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体液③
脱水症について
不足
高N
a血
症
血
清 145
N
a
濃
度
(
浸
透 135
圧
)
低N
a血
症

Na量 or E
CF
高張性脱水++
(Na量も水も欠乏)

等張性脱水

低張性脱水
(純粋Na量欠乏)

高張性脱水+
(Na量正常だが水欠
乏)

過剰
不足
Na過剰

(Na過剰水欠乏も含
む)

Na量
に対
して
の自
由水
の
割合

正常

SIADH

心不全
肝硬変
ネフローゼ症候群

過剰

脱水症

浮腫性疾患
正常体液分布イメージ
細胞

ICF
40%

ECF
20%

細胞

細胞

細胞

細胞

リンパ管

間質
15%

間質
膠質浸透圧

血漿
5%

細胞

動脈側

静水圧
静脈側
血漿浸透圧と張度①
?血漿1?中に存在する浸透圧物質の数。

?つまり血管内に水を引っ張る力をもった
物質が1?あたりどのくらい存在するか。
mg/dl×10
?
=mOsmol/Lで表す。
分子量
?血漿浸透圧=2Na+BUN/2.8+BS/18
血漿浸透圧と張度②
?張度とは有効な血漿浸透圧のこと
? NaとKは細胞膜を自由に通過できないため
有効な血漿浸透圧を形成できる
? 尿素は細胞膜を自由に通過できるため細
胞の内と外で濃度は変わらず浸透圧は無
K
Na
視可
ICF
ECF
?血糖↑:浸透圧↑&高張
尿素
尿素
?尿素↑:浸透圧↑&等張
尿素は水の引っぱり合い
の綱引きには参加せず
脱水症の考え方①
?摂取量=排泄量という恒常性の破綻
? Naと水の摂取量と喪失量のバランスパターンは
等張液or低張液
‥ バランスの破綻
摂
取

? Intake不足
? 偏食

ECF

正常

Na

等張

喪
失

Na欠乏

水

Na

?
?
?
?
?

水の欠乏

Naと水欠乏

水

低張

Na

水

等張

Na

唾液
胃液、胆汁、
膵液
十二指腸液
小腸液
下痢便、正常
便

Na

水

高張

水
高張
脱水症の考え方②
? 喪失?摂取でNaと水の割合が決まり張度とな
る
※高血糖や浸透圧利尿などはNa量低下しても高張度にな
る

? 張度から体液のどのコンパートメントにど
の体液成分が喪失しているかを推測できる
? 体液成分の喪失したコンパートメントにより
脱水をVolume depletionと Dehydrationに分類
することで問題となる病態をイメージする
脱水症の考え方③
血漿量減少
間質減少
細胞内液減少

頻脈、血圧低下、起立性低血圧、尿量減
少CRTの延長(4秒以上)、頸静脈虚脱
皮膚:ツルゴール低下、腋窩乾燥
粘膜:口腔内乾燥、舌乾燥、眼球乾燥

頭痛、嘔吐、痙攣、意識障害
Volume depletionのモデル
等張液の喪失
EX:出血

ICF

ECF

ICF
ECF

? Volume depletionで問題になるのは循環血漿量の低下。
? 喪失?摂取により等張液の喪失となりECFの濃度は変わ
らず
? 容量調節系でNaを再吸収することで代償。
Dehydrationのモデル
低張液の喪失
EX 発汗

ICF

ECF

ICF

ECF

? Dehydrationで問題になるのは濃度(浸透圧)。
? 高Na血症によりECFよりICFの減少が主体。
? 低張液の喪失はNa量の減少よりも水の減少が強く浸透圧
調節系で水を再吸収することで代償。
? 実際の臨床では強烈な口渇感で水を摂取するためそう簡単
には起きない。実際はどちらかというと低張性を示すこと
治療戦略はDO NOT DO HARM
? 容量調節系と浸透圧調節系の代償機構に逆らわ
ず生理的に手助けをするイメージで治療
?しかし臨床では完全に循環血漿量低下と高Na血
症を分けることはできない
? 循環血漿量低下と高Na血症でより問題な方を明
確にし容量調節系か浸透圧調節系のどちらを主
に助ける治療を行えばいいかを考えて適切に補
液する

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体液③