Transcript 산염기_전해질_한만길

혈액가스 분석의 이해
Man-Gil Han, DVM
Section of Veterinary Internal Medicine
Royal Animal Medical Center
용어 정리
 Acidosis (산증)
 몸속의 체액이 산성화 되려는 경향. 몸속에 산이 축적되거
나 알칼리의 감소가 생길 때에 일어난다.
 Acidemia (산혈증)
 혈액의 pH 상태. pH < 7.35.
 Alkalosis (알칼리증)
 체내에 알칼리가 축적되거나 체내의 산이 소실됨으로써 일
어나는 병적상태.
 혈중의 수소이온의 농도가 저하하고 혈액의 pH가 정상치
(7.34~7.45)이상이 된 상태
 Alkalemia (알칼리혈증)
 혈액의 pH 상태. pH > 7.45.
한만길 DVM
Royal Animal Medical Center
 산증 (Acidosis)
 대사성 산증 (Metabolic acidosis)
분비성 (Secretional)
적정성 (Titrational)
 호흡성 산증 (Respiratory acidosis)
 알칼리증 (Alkalosis)
 대사성 알칼리증 (Metabolic alkalosis)
 호흡성 알칼리증 (Respiratory alkalosis)
한만길 DVM
Royal Animal Medical Center
혈액가스 분석기
 Easy to use handheld units:
 I-STAT.
 IRMA SL.
IRMA SL
I-STAT
 Sophisticated bench top units:
 Bayer rapidpoint405.
한만길 DVM
Bayer Rapid
Royal Animal Medical Center
Osmetech OPTI CCA blood gas analyzer
한만길 DVM
Royal Animal Medical Center
Sampling (artery)
 Heparinized syringe with 23~26G needle.
 1 or 3 ml syringe
 Collecting sites:
 Dorsal pedal artery.
 Femoral artery.
 Lingual artery.
 Methods:
 45~60 angle to palpated pulse.
 Expel air and cap.
 Analyze immediately or put on ice and run within 1~2
hours.
한만길 DVM
Royal Animal Medical Center
혈액가스분석의 해석
 Item of Blood gas
 pH
 PCO2
 PO2
 BE (base excess)
 tCO2
 HCO3-
▶Na
▶K
▶Cl or
▶Hb
▶SO2
▶HCT
Ca++
 Pulmonary function = PaCO2, PaO2
 Acid-base status = pH, PCO2, HCO3한만길 DVM
Royal Animal Medical Center
혈액가스분석이 지시되는 상황
 To assess Oxygenation
Arterial Sample
 To assess Ventilation
 To assess Acid-Base balance
Arterial or Venous Sample
한만길 DVM
Royal Animal Medical Center
혈액가스분석이 지시되는 상황
 CPCR
 호흡곤란 환자
 폐수종, 폐출혈, ARDS
 질소혈증(Azotemia)이 있는 환자
 ARF, CRF
 Addison’s syndrome
 전해질 이상이 있는 환자
한만길 DVM
Royal Animal Medical Center
Normal values at FiO2 of 0.21 (artery)
Normal values
Acidosis
Artery
Vein
7.36 ~ 7.44
7.32 ~ 7.40
PCO2 (mmHg)
36 ~ 40
40 ~ 45
PO2 (mmHg)
90~100
40 ~ 50
±4
±4
20 ~ 24
20 ~ 24
pH
BE
Alkalosis
< 7.3
> 7.5
> 44
< 32
< 18
> 26
tCO2
HCO3 (mEq/L)
한만길 DVM
Royal Animal Medical Center
Normal values at FiO2 of 0.21
Royal AMC
Normal values
Artery
Vein
7.35 ~ 7.45
7.35 ~ 7.45
PCO2 (mmHg)
31 ~ 43
35 ~ 45
PO2 (mmHg)
83~103
47 ~ 56
±3
±4
tCO2
12 ~ 28
12 ~ 28
HCO3 (mEq/L)
19 ~ 26
21 ~ 24
pH
BE
한만길 DVM
Royal Animal Medical Center
Normal Arterial Blood Gas Values for Dogs in Fort Collins, CO
(1500 M: barometric pressure = 640 mm Hg)
pH
PaCO2
PaO2
HCO3
BE
Saturation
한만길 DVM
Mean
7.386
31.57
79.68
18.22
-4.55
92.74
SD
0.030
3.60
6.44
2.16
2.14
1.43
Royal Animal Medical Center
 Venous blood gases to assess the acid-base
status in dogs:
 Arterial pH = 0.039 + (0.961 X venous pH)
 Arterial pCO2 = 7.735 + (0.572 X venous pCO2)
 Arterial HCO3 = 0.538 + (0.845 X venous HCO3)
(Wingfield WE, Van Pelt DR, Hackett TB: Usefulness of venous blood gases in estimating
acid-base status of the seriously ill dog. J Vet Emer Crit Care 4:23-27, 1994.)
한만길 DVM
Royal Animal Medical Center
혈액가스 결과 해석 순서
1. 혈액 sample이 동맥혈액인지, or 정맥혈액인지 ?
2. Acid/Base status 평가 (pH, PCO2, HCO3-)?
3. Ventilation 평가 (PaCO2) ?
4. Oxygenation 평가 (PaO2) ?
5. Anion gap (AG) 평가 ?
한만길 DVM
Royal Animal Medical Center
1. 혈액 sample이 동맥혈액인지, or 정맥혈액인지 ?
 SO2 (saturation)
 If saturation >88%; Arterial
 If saturation <88%; mixed, venous, pulmonary dz, etc.
 채혈부위
 동맥: femoral artery, pedal artery.
 정맥: jugular vein.
한만길 DVM
Royal Animal Medical Center
2. Acid/Base status 평가 (pH, PCO2, HCO3-)?
 pH ⇒ Normal, Acidosis, or Alkalosis.
 PCO2 ⇒ Normal or Abnormal (↑산증, ↓알칼리증)
호흡성 (respiratory)
 HCO3- ⇒ Normal or Abnormal (↓산증, ↑알칼리증)
대사성 (metabolic)
 호흡성인지, 대사성인지 판단.
 보상성이 있는지 평가.
한만길 DVM
Royal Animal Medical Center
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
CO2 + H2O ⇔ H2CO3 ⇔ H+ + HCO3Respiratory
Acidosis
Alkalosis
한만길 DVM
Metabolic
pH < 7.3
pH
< 7.3
PaCO2 > 44
HCO3
HCO3: 보상성으로 증가
PaCO2: 보상성으로 감소
pH > 7.5
pH > 7.5
PaCO2 < 32
HCO3 > 26
HCO3: 보상성으로 감소
PaCO2: 보상성으로 증가
< 18
Royal Animal Medical Center
CO2 + H2O ⇔ H2CO3 ⇔ H+ + HCO3분
류
pH
PCO2
HCO3-
< 7.3
> 44
증가
(보상성)
> 7.5
< 32
감소
(보상성)
산증
(Acidosis)
< 7.3
감소
(보상성)
< 18
알칼리증
(Alkalosis)
> 7.5
증가
(보상성)
> 26
산증
(Acidosis)
호흡성
(Respiratory) 알칼리증
(Alkalosis)
대사성
(Metabolic)
한만길 DVM
Royal Animal Medical Center
Respiratory Acid/Base Status
 호흡성 산증(Respiratory acidosis)
 ↑ CO2
⇒ pH <7.35, PCO2 >40 mmHg
 Hypoventilation (저환기)
 CNS dz,
 Respiratory muscle weakness,
 Anesthesia or sedation,
 or Primary respiratory disease.
한만길 DVM
Royal Animal Medical Center
Respiratory Acid/Base Status
 호흡성 알칼리증(Respiratory alkalosis)
 ↓ CO2
⇒ pH >7.45, PCO2 <30 mmHg
 과호흡 (Hyperventilation)
 Panting, anxiety,
 Pain, heat stroke.
 대사성 산증의 보상작용으로…
한만길 DVM
Royal Animal Medical Center
Metabolic Acid/Base Status
 대사성 산증(Metabolic acidosis)
 ↓ HCO3
⇒ pH <7.35, HCO3 <18 mEq/L
 증가된 H+을 중화시키기 위해 HCO3의 요구량 증가.
 응급환자에서 가장 흔한 산-염기 불균형 장애.
 Renal failure, DKA, hypoadrenocorticism,
 Ethylene glycol toxicity,
 and Circulatory shock.
한만길 DVM
Royal Animal Medical Center
Metabolic Acid/Base Status
 대사성 알칼리증(Metabolic alkalosis)
 ↑ HCO3
⇒ pH >7.45, HCO3 >24 mEq/L
 due to the loss of upper GI fluid:
upper GI obstruction, vomiting
위액 손실 (HCl 손실)
 In response to diuretic therapy.
한만길 DVM
Royal Animal Medical Center
Condition
Primary
disturbance
Compensatory
factor
대사성 산증
↓ HCO3
↓ PaCO2
대사성 알칼리증
↑ HCO3
↑ PaCO2
호흡성 산증
↑ PaCO2
↑ HCO3
호흡성 알칼리증
↓ PaCO2
↓HCO3
한만길 DVM
Royal Animal Medical Center
보상성에 대한 평가
Disturbance
Clinical guideline for Compensation
Metabolic Acidosis
↓ 1 mEq/L in HCO3 ⇒ ↓ 0.7 mmHg in PCO2
Metabolic Alkalosis
↑ 1 mEq/L in HCO3 ⇒ ↑ 0.7 mmHg in PCO2
Respiratory Acidosis
Acute
Chronic
↑ 1 mmHg in PCO2 ⇒ ↑ 0.15 mEq/L in HCO3
↑ 1 mmHg in PCO2 ⇒ ↑ 0.35 mEq/L in HCO3
Respiratory Alkalsosis
Acute
↓ 1 mmHg in PCO2 ⇒ ↓ 0.25 mEq/L in HCO3
Chronic
↓ 1 mmHg in PCO2 ⇒ ↓ 0.55 mEq/L in HCO3
한만길 DVM
Royal Animal Medical Center
예
제
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
 pH=7.28, PaCO2=33mmHg, HCO3=14 mEq/L
한만길 DVM
Royal Animal Medical Center
Examples
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
 pH=7.28, PaCO2=33mmHg, HCO3=14 mEq/L
 Metabolic acidosis
 Mixed Acid-base disturbance if not compensated.
 Metabolic acidosis & respiratory alkalosis
 예상 PaCO2
= [38 – 0.7 × ΔHCO3] ± 2
= [38 – 0.7 × (22 – 14)] ± 2
= 32.4 ± 2
(30.4 ~ 34.4)
한만길 DVM
Royal Animal Medical Center
3. Ventilation 평가 (PaCO2) ?
 Hyperventilation ?
↓ PaCO2
 Hypoventilation ?
↑ PaCO2
 Normal ventilation ?
한만길 DVM
Royal Animal Medical Center
4. Oxygenation 평가 (A-a gradient) ?
 대기(room air)중에서 호흡하고 있을 때,
Alveolar-arterial (A-a) gradient
= PAO2 – PaO2
 산소 공급을 받고 있는 경우,
PaO2/FiO2 ratio
한만길 DVM
Royal Animal Medical Center
한만길 DVM
Royal Animal Medical Center
4. Oxygenation 평가 (A-a gradient) ?
 대기(room air)중에서 호흡하고 있을 때, (760 mmHg)
Alveolar-arterial (A-a) gradient
= PAO2 – PaO2
= [ (Barometric pressure – 47)×0.21 – PaCO2/0.8 ] – PaO2
= [ 150 – PaCO2/0.8 ] – PaO2
In dogs
A–a
Normal
0 – 10
Normal ?
11 – 20
ARDS ?
21 – 30
ARDS
한만길 DVM
> 30
Royal Animal Medical Center
산소공급을 받고 있는 경우
 PaO2/FiO2 ratio (P/F ratio)
 Useful in assessing severity of lung injury or disease
in patient receiving supplemental Oxygen
 정상소형견이 공기를 흡입할 때, PaO2는 100mmHg;
PaO2/FiO2 = 100 / 0.21 = 500
< 200 = ARDS (acute respiratory distress syndrome)
< 300 = Acute lung injury (ALI)
> 400 = Normal lung
한만길 DVM
Royal Animal Medical Center
Assessment of Pulmonary Function
 Expected PaO2 = 4.5~5.0 × FiO2
 Room air (FiO2 = 21%), PaO2 = 94.5~105
 Nasal O2 (FiO2 = 40%), PaO2 = 180~200
 Anesthesia (FiO2 = 100%), PaO2 = 450~500
한만길 DVM
Royal Animal Medical Center
Administration
Technique
Recommended Oxygen
Flow Rate (L/min)
Mean FiO
(%)
Face mask, Loose fit
2~5
40~50
Flow-by
2~5
25~40
Elization collar canopy
1~5
30~50
Nasal catheter (unilateral)
≤2
40~50
Nasal catheter (bilateral)
≤ 2 for each
40~50
1
40~60
As needed to maitain FiO2
at 40~60%
21~60
1~2
100
Intratracheal catheter
Oxygen cage
Mechanical ventilation
(Intubation)
한만길 DVM
Royal Animal Medical Center
5. Anion gap 평가
 Anion gap = (Na+ + K+) – (HCO3- + Cl-)
 Normal range
In dogs; 12 ~ 24 mEq/L
In cats; 13 ~ 27 mEq/L
한만길 DVM
Royal Animal Medical Center
한만길 DVM
Royal Animal Medical Center
Case #1
한만길 DVM
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
 5-year-old, FS, Golden Retriever
 2-day history of vomiting
 Mild dehydration
 Aterial blood gas
 pH
7.548
 PaCO2
57.6
 PaO2
58.9
Artery
HCO3 50.5
BE
+25.5
Royal Animal Medical Center
pH 7.548
BE +25.5
HCO3 50.5 PaCO2
PaO2 58.9
57.6
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
pH 7.548
BE +25.5
HCO3 50.5
PaO2 58.9
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
PaCO2 57.6
1. 동맥혈 채혈
2. pH 7.548
HCO3 50.5
 예상 보상작용
⇒ Alkalosis
⇒ Metabolic
 ∆HCO3 x 0.7 = ↑ in PaCO2
 (50.5-22)x0.7 ≒ 20±2
 예상 PaCO2 = 38+20 = 58±2
(56~60)
 측정 PaCO2 = 57.6 (보상)
Simple Metabolic Alkalosis
Royal Animal Medical Center
pH 7.548
BE +25.5
HCO3 50.5
PaO2 58.9
1. Arterial or
Venous ?
2. Acid/Base
status ?
PaCO2
57.6
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
3. PaCO2 57.6
 Hypoventilation
 Hypercarbia
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
pH 7.548
BE +25.5
HCO3 50.5
PaO2 58.9
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
PaCO2
57.6
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
4. PaO2 58.9 ⇒ Hypoxemia
 PaCO2 가 1 mmHg 증가할 때마다
PaO2는 1 mmHg 감소.
 예상 PaO2 값 = 95 – ΔPaCO2
= 95 – (57.6 – 38)
= 95 –19.6 = 75.4 mmHg.
 환자의 PaO2값은 너무 낮음.
 A-a gradient = PAO2 - PaO2 =
[150 – (57.6/0.8)] – 58.9 = 78–58.9
= 19.1 mmHg
Royal Animal Medical Center
Case #1
pH 7.548
HCO3 50.5
PaCO2 57.6
PaO2 58.9
 감별진단 목록은?
 기관 폐쇄성 질환:
Tracheal collapse
Obstruction in trachea
 원발성 폐질환:
Pneumonia (bacterial, viral, etc)
Aspiration pneumonia
한만길 DVM
Royal Animal Medical Center
Case #1
pH 7.548
HCO3 50.5
PaCO2 57.6
PaO2 58.9
 폐 실질 질환이 의심됨.
 PaO2 58.9
PaCO2 57.6
 A-a gradient:
= PAO2-PaO2
= [150 – (57.6/0.8)] – 58.9 = 78–58.9
= 19.1 mmHg
In dogs
 흉부방사선 촬영이 필요함.
Normal
0 – 10
Normal ?
11 – 20
ARDS ?
21 – 30
ARDS
한만길 DVM
A–a
> 30
Royal Animal Medical Center
Case #1
Aspiration pneumonia
한만길 DVM
Royal Animal Medical Center
Case #2
한만길 DVM
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
 10-year-old, MC, Pug
 History of mitral valve disease.
 Medication: Furosemide, Enalapril.
 발치를 위해 마취한 상태.
 Aterial blood gas
 pH
7.231
 PaCO2 34.6
 PaO2
482.2
Artery
HCO3 14.6
BE
-10.0
Royal Animal Medical Center
pH 7.231
BE -10.0
HCO3 14.6 PaCO2 34.6
PaO2 482.2
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
pH 7.231
BE -10.0
HCO3 14.6 PaCO2 34.6
PaO2 482.2
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
1. 동맥혈 채혈
2. pH 7.231
Acidosis
HCO3 14.6
Metabolic
 예상 보상작용
 ∆HCO3 x 0.7 = ↓ in PaCO2
 (22-14.6)x0.7 = 5.18±2
 예상 PaCO2 = 38-5.18=32.8±2
 측정 PaCO2 = 34.6
(보상)
Simple Metabolic Acidosis
한만길 DVM
Royal Animal Medical Center
pH 7.231
BE -10.0
HCO3 14.6 PaCO2 34.6
PaO2 482.2
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
3. PaCO2 34.6
 Mild hyperventilation.
4. PaO2 482.2; FiO2 = 100%
 예상 PaO2
= FiO2 x 5 = 500 mmHg.
 A-a gradient = PaO2/FiO2
= 482.2 / 1.0 = 482.2 (Normal)
5. Anion gap ?
Mild hyperentilation & Oxygenation
한만길 DVM
Royal Animal Medical Center
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
Case #3
 13-year-old, FS, German Shepherd
 Stuporous.
 Anuric acute renal failure.
 Venous blood gas:
 pH 6.900
 PvCO2 36.2
 PvO2 52.2
한만길 DVM
HCO3 5.9
BE -20.0
Royal Animal Medical Center
pH 6.900
BE -20.0
HCO3 5.9 PvCO2 36.2
PvO2 52.2
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
pH 6.900
BE -20.0
HCO3 5.9 PvCO2 36.2
PvO2 52.2
1. 정맥혈 채혈
1. Arterial or
Venous ?
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
2. pH 6.900
⇒ Acidosis
HCO3 5.9
⇒ Metabolic
 예상되는 보상작용
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
Artery
 ∆HCO3 x 0.7 = ↓ in PvCO2
 (22-5.9)x0.7 = 11.27±2.5
 예상 PvCO2 = 42.5-11.27=31.23±2.5
 측정 PvCO2 = 36.2
 비보상성 호흡성 알칼리증
Mixed Acid/Base Disorder
한만길 DVM
Royal Animal Medical Center
pH 6.900
BE -20.0
HCO3 5.9 PvCO2 36.2
PvO2 52.2
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
3. 정맥혈이기 때문에
 Ventilation과 Oxygenation 평가 불가
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
Case #4
 5-year-old, FS, Samoyed.
 History:
Diabetes mellitus
Vomiting, anorexia, and weakness
 Medication: insulin.
 Laboratory values:
Hyperglycemia (562 mg/dl), ketonuria,
Na 130; K 3.4; Cl 96
 Arterial blood gas:
 pH
7.17
 PaCO2 20.0
 PaO2
118
한만길 DVM
HCO3 7.0
BE
-28.0
Royal Animal Medical Center
pH 7.17
BE -28.0
HCO3 7.0
PaO2 118
PaCO2 20.0
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
Royal Animal Medical Center
pH 7.17
BE -28.0
HCO3 7.0
PaO2 118
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
PaCO2 20.0
1. 동맥혈 채혈
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
2. pH 7.17
⇒ Acidosis
HCO3 7.0
⇒ Metabolic
 예상 보상작용
∆HCO3 x 0.7 = ↓ in PaCO2
 (22-7) x 0.7 = 10.5±2
Expected PaCO2 = 38-10.5=27.5±2
PaCO2 = 20
severe Respiratory alkalosis




Mixed Acid/Base Disorder
한만길 DVM
Royal Animal Medical Center
pH 7.17
BE -28.0
HCO3 7.0
PaO2 118
1. Arterial or
Venous ?
2. Acid/Base
status ?
3. Ventilation ?
4. Oxygenation ?
5. Anion gap ?
한만길 DVM
PaCO2 20.0
3. PaCO2 20.0
Artery
Vein
7.36~7.44
7.32~7.40
PCO2
36~40
40~45
PO2
90~100
40~50
HCO3
20~24
20~24
pH
 Low ⇒ Hyperventilation.
4. PaO2 118;
FiO2 = 21%
 Expected PaO2
= FiO2 x 5 = 105 mmHg.
 A-a gradient
= (150 – 20/0.8) – 118 = 7 (normal)
Hyperventilation & Normal Oxygenation
Royal Animal Medical Center
Stepwise Blood gas Interpretation
1. pH 평가
2. PCO2 평가
3. HCO3 평가
4. PCO2와 HCO3의 보상성 평가
5. PaO2 평가: hypoxemic?
6. Ventilation 평가 (PaCO2)
한만길 DVM
Royal Animal Medical Center
전해질의 이상
한 만 길, DVM
Royal Animal Medical Center
Electrolytes
– Na
–K
– Cl
– Ca
–P
– Mg
한만길 DVM
Royal Animal Medical Center
Osmoles
 Osmolality (삼투질농도)
 Number of osmotically active particles per kg of solvent
 Osmolarity (삼투압농도)
 Number of osmotically active particles per L of solvent
 Measured osmolality
 Dog = 290~310 mOsm/kg, Cat = 290~330 mOsm/kg
 Urine = Highly variable, 150~2500 mOsm/kg
 Calculated plasma osmolality
= 2 x (Na + K) + Glucose/18 + BUN/2.8
한만길 DVM
Royal Animal Medical Center
Tonicity (장력)
 Ability of a solution to initiate water movement
 Depends on impermeant solute (Na, glucose)
 Not dependent upon permeant solute (urea, ethanol)
 can estimate as Posm – {BUN/2.8}
 Patients can be hyperosmolar but hypotonic.
 Example) Na = 125, BUN = 280, glucose = 90
P osm = 355 mOsm/kg
Tonicity = 255 mOsm/kg
한만길 DVM
Royal Animal Medical Center
Anion Gap (AG)
 AG = ( Na + K ) – ( HCO3 + Cl )
 항상 양(positive) 값을 가짐.
 Unmeasured anion의 존재를 반영
건강한 상태에서,
 Albumin
 Sulfates, phosphates, lactates
 Some globulins.
 AG의 증가
 Unmeasured anions의 증가를 의미함.
한만길 DVM
Royal Animal Medical Center
Unmeasured anion (질병상태)
 내인성 음이온 (3)
 Uremic acid (sulfates, phosphates, urates)
 Ketoacids (β-hydroxybutyrate, acetone, acetoacetate)
 Lactic acid
 외인성 음이온 (2)
 Ethylene glycol (부동액 중독)
 Salicylates (아스피린 중독)
한만길 DVM
Royal Animal Medical Center
Anion Gap (AG)
 AG의 감소
 저알부민혈증성 알칼리증
알부민: 주요 unmeasured anions
Albumin = weak acid.
치료해야 하는 산염기 질환으로 인지되지는 않음,
저알부민혈증의 정도에 따라 치료유무 결정
 AG의 음값(negative value)
 생리학적으로 발생하지 않음.
 할로겐화물(Br)이 존재할 때 가능.
 Cl이 높게 측정됨. (Br, Cl 함께 측정)
한만길 DVM
Royal Animal Medical Center
전해질 이상
 Na:
Hypernatremia or Hyponatremia
 Cl:
Hyperchloremia or Hypochloremia
 K:
Hyperkalemia or Hypokalemia
 Ca:
Hypercalcemia or Hypocalcemia
 Pi:
Hyperphosphatemia
or Hypophosphatemia
한만길 DVM
Royal Animal Medical Center
Hypernatremia
 Na & plasma osmolality
 water balance
 갈증, arginine vasopressin (ADH), the kidney.
 Hypothalamus
 Osmoreceptor: plasma osmolality (290~310 mOsm/kg in
dogs)
extremely sensitive.
can detect changes as little as 1~2% in osmolality.
갈증 ⇒ AVP분비(posterior pituitary) ⇒ 신장 요농축.
 Baroreceptor: BP
 Baroreceptor (aorta, aortic body, carotid sinus)
 Renin-Angiotensin-Aldosterone system (RAAS)
한만길 DVM
Royal Animal Medical Center
Hypothalamus
Paraventricular
nucleus
Supraoptic
nucleus
Hypothalamoneurohypophyseal
nerve tracts
(Pars distalis)
(Pars nervosa)
Vasopressin
Oxytocin
한만길 DVM
Royal Animal Medical Center
Hypernatremia
 Na이 160 mEq/L를 초과한 경우
 임상증상
 Na이 170 mEq/L 이상일 때 발현
 CNS signs in origin
Lethargy, weakness,
muscle fasciculation,
ataxia, seizure, stupor, coma
한만길 DVM
Royal Animal Medical Center
Cause of hypernatremia
Water loss
Pure water loss
Hypotonic water loss
Sodium gain
 Iatrogenic
– IV sodium bicarbonate
– IV hypertonic saline
– Sodium phosphate enema
Ingestion
Metabolic:
– hyperaldosteronism.
한만길 DVM
Royal Animal Medical Center
Cause of hypernatremia: Pure water loss
 Diabetes insipidus (central or nephrogenic)
 Insensible water loss:
 panting (fever, heatstroke, exercise, seizure)
 Inadequate water intake
 Lack of access to water
 Hypothalamic disorders
Primary hypodipsia (miniature Schnauzer)
Essential hypernatremia
한만길 DVM
Royal Animal Medical Center
Primary hypodipsia
 갈증(thirst) 기전의 결여로 발생
 AVP 생성과 분비는 정상이지만, 수분 손실이 계속됨.
 시상하부의 손상으로 발생
 종양, 외상, inflammatory brain dz, hydrocephalus
 Congenital defects, idiopathic
 Young miniature Schnauzer, Dalmatian puppy.
 Concentrated urine
 AVP의 생성과 분비가 정상.
 진단
 Hypodipsia, concentrated urine.
 Forced water intake: food with water, or IV (5%DEX)
한만길 DVM
Royal Animal Medical Center
Essential hypernatremia
 Damage to the osmoreceptors in the
hypothalamus.
 But hypothalamic baroreceptors respond to volume
stimuli.
 삼투압 증가시 AVP가 분비되지 않아 등장뇨 or 저장뇨
 혈관내 volume이 증가하면, AVP의 분비로 다뇨와 등장뇨.
 진단
 Hypodipsia, low urine osmolality
 Young Great Dane, adult mixed breed dogs.
한만길 DVM
Royal Animal Medical Center
Cause of hypernatremia: hypotonic water loss
 Renal
 ARF (non-oliguric); or CRF
 Chemical diuretics (furosemide, glucocorticoids)
 Osmotic diuretics (DM, mannitol, urea)
 Postobstructive diuresis
 Extrarenal
 GI: vomiting, diarrhea, small intestinal obstruction
 3rd space loss: peritonitis, pancreatitis.
 Cutaneous: burns
한만길 DVM
Royal Animal Medical Center
한만길 DVM
Royal Animal Medical Center
한만길 DVM
Royal Animal Medical Center
Treatment of hypernatremia
 치료 목적
 Isovolemia 상태로 전환
 대사성 산증 교정 (if severe; pH < 7.15)
NaHCO3 중 Na는 1 mEq/ml.
Tromethamine 으로 대체.
 혈중 Na을 정상(145 mEq/L in dogs)까지 감소
 원발성 질환을 확인하고 치료 (if possible) Mucous memb. color
GI fluid loss 조절, 발열 조절,
CRT
HR
Lactulose or 이뇨제 투여 중지,
BP
Hypercalcemia or Hypokalemia 치료
Pulse quality
 Volume status 평가 (즉, ECF의 상태 평가)
 구분: Hypovolemic, isovolemic, or hypervolemic
한만길 DVM
Royal Animal Medical Center
Treatment of hypernatremia
 치료 목적
 Isovolemia 상태로 전환
 대사성 산증 교정 (if severe; pH < 7.15)
NaHCO3 중 Na는 1 mEq/ml.
Tromethamine 으로 대체.
 혈중 Na을 정상(145 mEq/L in dogs)까지 감소
 원발성 질환을 확인하고 치료 (if possible)
GI fluid loss 조절, 발열 조절,
Lactulose or 이뇨제 투여 중지,
Hypercalcemia or Hypokalemia 치료
 Volume status 평가 (즉, ECF의 상태 평가)
Mucous memb. color
CRT
 구분: Hypovolemic, isovolemic, or hypervolemic
한만길 DVM
HR
BP
Pulse quality
Royal Animal Medical Center
Treatment
 Hypovolemic hypernatremia (hypertonic)
 First, to restore the ECF volume to normal.
Hypovolemia ⇒ Isovolemia (euvolemia)
탈수, 저혈류량이 없으면, isovolemic
hypernatremia처럼 수액처치.
 To reassess electrolytes.
 If hypernatremia, to correct pure water deficits.
 At a fluid rate that avoids significant complications
(cerebral edema: seizure, coma, or death)
한만길 DVM
Royal Animal Medical Center
Treatment
 Hypovolemic hypernatremia (for hypovolemic shock)
 Isotonic fluid bolus. (to the patient)
 11.7% NaCl (Na 2 mEq/ml) 첨가.
 Example:
 Na 194 mEq/L; 0.9% NaCl (Na 154 mEq/L)
 ΔNa = 194 – 154 = 40 mEq (20 ml of 11.7% NaCl)
 1L의 0.9% NaCl에 20ml의 11.7% NaCl 첨가
 or Isotonic crystalloid (0.9% NaCl, Hartmann’s)
 20~30 ml/kg, IV over 15~20 min.
 Reassess vital signs: 점막색깔, CRT, HR, BP, pulse quality.
 If poor perfusion; Hetastarch, bolus of 5ml/kg, over 5~10 min.
 Reassess.
 If inadequate; repeated as needed.
한만길 DVM
Royal Animal Medical Center
Treatment
 Isovolemic hypernatremia
 48~96시간에 걸쳐서 hypernatremia 교정
Because of idiogenic osmoles in brain cells.
Na decrease slowly (0.5~1 mEq/L/hr)
or < 8~12 mEq/L/day over 24-hour perieod.
 Isotonic saline (Never)
 If drinking; orally, or nasogastric tube.
 If unable to drink; IV fluid
0.45% NaCl or 5% dextrose.
Monitor Electrolytes & BP every 2~4 hr (at least
6 hours)
한만길 DVM
Royal Animal Medical Center
Treatment
 Isovolemic hypernatremia
10~12 (mEq/L/24h)을 Δ[Na]p으로 나누면 하루 필요한 수분량(ml/24hr)
한만길 DVM
Royal Animal Medical Center
예 제 (Isovolemic hypernatremia)
Example 1)
10kg, Na 180 mEq/L, 1L of 5% dextrose.
Example 2)
5kg, Na 180 mEq/L, 1L of 0.45% NaCl.
한만길 DVM
Royal Animal Medical Center
예 제 (Isovolemic hypernatremia)
Example 1)
10kg, Na 180 mEq/L, 1L of 5% dextrose.
 Δ[Na]p = (0 – 180) ÷ (0.6×10 + 1) = - 25.7 mEq/L
 1L의 5% dextrose로 Na 25.7 mEq/L 감소
 If decrease Na by 0.5 mEq/L/hr (12 mEq/L/24h),
12 / 25.7 = 0.47 L (470ml) 이 24시간 동안 필요.
20 ml/hr of 5% dextrose for 24 h.
한만길 DVM
Royal Animal Medical Center
예 제 (Isovolemic hypernatremia)
Example 2)
5kg, Na 180 mEq/L, 1L of 0.45% NaCl.
 Δ[Na]p = (77 – 180) ÷ (0.6×5 + 1) = - 25.75 mEq/L
 1L의 0.45% NaCl로 Na 25.75 mEq/L 감소
 If decrease Na by 0.5 mEq/L/hr (12 mEq/L/24h),
12 / 25.75 = 0.47 L (470 ml) 이 24시간 동안 필요.
20 ml/hr of 0.45% NaCl for 24 h.
한만길 DVM
Royal Animal Medical Center
Hypernatremia: Treatment
 Isovolemic hypernatremia
 Estimated ongoing loss should be replaced
according to the type of lose that is occurring.
If CDI (free water loss due to polyuria);
Free water orally, or 5% dextrose IV.
If hypotonic fluid loss (by renal or extrarenal
causes)
Hypotonic fluid therapy.
 Maintenance fluid requirements
isotonic crystalloids
한만길 DVM
Royal Animal Medical Center
Hypernatremia: Treatment
 Hypervolemic hypernatremia
 Free water deficits
5% dextrose if not dehydrated.
Isotonic replacement fluid if hypotension or
dehydration.
 Furosemide 2~4 mg/kg IV q8h.
 Essential hypernatremia & primary
hypodipsia/adipsia.
 5% dextrose, IV by 8~12 mEq/L/day.
한만길 DVM
Royal Animal Medical Center
Hypernatremia: Complications
 Neurologic signs: seizure, coma, or death
 Because of cerebral edema,
 Mannitol and furosemide
Mannitol 0.5~1.0 g/kg, IV over 15~30 min.
Furosemide 1~2 mg/kg, IV
 Diluting fluid should be stopped for several hours.
 Close electrolytes monitoring.
한만길 DVM
Royal Animal Medical Center
Causes of Hyponatremia
 Normal Osmolality
Hyperlipidemia
Hyperproteinemia
 High Osmolality
Hyperglycemia
Mannitol infusion
한만길 DVM
 Low Osmolality
Severe liver disease
CHF
Nephrotic syndrome
Advanced renal failure
Psychogenic polydipsia
Antidiuretics
Myxedema coma
Hypotonic fluid infusion
GI loss: vomiting, diarrhea
3rd space loss
Hypoadrenocorticism
diuretics
Royal Animal Medical Center
Hyponatremia
( < 140 mEq/L in dogs; < 149 mEq/L in cats )
Plasma osmolality ?
2 (Na + K) + Glu/18 + BUN/2.8
Normal Posm
(290~310 mOsm/kg)
한만길 DVM
Low Posm
( < 290 mOsm/kg)
High Posm
( > 310 mOsm/kg)
Royal Animal Medical Center
Hyponatremia
( < 140 mEq/L in dogs; < 149 mEq/L in cats )
Plasma osmolality ?
2 (Na + K) + Glu/18 + BUN/2.8
Normal Posm
(290~310 mOsm/kg)
Low Posm
( < 290 mOsm/kg)
High Posm
( > 310 mOsm/kg)
Hyperlipidemia ? 1 mg/dl of lipid reduces Na by 0.002 mEq/L
Hyperproteinemia ? 1 g/dl of protein (> 8 g/dl) reduces Na by 0.25 mEq/L
Pseudohyponatremia ?
한만길 DVM
Royal Animal Medical Center
Hyponatremia
( < 140 mEq/L in dogs; < 149 mEq/L in cats )
Plasma osmolality ?
2 (Na + K) + Glu/18 + BUN/2.8
Normal Posm
(290~310 mOsm/kg)
Low Posm
( < 290 mOsm/kg)
High Posm
( > 310 mOsm/kg)
Hyperglycemia ?
Mannitol infusion ?
한만길 DVM
Royal Animal Medical Center
Hyponatremia
( < 140 mEq/L in dogs; < 149 mEq/L in cats )
Plasma osmolality ?
2 (Na + K) + Glu/18 + BUN/2.8
Normal Posm
(290~310 mOsm/kg)
한만길 DVM
Low Posm
( < 290 mOsm/kg)
High Posm
( > 310 mOsm/kg)
Royal Animal Medical Center
Low Posm
( < 290 mOsm/kg)
Evaluation of Volume Status
Hypervolemia
Isovolemia
Hypovolemia
Severe liver disease
Congestive heart failure
Nephrotic syndrome
Advanced renal failure
한만길 DVM
Royal Animal Medical Center
Low Posm
( < 290 mOsm/kg)
Evaluation of Volume Status
Hypervolemia
Isovolemia
Hypovolemia
Psychogenic polydipsia
SIADH
Antidiuretic drugs (vasopressin)
Myxedema coma
Hypotonic fluids
SIADH: syndrome of inappropriate ADH
한만길 DVM
Royal Animal Medical Center
Low Posm
( < 290 mOsm/kg)
Evaluation of Volume Status
Hypervolemia
한만길 DVM
Isovolemia
Hypovolemia
Extra-renal
Renal
GI loss:
Vomiting/diarrhea
3rd space loss
Pancreatitis
Peritonitis
Pleural effesion
uroabdomen
Hypoadrenocorticism
Diuretic therapy
Royal Animal Medical Center
Clinical signs of hyponatremia
 Deaths & severe complications
 In human; acute decrease to < 120 mEq/L or ↓0.5
mEq/L/hr
 Cerebral edema, water intoxication.
 NO clinical signs in chronic disorders.
 Acute water intoxication
 Early signs: mild lethargy, nausea, slight weight gain.
 More severe signs:
vomiting, coma, marked increase in BW.
Pulmonary & brain edema ⇒ death
Weakness, incoordination, seizure
한만길 DVM
Royal Animal Medical Center
Treatment of hyponatremia
 Crystalloids fluids
 Lactated Ringer’s solution, 0.9% saline
 Na increased by < 10~12 mEq/L/24 hrs.
한만길 DVM
Royal Animal Medical Center
Clinical approach to Chloride (Cl-)
disorders
1. Calculate corrected Chloride
 Primary disorder due to changes in [Cl]
 Secondary disorder due to changes in water
↑H2O ⇒ ↓Na & ↓Cl
↓H2O ⇒ ↑Na & ↑Cl
2. Consider DDx for disturbance
 Calculate Anion gap
3. Treat
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Royal Animal Medical Center
Corrected Chloride
 Use Na as a marker of water balance
Cl(corrected)=Cl(measured) × {Na(normal)/Na(measured)}
 In dogs (normal range= 107~113 mEq/L);
Cl (corrected) = Cl × ( 144 / Na )
 In cats (normal range= 117~123 mEq/L);
Cl (corrected) = Cl × ( 154 / Na )
한만길 DVM
Royal Animal Medical Center
DDx of Cl disturbance
 Hyperchloremia with normal corrected Cl
(artifactual hyperchloremia)
 Pure water loss:
diabetes insipidus, essential hypernatremia
 Hypotonic loss (osmotic diuresis)
 Hypernatremia caused by Na gain
Hypertonic saline or NaHCO3 therapy.
 Hypochloremia with normal corrected Cl
(artifactual hypochloremia)
 Congestive heart failure
 Hypoadrenocorticism
 3rd space loss
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Royal Animal Medical Center
DDx of Cl disturbance
 Corrected hypochloremia
 Pseudohypochloremia: lipemic serum
 Excessive loss of Cl relatve to Na
Vomiting of stomach contents
Therapy with thiazide or loop diuretics
Chronic respiratory acidosis
Hyperadrenocorticism
Exercise
Selected GI disease associated with hyperkalemia/
hyponatremia in dogs without hypoadrenocorticism.
 Therapy with solutions containing high Na concentration
relative to Cl
NaHCO3
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Royal Animal Medical Center
DDx of Cl disturbance
 Corrected hyperchloremia
 Pseudohyperchloremia: lipemic serum, KBr therapy
 Excessive loss of Na relatve to Cl
 Small bowel Diarrhea
 Excessive gain of Cl relative to Na
 Therapy with Cl salts (NH4Cl, KCl)
 Total parenteral nutrition
 Fluid therapy (0.9% saline, hypertonic saline)
 Salt poisoning
 Renal Cl retention
 Renal failure, Renal tubular acidosis
 Hypoadrenocorticism, DM, chronic respiratory alkalosis
 Drug-induced: acetazolamide, spironolactone
한만길 DVM
Royal Animal Medical Center
DDx of Cl disturbance
 대부분의 상황에서, Na과 Cl은 평행하게 이동.
 전기적 중성을 유지하기 위해
 Most often due to metabolic acid-base
disturbance.
 Hypochloremia
 ↑ HCO3
 Metabolic alkalosis
 Hyperchloremia
 ↓ HCO3
 Metabolic acidosis, normal AG.
 Cl는 Na과 비례하여 ± 3 unit내에서 이동.
한만길 DVM
Royal Animal Medical Center
예
제
Analyte
Result
Reference
Unit
Na
148
138 - 148
Mmol/L
Cl
106
105 - 117
Mmol/L
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Royal Animal Medical Center
예
제
Analyte
Result
Reference
interval
Reference
Mid-point
Net value
Na
148
138-148
143
Na is +5 from mid
Cl
106
105-117
111
Cl is -5 from mid
 Cl은 Na에 비해 10 units 감소
 즉, 3 units 이상 감소하였으므로 중탄산 증가
 대사성 알칼리증
한만길 DVM
Royal Animal Medical Center
Hyperkalemia
 Hyperkalemia: if serum K is > 5.5 mEq/L.
 Causes
 Transcellular shifts (ICF ⇒ ECF)
 Decreased Urinary Excretion
 Iatrogenic
 Increased Potassium intake
 Pseudohyperkalemia
한만길 DVM
Royal Animal Medical Center
Causes of Hyperkalemia
Hyperkalemia Causes
Transcellular
shifts
(ICF ⇒ ECF)
 Metabolic & Respiratory acidosis
 Insulin deficiency – DKA
 Acute tumor lysis syndrome
 Reperfusion syndrom (after thrombus dissolution)
 Drugs – blockers (e.g. propranolol)
Decreased
Urinary
Excretion
 Hypoadrenocorticism
 Acute renal failure: oliguria-anuria.
 End-stage Chronic renal failure
 Urethral obstruction
 Ruptured bladder – Uroabdomen.
 Selected gastroenteritis (Trichuriasis,
Salmonellosis)
 Chylothorax with repeated pleural fluid drainage
 Hyporeninemic hypoaldosteronism
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Royal Animal Medical Center
Causes of Hyperkalemia
Hyperkalemia
Causes
Iatrogenic
 Excessive therapy of K-containing fluids
 K-sparing diuretics (spironolactone)
 ACE inhibitors (enalapril)
 Prostaglandin inhibitors (indomethacin)
 Digitalis
 α-Adrenergic agonists
(phenylpropanolamine)
Increased Potassium
intake
Pseudohyperkalemia
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 Hemolysis (Akita, Jindo)
 Thrombocytosis ( > 106/mm3)
 Leukocytosis ( > 105/mm3)
 Hypernatremia (dry reagent methods)
Royal Animal Medical Center
Hyperkalemia
 Clinical signs
 Mild to moderate hyperkalemia (K < 6.5 mEq/L)
Asymptomatic
 Generalized skeletal weakness
 Cardiac
Decreased myocardial excitability
Increased myocardial refractory period
Slowed conduction
Potential life-threatening cardiac rhythm
disturbances.
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Royal Animal Medical Center
ECG
한만길 DVM
Royal Animal Medical Center
Hyperkalemia: Treatment
Hyperkalemia
Mild
(≤6.0 mEq/L)
Drug
Method
IV fluid
(0.9% saline,
lactated Ringer’s
sol.)
60~100 ml/kg/day or greater
Dextrose
5~10% in IV fluids, or 0.25~0.5 g/kg
Regular insulin & Dog: 0.25~0.5 U/kg,
dextrose
Cat: 0.5 U/kg
Moderate
Dex 2g/U insulin
(6.0~8.0mEq/L)
(20%→10ml; 50%→4ml)
Severe
(≥8.0 mEq/L)
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Sodium
bicarbonate
1~3 mEq/kg IV over 30 min
10% calcium
gluconate
0.5~1.0 ml/kg IV slowly over 5~10 min
Royal Animal Medical Center
Hypokalemia
 Hypokalemia: < 3.5~4.0 mEq/L
 Causes
 Transcellular shifts (ECF to ICF)
 Increased Potassium loss
 Iatrogenic
 Pseudohypokalemia
한만길 DVM
Royal Animal Medical Center
Causes of Hypokalemia
Hypokalemia
Causes
Transcellular
shifts
(ECF ⇒ ICF)
 Metabolic alkalosis
 Diabetic ketoacidosis (DKA): insulin therapy
 Hypokalemic periodic paralysis (Burmese cats)
Increased
Potassium loss
 GI fluid loss
 Chronic renal failure (in cats)
 Distal (type I) renal tubular acidosis
 Proximal (type II) renal tubular acidosis after
NaHCO3 therapy
 Postobstructive diuresis
 Primary hyperadrenocorticism
 Secondary hyperadrenocorticism:
–Liver insufficiency, CHF, nephrotic syndrome
 Hyperthyroidism
 Hypomagensemia
한만길 DVM
Royal Animal Medical Center
Causes of Hypokalemia
Hypokalemia
Iatrogenic
Pseudohypokalemia
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Causes
 Potassium-free Fluid therapy (0.9% NaCl)
 Parenteral nutrition solutions
 Insulin therapy & Glucose fluid therapy
 NaHCO3 therapy
 Loop & thiazide diuretics
 Low dietary intake
 Hyperlipidemia (dry reagent methods)
 Hyperproteinemia (dry reagent methods)
 Hyperglycemia (dry reagent methods)
 Azotemia (dry reagent methods)
Royal Animal Medical Center
Hypokalemia
 Clinical signs
 Mild to moderate hypokalemia (3.0~4.0 mEq/L)
Asymptomatic
 Severe hypokalemia
Neuromuscular & Cardiovascular systems
Generalized skeletal weakness,
In cats; ventroflexion of the neck, forelimb
hypermetria, a broad-based hindlimb stance
< 3.5 mEq/L
In dogs; < 2.5 mEq/L
한만길 DVM
Royal Animal Medical Center
Treatment
 Potassium supplement
 Parenteral therapy (fluid therapy)
 Oral treatments
Potassium gluconate,
K 2 mEq/4.5kg bid PO
or K 2.2 mEq/100kcal/day, PO
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Royal Animal Medical Center
IV수액에 KCl 첨가 지침
Serum Potassium
(mmol/L)
※
Add KCl / L of fluid Maximum Infusion Rate※
(mmol/L)
(ml/kg/hr)
< 2.0
80
6
2.0 ~ 2.5
60
8
2.5 ~ 3.0
40
12
3.0 ~ 3.5
28
16
3.5 ~ 5.0
20
25
≤0.5 mEq/kg/hr of K+
Hartmann (K 4 mEq/L) = 125 ml/hr
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Royal Animal Medical Center
Hypercalcemia
 Ca > 12 mg/dl,
 Ca이 12~14 mg/dl일 때에는 임상증상이 없으나,
 Ca이 14 mg/dl 이상이면 임상증상을 나타냄
 임상증상
 Renal, GI, neuromuscular….
 PU/PD
 2nd NDI, 신장의 농축능력 상실, 신장의 전이성
mineralization.
 Lethargy, anorexia, vomiting, constipation, weakness, seizures
 중추성 or 말초성 신경계의 흥분성 감소,
 위장관 평활근의 흥분성 감소
 Cardiac arrhythmia : rare, Ca > 18 mg/dl.
 PR interval 지연, QT interval이 짧아짐.
한만길 DVM
Royal Animal Medical Center
Hypercalcemia의 감별진단
 Humoral hypercalcemia of malignancy (HHM):
lymphoma
 원발성 부갑상선기능항진증
 vitamin D 중독증
 부신피질기능저하증
 만성 신부전
 특발성 – cats
 실험실적 실수 (error)
한만길 DVM
Royal Animal Medical Center
감별진단 목록
질병명
검사방법
원발성 부갑상선기능항진증
[PTH]serum, 초음파, 수술
Hypercalcemia of malignancy
[PTHrP]plasma, 방사선(Th, Ab),
초음파, FNA-세포학적 검사
신체검사
Hypervitaminosis D
병력, 혈청 화학검사(Ca,P),
[Vitamin D]serum
부신피질기능저하증
전해질, ACTH 자극시험
만성신부전
혈청화학검사, 요검사
특발성 - 고양이
다른 감별진단목록 배제 후.
실험실적 실수 (error)
재검 실시
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Royal Animal Medical Center
한만길 DVM
Royal Animal Medical Center
칼슘과 인 대사에 영향을 주는 호르몬
Net effect
Hormone
Bone
Kidney
Intestine
Serum
Ca
Serum
PO4
PTH
Bone resorption
증가
↑Ca 흡수
↑PO4배출
NO
↑
↓
Calcitonin
Bone resorption
감소
↓Ca 흡수
↓PO4배출
NO
↓
↓
↑
↑
Vitamin D Ca 전달계 유지
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↓Ca재흡수
↑Ca 흡수
↑PO4흡수
Royal Animal Medical Center
Hypercalcemia의 비특이적 치료
 Acute therapy (대증 처치)
 수액처치: 탈수량 처치
 0.9% 생리식염수 이뇨유발
60~180 ml/kg/day, IV
 Loop 이뇨제
Furosemide 2~4 mg/kg, IV/IM/PO, q8-12h.
 Prednisolone, 1~2 mg/kg, q12h.
진단이 끝난 후 투여,
PDs 투여로 lymphoma 진단을 방해할 수 있기 때
문.
한만길 DVM
Royal Animal Medical Center
Hypercalcemia의 비특이적 치료
 앞의 치료로 실패시 추가적인 치료방법.
 NaHCO3, 1~4 mEq/kg, slow bolus IV
 Salmon Calcitonin, 4 U/kg IV ⇒ 4~8 IU/kg, SC, q8-
12h.
 Bisphosphonates
Pamidronate, 1~2 mg/kg, IV
 복강투석, 혈액투석
한만길 DVM
Royal Animal Medical Center
Hypercalcemia의 비특이적 치료
 장기적인 치료
 Furosemide
 Prendisolone
 저칼슘 사료
Hill’s prescription diet k/d, u/d, s/d
 Intestinal phosphate binders
고인산혈증이 있다면
 Bisphosphonates (=diphosphonate)
Etidronate 10~40 mg/kg/day, PO, divided q8-12h.
 Salmon calcitonin
4~8 IU/kg, SC, q12-24h.
한만길 DVM
Royal Animal Medical Center
Hypocalcemia
 Ca : < 9 mg/dl (adults dogs & cats)
 Ca: < 7 mg/dl (dogs & cats < 6 months of age)
 iCa: < 1.1 mmoL
Dog
Cat
Total Calcium
(mg/dl)
(mmol/L)
9.0~11.7
2.2~2.9
8.0~10.5
2.0~2.6
Ionized Calcium
(mg/dl)
(mmol/L)
4.6~5.6
1.12~1.42
4.5~5.5
1.1~1.4
한만길 DVM
Royal Animal Medical Center
Hypocalcemia의 감별진단
 우유로 칼슘의 손실 증가
 Puerperal tetany (eclampsia)
 뼈와 신장으로부터 칼슘 재흡수의 감소
 Primary hypoparathyroidism
 Renal failure (acute and chronic
 장으로부터 칼슘의 흡수 감소
 Malassimilation syndrome
 Increased precipitation-chelation of serum Ca
 Ethylene glycol 중독, 급성 췌장염
 Acute onset of hyperphosphatemia
 Hypoalbuminemic state
한만길 DVM
Royal Animal Medical Center
Hypocalcemia의 임상증상
 Ca이 7.5~9 mg/dl일 때는 증상이 없음.
 Ca이 7.5 mg/dl 미만일 때 임상증상 발현
 신경계증상: 신경의 흥분성 증가
 Nervousness, focal muscle twitching (귀와 얼굴),
 Stiff gait, tetany, seizure
 고양이에서 초기 증상은
 Lethargy, anorexia, intense facial rubbing, panting
 운동, 흥분, 스트레스가 임상증상을 유도하거나 악화.
 fever, “splinted” abdomen, weak femoral pulse,
muffled heart sound, tachycardia, cataracts.
한만길 DVM
Royal Animal Medical Center
Hypocalemia: Treatment
 Calcium gluconate (10%)
 0.5~1.5 ml/kg (5~15 mg/kg, Ca), IV slow or SC,
q6~8h.
혈중 Ca이 8 mg/dl 이상일 때 (Ca++ > 0.8 mmol/L)
피하주사 중지
 경구용 vitamin D와 칼슘보조제 처방
 장기간 치료시
 Vitamin D 처방
Calcitriol (vitamin D3), 30~60 ng/kg/day.
 초기에는 칼슘보조제 함께 처방.
한만길 DVM
Royal Animal Medical Center
끝
감사합니다.
한만길 DVM
Royal Animal Medical Center