ҵ ӻ ұ?
츮 () ϴ 60% Ѵ. ¾ 80% ̰, 60 ̻ Ǹ 50% ̸ Ѵٰ Ѵ. ȭ ϴ Ż ϱ ô ̴. ο 2L ̻ ö Ѵ. ̵ ̿ ϴ ٸ, ü߿ ٸٰ Ѵ. , 츮 ϰ ִ. ּе ᱹ ̴. ִµ, κ ̰, κ ϰ ִ.
ᱹ Ǵ Ż ϴ ȯϴ ȯְ Ѵ.
̷ Ȳ (Ư, ; , , , ) װ ϹǷ ҿ ϰ, ȭչ ̻ȭź ǹǷ (cell death) ϰ, ð ν ջ ϰ ȴ. ̷ Ȳ Ǵ ؼ ʿϴ.
ǽؾ ұ? Ź ϰ ȴ. 8 ؾ Ѵ(ǥ 1 ).
1. ȯڰ ũ ΰ?
ó ũ Ȯؾ ұ? ߴ ó ũ ü սǵǸ (ַ ) ȯ ̷ ʾ ٹ ջ Ѵ. ȯָ ʿ䰡 ֱ ũ Ȯϴ ̴.
ð ұ? 1ð ִ. ӻ 20 ְ, 30 ִ. , ִٸ ϶ ̴. ̷ ؾ װ ̷ ̴.
ũ ȯڿ ü˻ Ư¡ . ǽļҽ(, ȥ, ȥ), ð, Ǵ , â, CRT Ǵ Ұ, , ƹ Ǵ ҽ. ũ ȯڿ ؾ ұ? ϴ ü 8~9%, ̴ 5~6% . 80~90ml/kg, ̿ 50~60ml/kg 1volume ϴ ̴. ̷ 1ð ̳ 50~60% ٰ Ѵ. , 6kg Shih-Tzu ũ 쿡 500ml Ŀ 30~1ð ļ ؾ Ѵ. ̷ (Ǻ(cephalic vein) Ǵ ūη(saphenous vein)) 24G ī Ͽ Ѵٰ ϸ Ƹ ־ ð( 30 ~ 1ð) ̴. 22G ī Ѵٰ ص ̴. (jugular vein) 18~20G ī ϰ drop ϴ θ ̴. , ƿ ū ī ϴ ٶϴ.
ũ ŻǴ ȯ (强 ) ϰ Ÿ 찡 . ַ ȯ( ⸦ ϴ ̹, 岿(torsion Ǵ volvulus),忰, ĺ忰 ) ٴ ϴ (ź , DKA ) ִ. (cardiopulmonary arrest; CPA) ȯڿ һ ǽϸ鼭 ũ뷮 ߾, ֱٿ һ Ż ƴ϶ ũ뷮 ʴ´.
2. ŻǾ?
ũ Ͽ ũ뷮 ŭ Ͽ Ż ƴϴ. ũ ʰ Ż ִ 쵵 ִ. Ż ִ Ȯϴ ߿ϴ. , Ż ұ? Ż ִٴ ִ.
ܹ ϴ ϹǷ hematocrit(HCT) Ѵܹ(Total protien; TP) Ͽ ġ Ͽٸ Ż ִ ̴. , HCT 60%̰,TP 8.2g/dl ȯڴ и Ż ִ ̴. , ȯڰ Ż ? ġδ .
Ż ϴ Ȯ ŻDZ ü߿ Ż ü ̴. , ü 6kg̾ ȯڰ Ż Ͽ ü 5.4kg̾ٸ 600g Ż Ǵ ִ. ӻ ־ ȯ ü ˰ ִ . ٸ Ż ؾ Ѵ.
Ż Ȯϴ ְ ǥ Ǻα嵵(skin turgor) 游ð(capillaryrefilling time; CRT), Ծ , ð, ȱ Ը ̴. ڼ ǥ2 Ѵ.
5% ̸ Ż Ż Ȯ . Ż ȮεǴ Ǻα嵵 ̴. Ǻα嵵
Ǵ 5% ̻ Ż ִ. Ǻθ ÷ȴٰ Ǻΰ ġ ٷ ư Ѵ. Ż ִ Ǻΰ ְָų, · ưµ ð ɸ. ̰ tented ܾ Ͽ ǥѴ. ʹ Ǻΰ ޱޱ ȯڿ Ǻα嵵 Ż Ȯ .
ȱԸ CRT 2 ̻ Ǹ 6~8% Ż ִ ̴. CRT Ծ ġ հ 1~2 ٰ ƿ ð ϴ ̴. CRT 1.5 ̸̶ Ѵ. ġ ϰų ִ 쿡 CRT Ż . ִ 쿡 Ͽ Ծ (ġ) Ǿ ־ CRT 0.5 ̴̳.
ȱԸ Ȯϰ ȮεǴµ, ũ° ƴ϶ 10~12% Ż ִ. ̷ Ǻα嵵 ϰ, CRT Ǹ ϴ. Ȯ ũ ִٸ 12~15% Ż ִٰ .
Ǵܱ ̶⺸ٴ ̴ְ. óġϸ鼭 Žð Ż ؾ Ѵ. ó 5% Ż ִٰ Ǵϰ 5% Ż Ͽ, Ǻźµ ʾҴٸ ߰ Ż ؾ Ѵ.
8% Ż Ǵϰ, óġ ǽϿ µ 2ð Ŀ ȭ (ȣ, û wheezing sound ) ȴٸ ó Ż ߴٰ ִ. ̷ ϰ, ̴( furosemide 2~4mg/kg IV) 켱 Ѵ. Ż ض.
3. ʿѰ?
ũ Ǵ Ż Ͽ ʿ Ǵؾ Ѵ. , 䰡 ִ ȯڰ Ͽ. ǽ Ƿϰ ü˻ Ǻα嵵 CRT ̾. ȯڴ Ͽ. ̷ 쿡 ٴ (maropitant citrate, 1mg/kg, SC) ϰ Ѻ ٶ ̴.
ǽ 並 Ǻα嵵 CRT Կ ϴ 쿡 ٸ ʿ ̴. տ Ͽ, һ ſ ǽϿ, ֱٿ ȯ Ȳ Ѵ
4. ΰ?
ũŻ̵(crystalloid), ݷ̵(colloid), Ѵ.
ũŻ̵ ġ(replacement) װ (maintenance) Ѵ. ũŻ̵ (tonicity) 强(hypotonic), 强(isotonic), 强(hypertonic) Ѵ. ַ ϴ 强 ̴. 290~310mOsm/L 强 ̶ Ѵ. ̿ 0.9% Ŀ, ż(Ringers solution), Ʈ(Hartmanns solution = Lactated Ringers solution), Normosol-R, Plasma-Lyte 148 ִ. Normosol-R Plasma-Lyte ٰ ϱ ʴ. ַ 0.9% Ŀ Ǵ Ʈ Ѵ. 强 ַ ũóġ , Ż , Ǵ ÿ ȴ. Żÿ Ż Բ Ͽ 2~24ð ļ Ѵ.
10kg ȯڰ 7% ŻǾٰ . Ż 10kg 7% 1000ml = 700ml ̴. 7% 3~4ð ļ Ż ϴµ, 4ð Ż Ѵٰ ϸ ӵ 175ml/h̴. 7kg ӵ 21ml/hr̹Ƿ 196ml/h ӵ Ѵ. ÿ 10~15ml/kg/hr ӵ Ѵ.
强 Ʈ(Na) (Cl) 40~60mEq/L . ǥ 0.45% Ŀ, 0.3% Ŀ, 5% , Normosol-M, Plasma-Lyte 56 ̴. 0.45% Ŀ 2.5% ִ ִ. ַ ȴ. Żÿ 强 0.9% Ŀ ϰ, Ż 0.45% Ŀ ٲپ Ʈ ϴ Ѵ. Ϸ 强 ص Ǵ . 2 ̻ ʿ 쿡 强 üϰ Ϸ翡 1ȸ Ѵ.
强 5% 簡Ŀ(0.9% Ŀ 5% ִ ), 11.7%Ŀ ִ. 5% 252mOsm/L, ü 1ð ̳ Ǿ ȯǹǷ ʴ´. 5% 簡Ŀ 0.9% ϰ ϰ ȯڿ ϸ ȴ. ַ 6 ̸ ̿ Ѵ. 强 Ŀ 7%, 11.7%, 23.4% ִµ, 11.7% Ǹŵǰ ִ. 11.7% Ŀ 20ml 100ml Ǹŵǰ ְ, ַ 20ml (vial) Ѵ. 20ml 40mEq Na ԵǾ Ƿ 2mEq/ml̴. 强 Ʈ ʱ Ż ʹ Ͽ 0.9% Ŀ ŻϱⰡ ٰ Ǵܵ ȴ. ̷ 强 Ŀ ݷ̵ Ͽ 7.5% 4ml/kg 뷮 1ml/kg/min ӵ Ѵ. ̿ 5п ļ Ѵ.
强 Ȯ ݷ̵ Ȯ Ⱓ ִٴ ̴. Ȳ 7.5% 强 ؼ Ѵٸ ð ϴ. ̸ ǥ ΰų, 뷫11.7% Ŀ ݷ̵ 1:1 Ǵ 2:3 Ͽ 4ml/kg 5п ļ Ѵ.
ݷ̵ õ ݷ̵ ռ ݷ̵ Ѵ. õ ݷ̵ human albumin̰, ռ ݷ̵ hetastarch̴. ˺ι, DIC, 忰, ȴ. ˺ι ؼ ˺ι ġ ȸŰ ƴ. ˺ι ̿ ٸ ܹ ϱ Ѵ. ˺ι ˺ι ̱ ؼ human albumin Ѵ. ƴ϶ ̹Ƿ ˷ Ƿ Ÿ Ѵ. ˺ι ϴ ˷ , ξ⵿üͿ 2ml/kg bolus ϰ, 0.3ml/kg/hr ӵ ˺ι Ѵ. 1~2 ҿȴ. 6~10ml/kg 2~4ð ļ Ѵ. 20ml/kg ִ.
Hetarstach hydroxyethyl starch Ӹ̴. ʱ ڷ 400~700kDa ǰ Ͽ, pentarch ؼ ڷ 200kDa ǰ ߴ. ֱٿ ڷ 130kDa ǰ ϴµ ǰ 纥(Voluven)̴. Hetastarch ū ۿ ̴. 10~20ml/kg ϴµ, 纥 ڷ ۾ ϰ 33ml/kg ϰ 50ml/kg ߴٴ ִ.
5. η ΰ?
ȿ̰ ̿ϴ enteral fluid therapy̴. 츮 ġϴ κ ȯڵ 찡 . 汸(parenteral) ȣϰ ȴ. ַ ϴ Ǵ ̴. ü , 2 ̸ 쿡 ī 쿡 Ǵ ִ. ̷ 콺, Ʈ, , ġ Ư ַ Ѵ.
̿ óġ Ƽŭ ȿ . ī ϴİ ̴. ǻ Ȯϰ Ƴ ī ֵ ؾ Ѵ. Ǻ(cephalic vein) ūη(saphenous vein) Ƴ ī Ѵ. ַ ϴ Ƴ īʹ 24, 22, 18G̴. 5kg ̸ 쿡 24G, 5~15kg 쿡 22G, 15kg ̻ 쿡 18G ִ. ū üϼ ū G ī Ѵ. , Ͽ ǽ ī Ѵ. ī ϱ ؼ̴.
ũ ȯ Ǵ Ż 쿡 (jugular vein) Ƴī Ѵ. ü ̰ ƿ ī 쿡 Ѵ.
6. ӵ ΰ?
ϴ ӵ ϴ ǹ̴. ũȯڿ ӵ ؾ Ѵ. , 80~90ml/kg, ̿ 50~60ml/kg ̸ ð Ѵٸ 80~90ml/kg/hr̰, ̴ 50~60ml/kg/hr̴. ̸ 30п Ѵٰ ϸ 160~180ml/kg/hr̰, ̴100~120ml/kg/hr̴. 30и ؾ Ѵ. ѷ ̸ ؾ Ѵ. 10kg ũ뷮 Ѵٸ 800~900ml 800~900ml/kg/hr Ǵ 1600~1800ml/kg/hr ӵ Ѵ. 500ml 2ѿ 1000ml 1ѿ .
ſ ӵ ϰ 1п Ǵ ʿ ߸ ߴ. (drop) 15, 20, 60¥ ִ. ٷ ӵ ϴ . 60 60 1ð ʷ ̴.
()
= (60 60) / [ٹ ӵ(ml/hr)]
, 60ml/hr ӵ 20 , (6060)/(2060) = 3 ̴. 60 ϸ (6060)/(6060) = 1 ̴.
ߴ ֱٿ Ǵ ø ؼ ϴ 찡 . ӵ , ǥ ְ, Ǵ (air) ٿ ˶ ش. ̷ Ӹ ƴ϶ ȴ. 谡 , 赵 ִ. ξ 2~4ð ִ ʿ ִ.
տ Ͽ, ġӸ ƴ϶ ѵ Ȯϴ ̵ . , 4ð 500ml ϱ Ͽٸ 4ð 500ml Ǿ Ȯ ƴ϶ 500ml Ȯض. ٸ 縸ŭ ϴ 쵵 ִ. óġϴ 缱Կ Ǵ İ˻縦 Ѵٰ 쵵 ֱ ̴. óġ 쿡 缱Կ İ˻ Ż ǽص .
7. ΰ?
ߴ ó ӵ 谡 ִ. Ѵ.
= Ż + + ӼսǷo(ngoing loss)
ó Żÿ Ż ؼ ϰ, Ż Ŀ ӼսǷ ؼ Ѵ. Ż Ż ؼ Ѵ. սǷ(sensible loss) ҰսǷ(insensible loss) ̴. սǷ 12~20ml/kg/day, ҰսǷ 25~40ml/kg/day Ѵ. ӼսǷ 簡 Ƽ ü ս Ǵ ̴ۿ 财 ϴ 쿡 ؾ Ѵ.
Ϲ ϴ 40~60ml/kg/day̴. 15kg ̸ 쿡 60ml/kg/day ϰ, 15~30kg 50ml/kg/day, 30kg ̻ 40ml/kg/day Ѵ. Ͽ䱸 ϴٰ Ͽ ϴ ̴. ǥ 3 鰳 10kg 66ml/kg/day̰, 14kg 60ml/kg/day̸, 3kg 95ml/kg/day̰, 1kg 132ml/kg/day̴.
, 10~16kg 60ml/kg/day ϴ ũ , 5kg̸ 60ml/kg/day ϸ ִ. 5 kg ̸ Ƿ κ ʿ䰡 ִ. , ʴ´ٴ ̴. óġ ϱ Ͽٸ ϸ ȭ ִ. ϴ 쿡 50~60% ص .
̴ , üߵ Ƿ ϱ⺸ٴ ǥ4 ϴ ̴.
财 ϴ 쿡 ϸ Ż ִ. 财 ϴ Ȯ 䵵ī ϴ ̴. Feeding tube , 䰡 feeding tube 쵵 Ƿ ϴٸ Balloon urethral catheter ϴ . 15kg ̻ ƿ balloon urethral catheter ϱ ʴ. ܱ ִ urethral catheter Ǹϰ , ؾ ϹǷ 15 kg ̻ feeding tube ̿Ѵ. 䰡 ų feeding tube 찡 . 7 kg ̸ 6F urethral catheter ϰ, 7kg ̻ 8F urethral catheter Ѵ. ʹ ż 쿡 penis ۾Ƽ 7kg ̻ ̶ 8F ٴ 6F ؾ ִ. 䵵 б ū urethral catheter Ѵ. 2 ̻ ڰ ʿϰ, õ ʿϴ. 밡 ʿ ִ. ̴ Tom-cat ī ϰ, ̴ 6F urethral catheter Ͽ 财 Ѵ.
财 ϴ ǥ ȯ Ǵ ź 䵵 Ǿٰ ̴. ź (anuria) Ǵ (oliguria) 쿡 ȭ ؾ ϰ, ٴ(polyuria) 쿡 Ż ϱ ؼ 财 Ѵ. ź 쿡 ȭ ̱ , ϱ ؼ̴. ź ȯڴ 财 ϹǷ 财ŭ ؾ Ż ִ. , 5kg Ǫ 财 Ϸ翡 800ml̾ٸ սǷ 5kg 20ml/kg/day = 100ml̴. , Ϸ 100ml + 800ml = 900ml Ǵ ̴.
䵵 Ϲ ȯ ̿ ⼺ FLUTD Ἦ 䵵 Ǵ ̴. ̷ 24ð̻ 财 ϸ 汤 ܴϰ Ȯǰ, Ѵ. Tom-cat ī Ǵ 䵵ī( 5F feeding tube) Ǿ 䵵 ϰ Ǹ Ŀ ٴ ȴ. ̸ ̴ۿ(postobstructive diuresis)̶ θ. 䵵 Ͽ ó Ǵµ, 财ŭ 3~5 ٽ ϴ 찡 ִ. ̷ Ȳ 财 7~10ml/kg/hr ̻ ϴ 쵵 Ƿ 财 ϰ, ŭ ؾ Ѵ.
, 10kg 䵵Ἦ Ͽµ, BUN 200mg/dl, creatinine 10.7mg/dl ̾, 8% Ż ־. ó 4ð Ż Ͽ 财 500mlٰ̾ .
ʱ = Ż +
= [ ( 10kg 8% 1000 )/4hr ] + 28ml/hr
= 228ml/hr
4ð ӵ
= ս(=财) + Ұս
= 500ml/4hr + 0.83 10ml/hr
= 133.3ml/hr
⼭ ҰսǷ 0.83ml/hr 20ml/kg/day ð ̴. Ŀ 4~6ð 财 ϸ鼭 ӵ Ѵ. 财 Ƿ Ѵ. 䵵ī ϸ 财 Ͽ ϴµ ۿ뵵 ִ. ū ۿ ռ 汤̴. ַ 䵵ī Ͼ. Ѱ ߰ ϴ ٲپ ְ, ı 财 ҵ ־ Ѵ. ִ ó ߴٸ ٷ 䵵īʹ Ѵ. հ ǽɵǸ 䵵ī ÿ 似չ ˻縦 ǷѴ.
8. ΰ?
縦 쿡 ̷ ߰ ȯڰ Ḧ Ŵٸ ص ȴ. ٴ ̴ ȯ̴. 财ŭ Ѵٸ Ż Ͽ ִ. ٴ ִ ȯڴ Ϸ翡 25% ϸ鼭 ȯڰ ô ȮѴ. ϸ鼭 BUN creatinine Ͽ ٽ ϴ ȮѴ. ٽ ؼ Ͽ Ѵ. ӻ ȣڰ Ű⸦ ؼ ٷ ϰ Ű 찡 . ̷ 쿡 1~2 Ŀ ٽ װ˻ڰ ȣڿ Ѵ.
̻ Ϲ Ҵ.
Ż Ű ٸ ġẸ ߿ϴ. Ż Ȯϰ ǴϿ ϰ ǽ. ӻ ϴٺ vital sign(ü, ü, ɹڼ, ȣ ) Ż ʴ 찡 . ǽϴ ȿ Ż Ǿ, ȭ ʾҴ ؾ ϴµ, ׳ ġ 찡 .
ʿ 쵵 ȯڸ ϰų ̸ ߴ 쵵 ִ.
ϸ ǥ5 .
ִ 쿡 ϸ Ѵ. ü˻ ִ Ȯؾ Ѵ. 3 ϴ ̴.
ϴ = (Na + K) 2 + Glucose/18 + BUN/2.8 ̴.
, Ʈ Ѵ. ¿ ϸ ׳ ʾ Ͽ ȥ, ȥ, Ű Ÿ. ̿ 쿡 õõ ϰ, . Ƿ ⼭ Ѵ.