative,diuretic abuse시)
2) chronic renal ds' with renal medullary injury
potassium requirement감소
1) CRF
2) adrenal insufficiency
3) acute anuric renal failure
4) severe acidosis with hyperkalemia
parenteral nutrition
- maintenance electrolyte in 5% dextrose solution추천
이유 1.metabolized되는 calorie의 약 25%공급
2.endogenous protein의 catabolism을 감소
3.kidney에서 solute load감소시키기 위해
- 5% dextrose 이상일때
+--1.hyperglycemia
| 2.osmotic diuresis
| 3.intravenous thrombosis
+--4.infection
- standard infusate
성분;crystalline aminiacid solution,20% glucose,various electrolyte,
multiple vitamin,zinc,copper,chromium,manganese
투여개요)infusion rate;135ml/Kg/24hr, 120Cal/Kg/24hr
protein requirement;2.0-3.0g/Kg/24hr
lipid;20ml/Kg/every 10days
* peripheral vein 사용시 ex)neonate
: glucose concentrate 10%
amino acid 30%(30g/L);in older child
daily lipid
TPN complication
1.sepsis
2.severe hyperglycemia
3.profound hypophosphatemia
4.hyperammonemia
5.severe metabolic acidosis
6.electrolyte disturbance
* very low birth wt infant에서는 Ca, P의 ratio가 bone mineralization에
매우 중요
Deficit Therapy
Severity Of Deficit
: wt loss기준 (table 54-3)
* Types of dehydration
1) isotonic or isonatremic; Na 130-150mEq/L : 70% of pediatric dehydration
2) hypotonic or hyponatremic : <130mEq/L
: hypotonic ECF에서 ICF로 water shift → vol. depletion(ECF)
→ circulatory collapse 유발 가능
3) hypertonic or hypernatremic : >150mEq/L
: ICF에서 ECF로 water shift에 의한 ICF vol.감소
* B.Wt를 모르는 경우 infant에서 degree of dehydration결정
1.ant. fontanel
2.skin elasticity
3.eyes
4.Hx of recent pattern of urination
Clinical Manifestation
(table 54-3)
Laboratory Evaluation
1)hemoconcentration(increased in hemoglobin,hematocrit,and plasma protein)
2)serum electrolyte
① s-Na는 water의 Na와의 상대적인 loss를 나타낸다.그러므로 hyponatremic
dehydration patient에서도 total body sodium은 감소되어 있다.
② s-K+
③ bicarbonate : acidosis, akalosis, ABGA가 도움
3)BUN,creatine
4)routine UA
S.G<1.020 with dehydration시에는 intrinsic renal disease생각
dehydration시 mild-moderate proteinuria,hyaline and granular casts,
white blood cells,occasionally red blood cell contain함
5)anion gap
[sodium and potassium]-[chloride+bicarbonate]=15 5mEq/L
증가하는 경우 1.renal disease
2.ketosis
3.lactic acidosis
Chapter 55. Principles Of Therapy
* parenteral fluid therapy Ix
1)severe dehydration
2)vomiting pt.
3)profound ongoing loss;diarrhea pt amounts greater than 100ml/Kg/hr
* 3 phases
① initial therapy;rapid reexpansion of ECF volume and improve circulatory
dynamics and renal function
② subsequent therapy;replace remaining ICF and ECF deficit of water
and electrolyte
③ final therapy;return of pt.'s normal nutritional state and 환자가
oral feeding가능할때 시작
Initial Therapy
goal : ECF rapid expansion
* solution
1)metabolic alkalosis(pyloric stenosis);0.9%NaCl in glucose,5g/dl
2)metabolic acidosis functioning kidney;H/S
3)metabolic acidosis without functioning kidney;
7.5% NaHCO3 28ml to 0.9% NaCl solution 750ml
and increasing to 1L with 5% dextrose in water
Na;140mEq,Cl;115mEq,HCO3 25mEq
- severe dehydrated pt.에서 HCO3대신 lactate or acetate containing solution
사용시 안좋은점
;impaired circulation으로 HCO3 precursor가 HCO3로 쉽게 metabolized
되지않아 existing acidosis악화됨
- volume : 20-30ml/Kg,1hr 이내 shock교정안되면 2nd or 3rd dose
이때는 severely hypokalemia때도 K+ replace안함
- above Tx로 shock교정안되면
1)blood(10mg/Kg) or 5% albumin
2)other plasma volume expander사용
Subsequent Therapy
: deficit 계속 교정, ongoing loss교정,
maintenance fluid & electrolyte
- urine flow establish후 s-K+이 n'l or slightly low이어도 K+ replacement를
해 줘야 할 경우(보통은 치료시작 24시간 후에 한다.)
1)hypochloremic alkalosis of pyloric stenosis
2)prolonged diarrhea
3)diabetic acidosis
Correction Of Deficit
1) isonatremic dehydration
(1)external loss of Na from ECF
(2)movement of Na+ from ECF to ICF to compensate for iontracellular K= loss
(3)K+ 투여시 ICF sodium은 다시 ECF로 return ECF volume expansion초래
ECF Na, & water loss의 2/3만 교정 (첫 24시간동안)
예) severe,isonatremic dehydration,15% Bwt loss
deficit;water-150ml/Kg(15% of B.W)
Na+ :21mEq/Kg
: 첫 24시간동안 water는 100mg/Kg와 Na14mEq/Kg투여함, 이중에서 20-30ml/Kg of sodium을 첫 2-3hr에 투여하고 나머지는 다음 21-22hr동안 투여한다. 이때 ongoing normal loss + continuing abnormal loss도 교정
- 24hr 이후
목표;complete restore of Na + water loss,start replacing K+ loss
sodium and water requirement = (normal maintenance requirement +25%)
+ any ongoing abnormal loss
K+ loss;replaced over 3-4 days period
+--K+ concentration < 40mEq/L
+--rate of K administartion < 3mEq/Kg/24hr
2) hyponatremic dehydration
- extra sodium loss = (135-Na) x total body water (=0.5-0.55xB.W)
extra-amount는 수일에 걸쳐 교정
- abrupt elevation of s-Na필요한 경우;
water intoxication Sx(ex.convulsion);s-Na<120
Tx ; 3% NaCl solution, 1cc/min rate로 maximally 12cc/Kg of B.W
Hypernatremic Dehydration
# severe hyperosmolarity로 인해 cerebral damage
; cerebral hemorrhage
; thrombosis
; subdural effusion
# seizures
; frequently during treatment
- mechanism
/ cerebral cell during dehydration
: increase Na content, increase indiogenic osmoles(esp. taurine)
--> rehydration시 rapid fall in ECF
--> excessive water shifting into ICF
--> cerebral edema
- 예방
/
*10mEq/L/day 이하로
천천히 Na교정
# suitable regimen
; 60-75cc/Kg/24hr of 5% D/W 25mEq/L of sodium combination of carbonate & chloride
; maintenance ; 3/4 of 유지량 (∵high ADH level low urine volume)
- seizure Tx
1)3% NaCl 3-5ml/Kg, iv
2)hypertonic mannitol, iv
# ★Cx.
During Tx
; edema, esp. cardiac failure
- large amount of water with/without salt시 ECF volume expansion
; hypocalcemia
;
*renal tubular injury with
azotemia & loss of concentrating ability
;
*cerebral edema
- seizures
- due to inappropriate and aggressive rehydration
Assessment Of Response
1) clinical
; child's cry, degree of activity, skin turgor, blood pressure
2) I/O(stool & urine volume) & B.W
3) urine specific gravity
4) serial serum & urine electrolyte, osmolality, central venous pressure
5) EKG
Chapter 56. Fluid & Electrolyte Treatment Of Specific Disorder
56.1 Acute Diarrhea And Oral Rehydration
①isonatremic dehydration(70%) : rotavirus, non-infectious cause
②hyponatremic dehydration(10%): bacillary dysentery, cholera
③hypernatremic dehydration(20%)
: home-made high salt solution; boiled skim milk를 feeding함으로써 renal solute load 의 증가로 water를 censerve할 renal ability가 제한되어 질때 fever,high environmental temparature ,hyperventilation에 의해 potentiated 된다.
# ♥IV
Therapy Ix
; shock
; severe dehydration
; uncontrolled vomiting
; amounts of diarrhea > 100ml/Kg/hr
; exreme fatigue, stupor, coma로 drink할 수 없을때
; serious complocation
- ex)severe gastric distension
# ORS(oral rehydration solution) composition by WHO(mM/L)
★Table 55-1
; other method
NaCl(0.9% saline solution) 390ml +
5% D/W 400ml + KCl(2mEq/mL) 10mL +
NaHCO3(1mg/ml) 30ml + water to 1L
# ♥Oral
Rehydration Guidlines
; mild dehydration
- 50ml/Kg of ORS within 4hr
; moderate dehydration
- 100ml/Kg of ORS over 6hrs
; 동시에breast feeding or plain water 공급
; maintenance therapy
- 100ml/ORS/Kg/24hr
- stool volume측정 어려우면 10-15ml ORS/Kg/hr가 적당
# ♥Acute
Diarrhea초기에도 Oral Feeding 유지
이유
; small intestine can absorb various nutrients and up to 60% of food eaten
; better weight gain than NPO group
; fasting reduce ability of small intestine to absorb nutrients
; no physiologic basis for bowel “rest” during acute diarrhea
- 대개 NPO for 48hrs with IV therapy시에는 stool 횟수와 양
oral feeding with gastric distension & vomiting(-)
7-8일이면 usual dietary intake 가능
- antibiotics Ix
1.cholera
2.shigella
3.amebic dysentery
4.acute giardiasis
opiate (intestinal paralysis )--+infantile diarrhea에 별 도움(-)
kaolin,pectin(absorbent) --+
出 2.diarrhea in chronically malnourished children
1)s-Na ,K+ ,Mg (tetany유발)
2)s-protein<3.6g/dl
3)muscle Na+ ,muscle K & Mg
4)EKG;tachycardia,low amplitude,flat or inverted T wave
Cx ; heart failure,lowered cardiac reserve
- dehydration sign과 reduced body water에도 불구하고 chronically malnourished
child에서lower urine osmolarity이유는
1)relative absence of urea to contribute hypertonic fluid in renal papilla
2)low dietary protein intak e tubular conservation of water의 failure
- calory supply(vomiting & gatric ditension없을때)
1)30-40Cal/Kg/24hr,slowly intra-gastric drip
2)50-100Cal/Kg/24hr & 1-2g protein/Kg/24hr in a few days
3)250-300Cal/Kg/24hr for suceeding wks iron & copper보충
- initial parenteral therapy는 hyponatremic dehydration에 준해 solution사용할것
出 * 1-1.5ml of 50% MgSO4 (4.0mEq/mL)1M q 12hr for 1-3days
; severe malnutrition인한 diarrhea로 회복되는 동안 일어는 seizure는 magnesium에 잘 반응
* chronic diarrhea
고려; 1)cow's milk protein allergy
2)specific disacharidase def.(acquired;lactose)
3.congenital alkalosis of G-I origin
congenital defect in chloride transport in small & large bowel
;pyloric stenosis와 비슷하게 치료
4. Pylroric stenosis
특징; 1)되도록 빨리 KCl 투여 (urination하자마자)
2)relatively more Na + K 투여 as chloride salt
+-- 1. large deficit of chloride
+-- 2. some correction of alkalosis as volume is expanded
paradoxic aciduria with alkalosis시 K+ depletion의심
repletion시 potassium amount 증가시킴, 대개 12hr내에 교정
出 * delay operation for at least 36-48hr
: optimal adjustment of body functions
1)adequate fluid Tx
2)stomach decompression
5. fasting and thirsting
* Tx ; isotonic solution +--rapid ECF expansion
+--improve renal function
child,adult는 infant에 비해 given degree of dehydration시 1/3-1/4 water & Na 적게 투여
6. Electrolyte disturbances associated with central nervous system disorders
: 종종 sodium conc. 이상을 초래 (hyponatremia)
1)surgical or traumatic damage of brain,encephalitis,bulbar poliomyelitis,
CVA,4th ventricle tumor,subdural hematoma Na urine loss 多
2)SIADH : neonatal hypoxia, hydrocephalus시 urine Na증가 (20meq/L)
3)acute symptomatic hyponatremia치료
: prompt hypertonic saline과 furosemide
* chronic asymptomatic hyponatremia : water restriction
7. preoperative,intraoperative, and postop. fluids
- 목적;supply carbohydrate to ensure adequate glycogen storage
- vomiting 없는 small infant시 operation 3시간 전까지는 P.O.로
- intestinal obstruction시 high bilirubin발생
- hypoprothrombinemia ; vit.K1 1mg I.M
- over administration of fluid ; most common error
- K+ 주지 말것
1)extensive tissue trauma or anorexia시 intracellular K+ 많은 양이 release
2)shock시 acute renal loss 가 합병되어 hyperkalemia 치료 더욱 어렵다.
- postop시 intake limitation for 24hrs
water intake ;85ml /100Cal
( antidiuretics from trauma or circulatory readjustment)
Isolated Disturbances In Blood Ph And Concentrations Of Electrolytes
Acidosis
(1)respiratory acidosis
Tx;assisted ventilation
(2)metabolic acidosis
:lactic acidosis,glycogen disorder,circulatory insufficiency,hypoxiaEosms sodium lactate가 적절하게 metabolized안될 수 있다. 그러므로 이때에는 sodium bicarbonate
1-2mEq/Kg투여
- 필요한 bicarbonate(mEq);Astrup법
소요량 of bicarbonate= (-BE) x B.W. x0.3
0.5ml/Kg of sodium bicarbonate ; s-HCO3 1 mEq/L
- acidosis로 인한 Sx이 현저할때를 제외하고는 s-bicarbonate level을 15 mEq/L이상으로 올리려고 할 필요없다.
( overcorrecting acidosis가 tetany를 초래)
즉 underlying cause Tx가 필요
Alkalosis
(1)metabolic alkalosis
-경우 ①administration of excess amount of alkali
②loss of H+ ion
③volume contraction with disproportionate loss of Cl-
④severe hypokalemia
-severe alkalotic therpy
Tx;ammonium chloride;/d(0.2-0.3)
a)metabolic alkalosis with volume contraction
urine chloride < 10mM/L
경우;vomiting,gastric suction,congenital chloridic diarrhea,dietary
chloride def,diuretic administration
Tx;volume expansion with K,Cl deficit replace
b)chloride-resistant
urine chloride > 15mM/L
경우;①hyperadrenalism
②Bartter syndrom
③severe K+ depletion
④licorice ingestion
(2)respiratory alkalosis
경우; ①salicylate intoxication
②CNS disease such as, trauma,infection,tumor
③fever or anxiet
④CHF
⑤hepatic insufficiency
⑥gram-nagative septisemia
Tx;underlying cause
Hyponatremia
1)asymptomatic hyponatremia
Tx;fluid restriction water overload에 의한 경우
-urine Na<10mEq/L경우
①sodium depletion
②nephrotic syndrom
③CHF
④hepatic failure
-urine Na=50mEq/L
①expansion of ECF with water
②renal tubular injury
2)symptomatic hyponatremia
hypertonic saline solution
出 Na mEq required=(Cd-Ca) x 0.- 0.7 x B.W
12mEq/Kg of 3% NaCl(6mEq Na/Kg)는 s-Na 10mEq/L 올린다.
s-Na증가는 5-10mEq/L over 1-4hr로 소량씩
Hypernatremia
brain cell로부터 water shift
subdural,subarachnoid,intracerebral hemorrhage초래
; high mortality, esp, if exceeds 158 mEq/L
# Treatment
; IV fluid consist of glucose in water, potassium acetate, calcium
;
*peritoneal dialysis
Hypokalemia
경우 1)primary hyperaldosteronism
2)Bartter syndrome
3)congenital alkalosis of G-I origin;KCl loss
4)thiazide & loop diuretics(lasix)
severe hypokalemia시
①skeletal muscle weakness
②peristalsis
③ileus
④inability to the kidney to concentrate urine
# Treatment
;
*up to 3mEq/kg/24hr
; in bartter syndrome
- 10 mEq/kg/24hr
- indomethacin
; in Gitelman’s syndrome
- MgCl2
Hyperkalemia
# ♥K+ > 6.5meq/L시 Tx.
Promptly
①all K+ intake discontinue
②sodium bicarbonate IV rapidly
; 1-3mEq/Kg over 5-10min
③glucose & insulin
; 0.5 -1g of glucose/Kg with 1 unit crystalline insulin/g of glucose over 2hr period
④IV calcium gluconate
; 0.5ml of 10% solution/Kg over 2-4min
;potassium의 cardiac toxicity에 맞서기 위함
⑤*kayexalate
1g/Kg/24hr p.o or enema every 6-12hr
⑥hemodialysis,peritoneal dialysis
Hypomagnesemia
<1.3mEq/L시 latent or manifest tetany
경우 ①chronic diarrhea or vomiting
②sprue
③celiac disease
④prolonged parenteral fluid Tx
⑤hyperaldosteronism
⑥infantile tetany(transient hypoparathyroidism)
Tx; ① 0.1ml of 24% solution MgSO4(0.2mEq/Kg, q 6hrs)
②3mEq/L Mg to maintenance fluid
Hypermagnesemia
; >10mEq/L
①drowsiness
②coma
③abolished DTR
④respiratory depression
⑤atrioventricular or intraventricular conduction defect
# 원인
; ARF, addison disease, iatrogenic(using Mg in treating toxemia of pregnancy)
# Treatment
;
*IV calcium gluconate
56.9 Tetany
; state of hyperexcitability of the CNS & PNS
; ★경우
- decrease of H+
- decrease of Ca++
- decrease of Mg++
; Ca++ in normal albumin
- 40-50% of total calcium
- 4.0-5.2mg/dl
-
*albumin 1g/dl : calcium 0.8mg/dl 의
비율로 감소
- tetany develop at Ca++ < 3.0mg/dl (total Ca<7.0mg/dl)
/
*almost alway develop at Ca++
< 2.5mg/dl (total Ca<5mg/dl)
; normal serum Mg
- 1.6-2.6 mg/dl(75%는 Mg++)
- *tetany develop at Mg++ < 1.0mg/dl
Manifest Tetany
; carpopedal spasm - wrist & ankle M. spasm
; laryngospasm
- vocal cord spasm
--> inspirtory obstruction
--> high pitched insp. crow
; paresthesia
- numbness & tingling sense of hand & feet
; convulsion
-
*infant에서 nervous system hyperexcitability의
유일한 증거
Latent Tetany
; induction of manefest tetany by ischemia, mechanical, electrical stimultion
; Trouseau Sign
- B.P cuff를 arm에 대고 systolic B.P 상방에서 3분간 inflate시켜 동맥순환을 못하게 하여 carpopedal spasm 유발
; chvostek sign
- external auditory meatus의 전방을 tapping하여 facial n.를 자극하여 upper lip or entire mouth의 twitch와 orbicularis oris contraction을 유발
; peroneal sign
- fibular head를 tapping시 foot의 dorsiflexion & foot의 abduction 유발
; Erb sign
- positive response of motor nerve to electrical stimulation less than normal state
; prolonged Q-T interval
Alkalotic Tetany
; very rare
; be induced through spontaneous overventilation,producing resp. alkalosis
; Treatment
- rebreath into a bag or baloon to increase PCO2
Hypocalcemic Tetany
Disorders Of Parathyroid Function
# neonatal hypocalcemia
(=transient physiologic hypoparathyroidism of the newborn)
;
*▲common
;
♥기전
- physilogically inactive parathyroid gland failing to respond to low Ca++ concentrattion
- partial refratoriness of target cell to PTH in newborn
-
*excessive thyrocalcitonin
secretion
/
*major factor of persistent
hypocalcemia in pemature infants
- inadequate intake of vitamin D & little exposure to sunshine
-
*physiologic mild maternal
hyperparathyroidism
/ hypercalcemia of fetus
-->
*inhibition of the fetal
parathyroid
Early Hypocalcemia
; during first 72hr, before significant oral intake
;
★High Risk Group
- LBW with IUGR
- infants born of diabetic mother
- infants of prolonged difficult labor
- infant of mother with adenoma
- infant with familial hypoparathyroidism
; premature infant with RDS
-
*extremely high incidence
- 이유
/ low calcium intake, increased endogenous phosphate from catabolism
/ receive sodium bicarbonate
; asymptomatic hypocalcemia of premature infant
- usually spontaneous recovery
-
*oral calcium gluconate으로
치료를 한다.
Late Hypocalcemia
; during first 5-10days
; high phosphate milk
-
*▲common cause
; 기전
- high phosphate food(e.g. cow's milk) intake & relatively high tubular reabsorption & low GFR
--> elevated serum phosphate
--> decrease calcium level through depositon of calcium phosphate
--> poor response of infant parathyroid gland
--> progressive hypocalcemia
Clinical Manifestation
;
*convulsion
- ▲important
; carpopedal spasm - rare, chvostek sign - common
- infant에서는 no sing of tetany
; laryngospasm
;
*irritability, muscular twitching,
tremor, jitteriness
- common in newborn
; nonspecific symptoms
- poor feeding, vomiting, lethargy
; prolonged Q-T
Diagnosis
; s-Ca < 7mg/dl
- < 7.5mg/dl : suggestive
Treatment
# convulsing infant
; 10% ca-gluconate 2ml/kg slowly I.V
; repeat bolus at 6-8hr interval or continous infusion (50-75mg elemental Ca/Kg/24hr)
# oral calcium gluconate or lactate
; calcium latate를 선호
;
*1-3일후에야 normal calcium level
; 최소한 1주일 투여
; calcium lactate powder (13%) : 100mgCa++/770mg
-
*Ca : P=4 : 1
; normal serum calcium되면
- reduced calcium supplement in steps
; in most infants, normal calcium homeostasis & normal parathyroid responsiness in 1-2wks
; 호전이 안되면
- congenital hypoparathyroidism, vit.D def., absorptive or metabolic abnormalities of vit.D 의심
Congenital Absence Of The Parathyroids
DiGeorge synd. +--ⅰ)aplasia of thymus
| ⅱ)abnormalities of great vessels of heart
+--ⅲ)isolated parathyroid aplasia
Tx; ⅰ)dihydrotachysterol 0.05-0.1mg/day
ⅱ)1,25(OH)2vitD3 0.25-0.5 ug/day
Hypocalcemia & Tetany Caused By Vit.D Def. Or
Abnormalities Of Vit.D Metabolism
-onset;ⅰ)vit.D def. mother가 breast feed시
ⅱ)failure of normal vvit.D metabolism
neonatal hepatitis,cytomegalic inclusion d's,biliary atresia
ⅲ)vit.D-dependent (pseudodeficient) rickets ; kidney에서 1-hydroxylation 장애
ⅳ)steatorrhea due to pancreatic lipase def. or intrinsic intestinal mucosal disorder
ⅴ)large combined anticonvulsant;phenobarbital, diphenylhydantoin,primidone
Hypomagnesemic Tetany
① transient physiologic hypoparathyroidism of newborn
: hypomagnesemia, hypocalcemia, hyperphosphatemia : Tx. Mg 공급
② prolonged Mg-free parenteral nutrition
③ renal tubular dysfunction or nephropathy(aminoglycoside, cisplatin사용)
④ intestinal malabsorption