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1、2014歐洲低鈉血癥診療指南解讀山東大學(xué)附屬千佛山醫(yī)院呼吸科張劭夫歐洲危重病學(xué)會(huì)(ESICM),歐洲內(nèi)分泌學(xué)會(huì)(ESE)歐洲腎臟最佳臨床實(shí)踐(EuropeanRenalBestPracticeERBP)為代表的歐洲腎臟病協(xié)會(huì)和歐洲透析與移植協(xié)會(huì)(ERA-EDTA)共同制定了歐洲低鈉血癥臨床診療指南低鈉血癥Hyponatraemia,definedasaserumsodiumconcentration<135mmol/l,isthemostcommondisorderofbodyfluidandelectrolytebalanceencounteredincl
2、inicalpractice.Itoccursinupto30%ofhospitalisedpatientsandcanleadtoawidespectrumofclinicalsymptoms,fromsubtletosevereorevenlifethreatening(10,11)定義:血清鈉低于135mmol/L臨床最常見(jiàn)的水鹽失衡,其發(fā)生率約占住院患者的30%癥狀不一,從輕微到致命Inmostcases,hyponatraemiareflectsloweffectiveosmolalityorhypotonicity,whichcausessympt
3、omsofcellularoedema.However,hyponatraemiamayalso(rarely)occurwithisotonicorhypertonicserumiftheserumcontainsmanyadditionalosmoles,suchasglucoseormannitol.Therefore,wediscussnotonlyhowhypo-osmolarbutalsohowisosmolarandhyperosmolarstatesdevelop.絕大多數(shù)情況下,低鈉血癥反映了低有效滲透壓狀態(tài),主要引起細(xì)胞水腫然而,如果血清含
4、有其他滲透性物質(zhì)如葡萄糖和甘露醇,則低鈉血癥在個(gè)別情況下也可發(fā)生于等滲或高滲情況。因此,低鈉血癥不僅見(jiàn)于低滲,也見(jiàn)于等滲和高滲的情況。Severesymptomsofhyponatraemiaarecausedbybrainoedemaandincreasedintracranialpressure.Braincellsstarttoswellwhenwatermovesfromtheextracellulartotheintracellularcompartmentbecauseofadifferenceineffectiveosmolalitybetwee
5、nbrainandplasma.patientswithchronichyponatraemiaandnoapparentsymptomscanhavesubtleclinicalabnormalitieswhenanalysedinmoredetail.Suchabnormalitiesincludegaitdisturbances,falls,concentrationandcognitivedeficitspatientswithchronichyponatraemiamoreoftenhaveosteoporosisandmorefrequentlys
6、ustainbonefracturesthannormonatraemicpersons低鈉血癥嚴(yán)重癥狀為腦水腫。低滲的血漿向高滲的腦細(xì)胞進(jìn)行水轉(zhuǎn)移,導(dǎo)致細(xì)胞腫脹慢性和無(wú)明顯癥狀的低鈉血癥患者,可有如下輕微癥狀:步態(tài)不穩(wěn),跌倒,注意力不集中和認(rèn)知障礙慢性低鈉血癥患者更易發(fā)生骨質(zhì)疏松和骨折圖示:大腦對(duì)低鈉血癥的適應(yīng)過(guò)程:1即可反應(yīng)2快速適應(yīng)3慢適應(yīng)調(diào)節(jié)4不適當(dāng)糾正(快速升高滲透壓)5適當(dāng)糾正(緩慢提高滲透壓)6.低鈉血癥診斷Diagnosisofhyponatraemia6.1.分類:Classificationofhyponatraemia根據(jù)血鈉濃度分類:6
7、111:輕度(mild)低鈉血癥:血鈉:130~135mmol/l6112:中度(moderate)低鈉血癥:血鈉:125~129mmol/l6113:重度(profound)低鈉血癥:血鈉:<125mmol/l依據(jù)發(fā)生時(shí)間分類:6121:急性低鈉血癥<48h6122:慢性低鈉血癥≥48h6123如果不能對(duì)其分類,除非有臨床或回顧性反證(表8),則應(yīng)認(rèn)為系慢性低鈉血癥為何以48小時(shí)為界限界定急慢性低鈉血癥?Thisusuallyoccurswhenhyponatraemiadevelopsrapidly,andthebrainhashadtoolittleti
8、metoadapttoitshypot