!"#$%&'()*+,(-./&(0+/1234.5*&/(
62/.5(7&%%&38+9:(;6<:()!<=>-!:(!!?<(
;&,+*.%(@51&5/+8&(!.3&(A5+1(
B4C&*1+8&/(
• A1+%+D&(.(/E/1&#.1+*(.$$3".*F(1"(&8.%2.1&(.*+,>
4./&(,+/1234.5*&/(
• @,&51+GE(.*+,>4./&(,+/1234.5*&/((
• @,&51+GEH3&*"I5+D&(1F&(&1+"%"IE("G(.*+,(4./&(
,+/"3,&3/(
• )$$%E(32%&/("G(*"#$&5/.1+"5((
• @,&51+GEH3&*"I5+D&(*"#$%&'(J#+'&,:(/&*"5,.3E:(
1&31+.3EK(.*+,(4./&(,+/"3,&3/(
ABG’s
Base
Excess
?
??
pH
Acidosis
pH.
Anion Gap
HC03Ё
Henderson-Hasselbalch
Alkalosis
PaC02
SID
??
Respiratory
Metabolic
ǻ/ǻ
61&$L+/&()5.%E/+/(
MK
OK
QK
SK
0"(7+/1"3E(.5,(=FE/+*.%(N(%""9(G"3(.*+,>4./&(*%2&/((
P&3+GE(1F.1(1F&(%.4(8.%2&/(.3&(*"5/+/1&51(
@/($7(%"L:(5"3#.%("3(F+IFR(
@/(1F&($3+#.3E(,+/1234.5*&(#&1.4"%+*("3(3&/$+3.1"3ER((@G(4"1F(
.3&(.45"3#.%:($+*9(1F&("5&(1F.1(/&&#/(#"/1(/&8&3&(.1(G+3/1(
I%.5*&T(
UK @/(1F&(,+/1234.5*&(.*21&("3(*F3"5+*V(7.8&(*"#$&5/.1"3E(
*F.5I&/("**233&,R(
WK X"3(;&1.4"%+*()*+,"/+/:(LF.1(+/(1F&()YR(ZF+/(L+%%(F&%$(
,&8&%"$(E"23(%+/1("G(,+GG&3&51+.%/T(
[K @/(1F&3&(.(/&*"5,.3E("3(1&31+.3E(,+/1234.5*&($3&/&51R(
(
7(\(=(!%2&/(
•
•
•
•
•
•
•
•
P"#+1+5I(N(;&1.4"%+*()%9.%"/+/(
7+/1"3E("G(0+.4&1&/(N(;&1.4"%+*()*+,"/+/(
7+/1"3E("G(/#"9+5I(H(!B=0(N(?&/$+3.1"3E()*+,"/+/(
7+/1"3E("G(]+8&3(0+/&./&(N(?&/$+3.1"3E()%9.%"/+/(
?&*&51(4+5I&(,3+59+5I(N(;&1.4"%+*()*+,"/+/(
0+.33F&.(N(;&1.4"%+*()*+,"/+/(
Z.*FE$5&.(N(?&/$+3.1"3E()%9.%"/+/(
7E$"1&5/+"5(N(;&1.4"%+*()*+,"/+/(
(
• P&3+GE(!"5/+/1&5*E("G(].4(P.%2&/(
( (( 7!^Q(J)-YK(_(!^O(J8&5"2/(&%&*13"%E1&/K( O(
• `8.%2.1&(1F&($7(N(@/(+1(.*+,"1+*(Ja([TQUK:(5"3#.%(
J[TQU(N([TSUK("3(.%9.%"1+*(J(b([TSUKR(
• @/(1F&($3+#.3E(,+/1234.5*&(#&1.4"%+*("3(
3&/$+3.1"3ER(@G(4"1F(.3&(.45"3#.%:($+*9(1F&(
"5&(1F.1(+/(#"/1(/&8&3&(.1(G+3/1(I%.5*&T(
)*+,&#+.((
(
]"L(7!^Q(
7+IF(=!^O(
(]"L(7*^Q(
]"L(=!^O(
7+IF(7!^Q(
7+IF(=!^O(
7+IF(7!^Q(
]"L(=!^O(
=3&,"#+5.51(
;&1.4"%+*()*+,"/+/(
=3&,"#+5.51(
?&/$+3.1"3E()*+,"/+/(
(
;+'&,(#&1.4"%+*(
.*+,"/+/(.5,(
3&/$+3.1"3E(.*+,"/+/(
<"1($"//+4%&V(%+9&%E(
%.4(&33"3(
)$$%E(!"#$&5/.1+"5(?2%&/(
;&./23&,(
=!^O(1""(
F+IF(
;&./23&,(
=!^O(1""(
%"L(
;+'&,(
#&1.4"%+*(
.*+,"/+/(
.5,(
3&/$+3.1"3E(
.*+,"/+/(
;+'&,(
#&1.4"%+*(
.*+,"/+/(
.5,(
3&/$+3.1"3E(
.%9.%"/+/(
;&./23&,(
=!^O(+/(
.$$3"$3+.1&(
6+#$%&(
#&1.4"%+*(
.*+,"/+/(
(
;&./23&,(
7!^Q(+/(1""(
%"L(
;+'&,(
3&/$+3.1"3E(
.*+,"/+/(
.5,(
#&1.4"%+*(
.*+,"/+/(
;&./23&,(
7!^Q(+/(1""(
F+IF(
;+'&,(
3&/$+3.1"3E(
.*+,"/+/(
.5,(
#&1.4"%+*(
.%9.%"/+/(
;&./23&,(
7!^Q(+/(
.$$3"$3+.1&(
6+#$%&(
3&/$+3.1"3E(
.*+,"/+/(
)%9.%&#+.((
(
7+IF(7!^Q(
]"L(=!^O(
(7+IF(7*^Q(
7+IF(=!^O(
]"L(7!^Q(
]"L(=!^O(
=3&,"#+5.51(
;&1.4"%+*()%9.%"/+/(
=3&,"#+5.51(
?&/$+3.1"3E(
)%9.%"/+/(
]"L(7!^Q(
7+IF(=!^O(
(
;+'&,(#&1.4"%+*(
.%9.%"/+/(.5,(
3&/$+3.1"3E(.%9.%"/+/(
<"1($"//+4%&V(%+9&%E(
%.4(&33"3(
)$$%E(!"#$&5/.1+"5(?2%&/(
;&./23&,(
=!^O(1""(
F+IF(
;&./23&,(
=!^O(1""(
%"L(
;+'&,(
#&1.4"%+*(
.%9.%"/+/(
.5,(
3&/$+3.1"3E(
.*+,"/+/(
;+'&,(
#&1.4"%+*(
.%9.%"/+/(
.5,(
3&/$+3.1"3E(
.%9.%"/+/(
;&./23&,(
=!^O(+/(
.$$3"$3+.1&(
6+#$%&(
#&1.4"%+*(
.%9.%"/+/(
(
;&./23&,(
7!^Q(+/(1""(
%"L(
;+'&,(
3&/$+3.1"3E(
.%9.%"/+/(
.5,(
#&1.4"%+*(
.*+,"/+/(
;&./23&,(
7!^Q(+/(1""(
F+IF(
;+'&,(
3&/$+3.1"3E(
.%9.%"/+/(
.5,(
#&1.4"%+*(
.%9.%"/+/(
;&./23&,(
7!^Q(+/(
.$$3"$3+.1&(
6+#$%&(
3&/$+3.1"3E(
.%9.%"/+/(
;&1.4"%+*()*+,"/+/(
$7(a([TQU(L+1F(5"3#.%("3(љ,Ϭϯ(
(
• !.2/&,(4E("5&("G(G"23(#&*F.5+/#/(
– 0&*3&./&,(7ЀĞdžĐƌĞƚŝŽŶ>(0+/1.%(?Z)(
• 0+#+5+/F&,(<7SЀƉƌŽĚƵĐƚŝŽŶN(?&5.%(G.+%23&:(
7E$".%,"/1&3"5+/#(JZE$&(@P(?Z)K(
– @5*3&./&,(7ЀůŽĂĚN(%.*1.1&:(0c):(1"'+5/:(?F.4,"(
– -+*.34"5.1&(%"//(N(0+.33F&.:(=.5*3&.1+*(X+/12%.:(A3&1&3.%(
0+8&3/+"5T((?&5.%(4+*.34(%"//(J=3"'+#.%(?Z)K(
– -+*.34"5.1&(,+%21+"5(
(
;.3+5+:(d"F5(dT(.5,(eF&&%&3:()31F23(=T(JO^M^K(!3+1+*.%(!.3&(;&,+*+5&f(ZF&(`//&51+.%/(X"231F((`,+1+"5T(
=F+%.,&%$F+.:(=)T(]+$$+5*"11:(e+%%+.#/(.5,(e+%9+5/T(
;&1.4"%+*()*+,"/+/(
• ZF3&.1/(1"(%+G&(
– 7&#",E5.#+*(@5/1.4+%+1E(JљŵLJŽĐĂƌĚŝĂů
*"513.*1+%+1E:( љŝŶƚƌĂǀĂƐĐƵůĂƌǀŽůƵŵĞ͕љWsZͿ(
– !.3,+.*(.33FE1F#+./(JFE$&3("3(FE$"9.%&#+.K(
– P&51+%.1"3E(G.+%23&(
– =3&/&5*&("G(1"'+5/(
– <213+1+"5.%(,&G+*+&5*E(J-(8+1.#+5/:(e&35+*9&g/K(
(
Halperin, Mitchell L., Kamel, S. and Goldstein, Marc B. (2010) Fluid, Electrolyte and Acid-Base
Physiology: A Problem Based Approach, Fourth Edition. Philadelphia, PA. Saunders Elsevier.
)5+"5(Y.$(
• ( )Y(_(J<.ЀͿN(J7!^ЈЁн!%ЁͿ(
• ZF3&&(*%+5+*.%(.$$%+*.1+"5/(
MK((((=3&/&5*&("3(.4/&5*&("G(.5()Y(.//+/1/(+5(,&1&3#+5+5I(1F&(
*.2/&("G(1F&(#&1.4"%+*(.*+,"/+/T(
OK((((ZF&()Y(+/(2/&G2%(+5(,&1&3#+5+5I(1F&($3&/&5*&("G(.(#+'&,(
.*+,H4./&(,+/1234.5*&(4E(*.%*2%.1+5I(1F&(0&%1.(?.1+"(
QK((((ZF&()Y(*.5(4&(2/&G2%(+5(,&1&*1+5I(/&%&*1&,(,+/"3,&3/(1F.1(
"**23(L+1F(.(%"L:(5"1(F+IF()YT(J]+1F+2#(1"'+*+1E:(;2%1+$%&(
;E&%"#.(L+1F($3",2*1+"5("G(*.1+"5+*($.3.$3"1&+5/K(
(
Marini, John J. and Wheeler, Arthur P. (2010) Critical Care Medicine: The Essentials Fourth
Edition. Philadelphia, PA. Lippincott, Williams and Wilkins.
)5+"5(Y.$(
http://www.flickr.com/photos/dokidok/2369729114/in/photostream/
),C2/1&,()5+"5(Y.$(
• 7E$".%42#+5&#+.(*.5(#./9(.5(+5*3&./&,(*"5*&513.1+"5("G(
I.$(+"5/(.5,(%"L&3+5I(1F&(8.%2&("G(1F&()YT((
• ),C2/1&,()Y(_(((
( 'нϮ͘ϱdž;ŶŽƌŵĂůĂůďƵŵŝŶŐͬĚ>N(.%42#+5(IH,]K((
Example: Pt. albumin 2.0g/dL and AG 15
15 + 2.5 x (4 – 2) = 15 + 5
Adjusted AG = 20
`1+"%"IE("G()5+"5(Y.$(;&1.4"%+*()*+,"/+/(
• `'*&//(&5,"I&5"2/("3(&'"I&5"2/(.*+,(
• ;2,$+%&/(
™ Af((A3&#+.(
™ ;f(;&1F.5"%(
™ 0f(0+.4&1+*(c&1".*+,"/+/(((
™ =f(=3"$"G"%((J=.3.%,&FE,&K(
™ @f((@/*F&#+.:((@<7(
™ ]f((].*1+*(.*+,"/+/(
™ `f((`ZB7(9&1".*+,"/+/(H(`1FE%&5&(Y%E*"%(
™ 6f((6.%+*E%.1&/(H(/1.38.1+"5(9&1".*+,"/+/(
• ;.//+8&(?F.4,"#E"%E/+/(N(3&%&./&("G(+513.*&%%2%.3($F"/$F.1&(.5,(
/2%G.1&(
YB]0(;)?c(
Y(>(Y%E*"%/(N(`1FE%&5&(I%E*"%(.5,(#&1F.5"%(
B(>(B'"$3"%+5&(
]((>(].*1+*(.*+,"/+/(J@5.,&h2.1&($&3G2/+"5K(
0(>(].*1+*(.*+,"/+/(J@5*3&./&,(%.*1.1&($3",2*1+"5("3(,&*3&./&,(
%.*1.1&(21+%+D.1+"5(
(
;(>(;&1F.5"%(
)((>()/$+3+5(
?((>(?&5.%(X.+%23&(
c(>(c&1".*+,"/+/(((
(
(<"5>Y.$(;&1.4"%+*()*+,"/+/(
•
•
•
•
(
•
(
Y@(]"//&/("G(7!^QЀ;ŝĂƌƌŚĞĂ͕ĨŝƐƚƵůĂƐͿ(
?&5.%(7!^QЀůŽƐƐ;dLJƉĞ//ZdͿ(
?&5.%(,E/G25*1+"5(J7E$".%,"/1&3"5+/#:(ZE$&(@P(?Z)K((
@5I&/1+"5/(N(.##"5+2#(*F%"3+,&:(FE$&3.%+#&51.1+"5(G%2+,/(
0+%21+"5.%(#&1.4"%+*(.*+,"/+/(
• A/2.%%E(,2&(1"(.,#+5+/13.1+"5("G(%.3I&(8"%2#&(/.%+5&(
)(e"3,()4"21(<.7!^Q(
• 0+3&*1(13&.1#&51("G(.*21&(#&1.4"%+*(.*+,"/+/(L+1F(<.7!^Q(+/(
!"#(+5,+*.1&,:($!%&''f(
– $7(a([TM^((
– B8&31($FE/+"%"I+*(*"#$3"#+/&(+/($3&/&51(
– `'*&//+8&(L"39("G(43&.1F+5I(+/(3&h2+3&,(1"(#.+51.+5($7(b(
[TO(
• <.7!^Q(+/(5"1(+5,+*.1&,(+5(0c):(&8&5(L+1F($7(a([TM^(,2&(1"(
1F&(3+/9/("G(,&8&%"$+5I(3&4"25,(.%9.%"/+/("3(&'.*&34.1+5I(
FE$&3"/#"%.3+1ET(
(;&1.4"%+*()%9.%"/+/(
• $7(b([TSU(L+1F(5"3#.%("3(ј,Ϭϯ(
MK(((()5+"5(%"//(((
• !F%"3+,&(3&/$"5/+8&(
• !F%"3+,&(253&/$"5/+8&(
• 0&1&3#+5&,(4E(#&./23+5I(23+5&(&%&*13"%E1&/(
OK((!.1+"5(I.+5(
• !"33&*1+"5("G(%"5I>/1.5,+5I(3&/$+3.1"3E(.*+,"/+/(L+1F(
+5/1+121+"5("G(+58./+8&("3(5"5>+58./+8&(#&*F.5+*.%(8&51+%.1+"5(
• ?.3&%E:(,2&(1"(3&I2%.1+"5("G(c ЀďLJĞdžĐŚĂŶŐŝŶŐ,ЀŝŽŶƐĨŽƌ<ЀŝŶ
1+//2&/(.5,(9+,5&E/(3&/2%1+5I(+5(7ЀǁĂƐƚŝŶŐ(J!2/F+5I/:(/1&3"+,(
1F&3.$EK(
(
((;&1.4"%+*()%9.%"/+/(
)*%"+,-&(.&'/"!',0&(
(
(A3+5&(/",+2#(%"L(JaO^K(
(
Y./13+*(%"//(
((J8"#+1+5I:(<Y(/2*1+"5K(
A3+5.3E(%"//(
(
(J,+23&/+/:(#.55+1"%K(
?&5.%(3&/$"5/&(1"(FE$&3*.$5&.((
(
J!%ЁůŽƐƐĂƚƌĞŶĂůƚƵďƵůĞĂƐ,ϬϯЀŝƐ
I&5&3.1&,K(
(
(
(
(
)*%"+,-&(1!+&'/"!',0&(
A3+5&(/",+2#(b(O^(
=3+#.3E(FE$&3.%,"/1&3"5+/#(
!"31+*"/1&3"+,/(
!"33&*1+"5("G(%"5I>/1.5,+5I(3&/$+3.1"3E(
.*+,"/+/(J+5/1+121+"5("G(+58./+8&("3(5"5>
+58./+8&(#&*F.5+*.%(8&51+%.1+"5K(
7E$"9.%&#+.(
Marini, John J. and Wheeler, Arthur P. (2010) Critical Care Medicine: The Essentials Fourth
Edition. Philadelphia, PA. Lippincott, Williams and Wilkins.
?&/$+3.1"3E()*+,"/+/((
• $7(љϳ͘ϯϱǁŝƚŚŶŽƌŵĂůŽƌјWĂϬϮ(
• 0&*3&./&,(8&51+%.1+"5(
– )*21&(
• (`'.*&34.1+"5("G(/&8&3&(./1F#.(
• (=<)(
• =2%#"5.3E(&,&#.(
• ="/1(*.3,+.*>.33&/1(
• 032I("8&3,"/&(
• ),#+5+/13.1+"5("G(^O(+5(/&11+5I("G(*F3"5+*(FE$&3*.$5&.T(
– !F3"5+*f(*F3"5+*("4/132*1+8&(%25I(,+/&./&/(
(
6E#$1"#/("G(?&/$+3.1"3E()*+,"/+/(
•
•
•
•
•
•
•
•
•
7&.,.*F&(
-%233&,(8+/+"5(
?&/1%&//5&//(
)5'+&1E(
Z3&#"3/(
)/1&3+'+/(
0&%+3+2#(
6"#5"%&5*&(
7E$"1&5/+"5(LF&5($7(G.%%/(4&%"L([TM^(
!F3"5+*(?&/$+3.1"3E()*+,"/+/(
)"2/&!'3#&-(
1!4"2/&!'3#&-(
`%&8.1&,(=.!^O(
`%&8.1&,(=.!^O(
<&.3(<"3#.%($7(
$7(a([TQU(
?&/$+3.1"3E()%9.%"/+/(
• $7(јϳ͘ϰϱǁŝƚŚŶŽƌŵĂůŽƌљWĂϬϮ(
• @5*3&./&,(8&51+%.1+"5(
– !<6(0+/1234.5*&/(
– =.+5(
– @5.$$3"$3+.1&(#&*F.5+*.%(8&51+%.1+"5(
– 032I/(J/.%+*E%.1&/:(*.1&*F"%.#+5&/:(1F&"$FE%%+5&K(
– 7E$"'&#+.(
– ]+8&3(0+/&./&(
– =2%#"5.3E(3&*&$1"3(/1+#2%.1+"5((H(љůƵŶŐĐŽŵƉůŝĂŶĐĞ;WE͕
$2%#"5.3E(&#4"%+/#:(./1F#.:($2%#"5.3E(G+43"/+/:($2%#"5.3E(&,&#.K(
– =3&I5.5*E(
?&/$+3.1"3E()%9.%"/+/(
• 6E#$1"#/(
– =.3./1F&/+./:(1&1.5E:(13&#"3(
– !F&/1($.+5:(*+3*2#"3.%($.3./1F&/+.:(
%+IF1F&.,&,5&//(
– .5'+&1E(
(
!"#$&5/.1+"5(-./+*/(
• !"#$&5/.1"3E(*F.5I&/(.3&(,&$&5,&51(2$"5(5"3#.%(
G25*1+"5("G(1F&(*"#$&5/.1+5I(/E/1&#(
• ;"/1(*"#$&5/.1+"5(+/(+5*"#$%&1&(
• ].*9("G(.,&h2.1&(*"#$&5/.1+"5(#.E(+5,+*.1&(1F&(
$3&/&5*&("G(.(*">&'+/1+5I(/&*"5,.3E(,+/"3,&3(
• 0+GG&3&51(*"#$&5/.1"3E(G"3#2%./(.3&(.$$%+&,:(
,&$&5,+5I(2$"5(1F&($3+#.3E(,+/1234.5*&(
• 72#.5/(F.8&(I"",(42GG&3+5I(/E/1&#/(G"3(.*+,"/+/(421(
.(3&,2*&,(.4+%+1E(1"(42GG&3(.%9.%"/+/(
?&/$+3.1"3E(!"#$&5/.1+"5((
• =!^O(*F.5I&/(+5(1F&(/.#&(,+3&*1+"5(./(1F&(/&32#(7!^Q(
– =!^O(љŝŶŵĞƚĂďŽůŝĐĂĐŝĚŽƐŝƐ(
– =!^O(јŝŶŵĞƚĂďŽůŝĐĂůŬĂůŽƐŝƐ(
• ?&/$+3.1"3E(*"#$&5/.1+"5(,&*3&./&/(1F&(*F.5I&(+5(3.1+"("G(
7!^Qf=!^O:(.5,(1F&3&G"3&(+5(1F&($7T(
• ?.$+,("5/&1("G(3&/$"5/&:(L+1F+5(Q^(#+521&/(
• !"#$%&1&(L+1F+5(MO>OS(F"23/(
• ?&/$+3.1"3E(*"#$&5/.1+"5(*.5("**23(1"(.($FE/+"%"I+*(#.'("G(
=.!^O(U^(1"(UUV(F+IF&3(=.!^O(+5(1F+/(/+12.1+"5(+5,+*.1&/(.(
*"5*"#+5.51(?&/$+3.1"3E()*+,"/+/(
Emmett, M., Sterns, Richard H. and Forman, John P. (2013) Simple and mixed acid-base disorders.
http://www.uptodate.com.proxy.library.vanderbilt.edu/contents/simple-and-mixed-acid-basedisorders?detectedLanguage=en&source=search_result&search=winters+formula&selectedTitle=1~2&provider=noProvider#H36526
3262 8/7/2013
?&5.%(!"#$&5/.1+"5(
• 7!^Q(*F.5I&/(+5(1F&(/.#&(,+3&*1+"5(./(1F&(=!^O((
– 7!^Q(јŝŶƌĞƐƉŝƌĂƚŽƌLJĂĐŝĚŽƐŝƐĚƵĞƚŽŝŶĐƌĞĂƐĞĚ,Ѐ
/&*3&1+"5(
– 7!BQ(љŝŶƌĞƐƉŝƌĂƚŽƌLJĂůŬĂůŽƐŝƐĚƵĞƚŽĚĞĐƌĞĂƐĞĚ,Ѐ
/&*3&1+"5(.5,(23+5.3E(7!^Q(%"//(
• 6%"L&3("5/&1("G(*"#$&5/.1+"5:(L+1F+5(F"23/(
• !"#$%&1+"5(1.9&/(,.E/(1"(L&&9/(G"3(#.'+#.%(&GG&*1(
• `'$&*1&,(G+5,+5I/(,+GG&3(+5(.*21&(J%+11%&("3(5"(3&5.%(
*"#$&5/.1+"5K(.5,(*F3"5+*(JG2%%(3&5.%(*"#$&5/.1+"5K(
3&/$+3.1"3E(.*+,>4./&(,+/"3,&3/T(
Emmett, M., Sterns, Richard H. and Forman, John P. (2013) Simple and mixed acid-base disorders.
http://www.uptodate.com.proxy.library.vanderbilt.edu/contents/simple-and-mixed-acid-basedisorders?detectedLanguage=en&source=search_result&search=winters+formula&selectedTitle=1~2&provi
der=noProvider#H365263262 8/7/2013
(
)*+,>-./&(<"#"I3.#(
http://pic.pimg.tw/mulicia/1179210017.jpg
`'$&*1&,(!"#$&5/.1+"5(G"3()*+,>-./&(0+/"3,&3/(
5+,23+6(7,'"+-&+(
5+,23+6()*3!8&(
)"2/&!'3#"+6()*3!8&( 9:/&4#&-(
)"2/&!'3#,"!(
;&1.4"%+*()*+,"/+/(
љ,ϬϯЁ(
љWĂϬϮ(
ȴ=.!^O(_(MTO(ȴ(7!^QЁ(
;&1.4"%+*()%9.%"/+/(
ј,ϬϯЁ(
јWĂϬϮ(
ȴ=.!^O(_(^Ti(ȴ(7!^QЁ(
(
?&/$+3.1"3E()*+,"/+/(
((((()*21&(
(((((!F3"5+*(
(
ј=.!^O(
(
(
ј7!^QЁ(
(
(
ȴ,ϬϯЁсϬ͘ϭϬȴ(=.!^O(
ȴ,ϬϯЁсϬ͘ϯϱȴ(=.!^O(
?&/$+3.1"3E()%9.%"/+/(
((((()*21&(
(((((!F3"5+*(
(
љ=.!^O(
(
(
љ7!^QЁ(
(
(
ȴ,ϬϯЁсϬ͘Ϯȴ(=.!^O(
ȴ,ϬϯЁсϬ͘ϱȴ(=.!^O(
Marini, John J. and Wheeler, Arthur P. (2010) Critical Care Medicine: The Essentials Fourth
Edition. Philadelphia, PA. Lippincott, Williams and Wilkins.
ȴ(=.!^O(_(MTO('(ȴ(7!^Q(
(
ȴ(7!^Q(_((OS(J"$1+#.%K(N(#&./23&,(7!^Q((
(ȴ(=.!^O((_((S^(J"$1+#.%K(N(*.%*2%.1&,:(&'$&*1&,(*F.5I&(+5(=.!^O(
(
• /;(<=>>(?(@A(?((BA(
ȴ(7!^Q(_(OS(N(M^(_(MS(
( ( MTO( (MS(_(MWTj(
( ( ȴ(=.!^O(_(S^(N(MWTj(_(OQTO(
( (
( ( `'$&*1&,(=.!BO(_(OQTO##7IT(
• !"5*%2/+"5(N(<"1(*"#$%&1&%E(*"#$&5/.1&,(V(4&*.2/&(=.!^O(/F"2%,(4&(OQ(
421(+1(+/(Q^T(
(
!"#$&5/.1+"5(G"3(;&1.4"%+*()*+,"/+/(
MK ȴ(=.!^O(_(MTO(ȴ(7!^Q(
(
>C( /;(D(%3'#(#E"(-,8,#'("F(53)A>(
( /;(<=>G(їWĂϬϮϮϱ(
(
@C(( H,!#&+I'(J"+2$%3(K(9'#,23#&'(#*&(&:/&4#&-(5)L>((
( ( MB=G(:(;)A@C(N(O(D(53)A>(( ((>(
( (((
(
(
e+51&3g/(X"3#2%.(k(
;ϭ͘ϱdž,ϬϯͿнϴсWĂϬϮ
• PQRS(<=>>(?(@A(?(BA((((
• <.(MQi:(c(ST^:(!%(i^:(!^O(M^(
(
((;ϭ͘ϱdžϭϬͿнϴсϮϯ(
(
((OQ( (O(+/(a((#&./23&,(=.!^O(JQ^K(
`'$&*1&,(=!^O(_(OQ(
!"5*%2/+"5(N(<"1(*"#$%&1&%E(*"#$&5/.1&,(
(
O(
!"#$&5/.1+"5(=&.3%/(G"3((
!F3"5+*(;&1.4"%+*()*+,"/+/(
(
• @G(=.!^O(+/(b(&'$&*1&,:(1F&5(1F&(1+#&(G"3(3&/$+3.1"3E(((((((((((
*"#$&5/.1+"5(F./(4&&5(1""(/F"31V("3(.(3&/$+3.1"3E((((
.*+,"/+/(+/(.%/"($3&/&51T(
• (@G(1F&(=.!^O(+/(a(&'$&*1&,:(1F&5(.(*"5*"#+5.51((
(((((3&/$+3.1"3E(.%9.%"/+/(+/(.%/"($3&/&51(
(
!"#$&5/.1+"5(X"3#2%./(G"3(;&1.4"%+*(
)%9.%"/+/(
MK (ȴ=.!^O(_(^Ti(ȴ(7!^Q(
(
OK =.!^O(јϬ͘ϳŵŵ,ŐĨŽƌĞǀĞƌLJϭŵƋĞůĞǀĂƚŝŽŶŝŶƚŚĞ
/&32#(7!^Q(*"5*&513.1+"5(
(
QK WĂϬϮсϰϬн͘ϳ;ŵĞĂƐƵƌĞĚ,ϬϯN(5"3#.%(7!^QK(
(
TC 53)A>(D(MA=U(:(;)A@C(N(BG(
(
WĂϬϮс;Ϭ͘ϵdž,ϬϯͿнϭϱ(
PQR(<=GV(?(TT(?(<A(?(@O(
(
• WĂϬϮс;Ϭ͘ϵdž,ϬϯͿнϭϱ(
( Ϭ͘ϵdžϯϴнϭϱсϰϵ͘Ϯ(
`'$&*1&,(=.!^O(_(SiTO(
(
!"5*%2/+"5(>(<"1(*"#$%&1&%E(*"#$&5/.1&,(
(
!"#$&5/.1"3E(X"3#2%./(G"3(?&/$+3.1"3E(
)*+,"/+/(
• )*21&(
MK 7!^Q((јϭͬϭϬŵŵ,ŐŝŶĐƌĞĂƐĞŝŶWĂϬϮ(
OK ȴ7!^Q(_(^TM^((ȴ(=.!^O(
@C ;)A@(D((M5)A>(W(TA(?(BAC(N(>T(
• !F3"5+*(
MK 7!^Q((јϯ͘ϱͬϭϬŵŵ,ŐŝŶĐƌĞĂƐĞŝŶWĂϬϮ(
OK ȴ7!^Q(_(^TQU((ȴ(=.!^O(
@C ;)A@(D(M(5)A>(W(TA?(GC((N(>T(
(
)*21&(
7!^Q(_(J=!^O(N(ϰϬͬϭϬͿнϮϰ(
(
)-Yf([TOO(H([^(H(OU(
7!^Q(_(J=!^O(N(ϰϬͬϭϬͿнϮϰ(
[^>S^(_(Q^(
Q^(HM^((_(Q(
džƉĞĐƚĞĚ,ϬϯŝƐϯнϮϰсϮϳ(
(
!"5*%2/+"5(N(@5*"#$%&1&(*"#$&5/.1+"5( (
(
!F3"5+*(
7!^Q(_(J=!^O(N(ϰϬͬϱͿнϮϰ(
)-Yf(([TQ^(H(i^(H(Qj(
7!^Q(_(J=!^O(N(ϰϬͬϱͿнϮϰ(
( i^(N(S^(_(U^(
( U^(H(U(_(M^(
( džƉĞĐƚĞĚ,ϬϮŝƐϭϬнϮϰсϯϰ(
(
!"5*%2/+"5(N(@5*"#$%&1&(*"#$&5/.1+"5(
(
!"#$&5/.1"3E(X"3#2%.(G"3(?&/$+3.1"3E(
)%9.%"/+/(
• )*21&(
( MK(( 7!^Q(љϮͬϭϬŵŵ,ŐĚĞĐƌĞĂƐĞŝŶWϬϮ(
(((((OK(( ȴ(7!^Q(_(^TO^((ȴ(=.!^O(
( QK((((;)A@(D(>T(K(MTA(W(53)A>(?(GC((
• !F3"5+*(
( MK( 7!^Q((љϱͬϭϬŵŵ,ŐĚĞĐƌĞĂƐĞŝŶWϬϮ(
( OK(( ȴ(7!^Q(_(^TU((ȴ(=.!^O(
( QK((((;)A@(D(>T(K(MTA(W(53)A>(?>(C((
(
)*21&(
7!^Q(_(OS(>(JS^(N(=.!^O(H(UK((
(
PQRS(<=G>(?(>O(?(>T(
7!^Q(_(JS^(N(=.!^OK(H(U((
S^(N((Oj(_(MO(
MO(H(U(_(OTS(нϮϰсOWTS(
`'$&*1&,(7!^Q(
(
!"5*%2/+"5(N(@5*"#$%&1&(*"#$&5/.1+"5(
!F3"5+*(
(7!^Q(_(OS(>(JS^(N(=.!^O(HO(K(
)-Y([TSS(H(OO(H(Mj(
• 7!^Q(_(OS(>(JS^(N(=.!^O(HO(K(
(((((S^(N(OO(H(O(_((i(
((((((OS(N(i(_(MU(
`'$&*1&,(7!^Q(MU(
(
!"5*%2/+"5(N(@5*"#$%&1&(*"#$&5/.1+"5(
(
`./E(!"#$&5/.1+"5(X"3#2%./(
5+,23+6(7,'"+-&+(
)"2/&!'3#"+6(
)*3!8&(
9:/&4#&-()"2/&!'3#,"!(
;&1.4"%+*()*+,"/+/(
љWĂϬϮ(
;ϭ͘ϱdž,ϬϯͿнϴсWĂϬϮlO(
;&1.4"%+*()%9.%"/+/(
јWĂϬϮ(
WĂϬϮс;Ϭ͘ϵdž,ϬϯͿнϭϱ(
(
?&/$+3.1"3E()*+,"/+/(
((((()*21&(
(((((!F3"5+*(
ј,ϬϯЁ(
(
(
7!^Q(_(J=!^O(N(ϰϬͬϭϬͿнϮϰ(
7!^Q(_(J=!^O(N(ϰϬͬϱͿнϮϰ(
?&/$+3.1"3E()%9.%"/+/(
((((()*21&(
(((((!F3"5+*(
љ,ϬϯЁ(
(
(
7!^Q(_(OS(>(JS^(N(=.!^O(H(UK((
7!^Q(_(OS(>(JS^(N(=.!^O(HO(K(
X+5,+5I(;+'&,()*+,>4./&(0+/1234.5*&/(
MK(( =!^O(.5,(7!^Q(4"1F(.,,+5I(1"(1F&($7(*F.5I&(
їŵŝdžĞĚĐŝĚ>4./&(,+/"3,&3(+/($3&/&51(
OK( ĂůĐƵůĂƚĞĐŽƌƌĞĐƚĞĚ,Ϭϯс,Ϭϯнȴ()Y(
( !"33&*1&,(7!^Q(b(Oj(їůŬĂůŽƐŝƐ(
( !"33&*1&,(7!^Q(a(O^(їĐŝĚŽƐŝƐ(
@C((()3%4$%3#&(#*&(7&%#3(.3#,"(M(ȴ(?(ȴC(
( (((ȴ(P!,"!(R3/?(ȴ(;)A@Ё(
(
((
)*+,&#+.((
(
]"L(7!^Q(
7+IF(=!^O(
(]"L(7*^Q(
]"L(=!^O(
7+IF(7!^Q(
7+IF(=!^O(
7+IF(7!^Q(
]"L(=!^O(
=3&,"#+5.51(
;&1.4"%+*()*+,"/+/(
=3&,"#+5.51(
?&/$+3.1"3E()*+,"/+/(
(
;+'&,(#&1.4"%+*(
.*+,"/+/(.5,(
3&/$+3.1"3E(.*+,"/+/(
<"1($"//+4%&V(%+9&%E(
%.4(&33"3(
)$$%E(!"#$&5/.1+"5(?2%&/(
;&./23&,(
=!^O(1""(
F+IF(
;&./23&,(
=!^O(1""(
%"L(
;+'&,(
#&1.4"%+*(
.*+,"/+/(
.5,(
3&/$+3.1"3E(
.*+,"/+/(
;+'&,(
#&1.4"%+*(
.*+,"/+/(
.5,(
3&/$+3.1"3E(
.%9.%"/+/(
;&./23&,(
=!^O(+/(
.$$3"$3+.1&(
6+#$%&(
#&1.4"%+*(
.*+,"/+/(
(
;&./23&,(
7!^Q(+/(1""(
%"L(
;+'&,(
3&/$+3.1"3E(
.*+,"/+/(
.5,(
#&1.4"%+*(
.*+,"/+/(
;&./23&,(
7!^Q(+/(1""(
F+IF(
;+'&,(
3&/$+3.1"3E(
.*+,"/+/(
.5,(
#&1.4"%+*(
.%9.%"/+/(
;&./23&,(
7!^Q(+/(
.$$3"$3+.1&(
6+#$%&(
3&/$+3.1"3E(
.*+,"/+/(
;+'&,(;&1.4"%+*()*+,"/+/(=&.3%/(
(
@G(1F&(=.!^O(b(&'$&*1&,(7!^QЁ͕ƚŚĞŶƚŚĞƚŝŵĞĨŽƌ
3&/$+3.1"3E(*"#$&5/.1+"5(F./(4&&5(1""(/F"31V("3(.(
3&/$+3.1"3E(.*+,"/+/(+/(.%/"($3&/&51T(
@G(1F&(=.!^O(a(&'$&*1&,(7!^QЁ͕ƚŚĞŶĂĐŽŶĐŽŵŝŶĂŶƚ
3&/$+3.1"3E(.%9.%"/+/(+/(.%/"($3&/&51(
(
0&%1.(?.1+"(
• 0&%1.(?.1+"(_(( ȴ()5+"5(Y.$H(ȴ(7!^QЁ(
( ȴ(H(ȴ(_(M>O(їƵŶĐŽŵƉůŝĐĂƚĞĚŚŝŐŚ'
#&1.4"%+*(.*+,"/+/(
( ȴ(H(ȴ(a(M((їĐŽŵďŝŶĞĚŚŝŐŚ'ŵĞƚĂďŽůŝĐ
.*+,"/+/(.5,(5"3#.%()Y(#&1.4"%+*(.*+,"/+/(
( ȴ(H(ȴ(b(O(їĐŽŵďŝŶĞĚŚŝŐŚ'ŵĞƚĂďŽůŝĐ
.*+,"/+/(.5,(*"5*233&51(#&1.4"%+*(.%9.%"/+/(
(
0&%1.(H(0&%1.(
ȴ'ͬȴ7!^QЁ(
MK()-Yf(([TOW(H(MU(H(MS(
( -;=f((<.(MQ^:(!%(i^:(!^O(MU:()Y(_(OU(
( OU(>(M^(H(OS>MU(_(MUHi(_(MTWW(
( ȴͬȴ(M>O(f(A5*"#$%+*.1&,(F+IF()Y(#&1.4"%+*()*+,"/+/((
(
OK()-Yf([TOO(H(Q^(H(M^((
( -;=f(<.(MQi:(!%(MM^:(!^O(M^:()Y(_(Mi(
( Mi(N(M^(H(OS(N(M^(_(iHMS(_(^TWS(
( (ȴͬȴ(f(!"#4+5&,(F+IF()Y(#&1.4"%+*(.*+,"/+/(.5,(5"3#.%()Y(
#&1.4"%+*(.*+,"/+/(
62##.3E("G(c&E(="+51/(
• 6E/1&#.1+*(.$$3".*F:(2/&(7\=(*%2&/(
• =+*9(1F&(#"/1(/&8&3&>.$$&.3+5I(.45"3#.%+1E(
.5,(/1.31(1F&3&(
• ZF&(G%"L(*F.31/(.3&(E"23(G3+&5,/(
• )$$%E(*"#$&5/.1+"5(G"3#2%./(N(G+5,(1F&(
G"3#2%./(1F.1(.3&(&./+&/1(G"3(E"2(
• A/&(0&%1.(H(0&%1.(1"(,&1&*1(#+'&,(,+/1234.5*&/(
?&G&3&5*&/(
-3+'&E:()52T((;@!A(()!<=(%&*123&:((6$3+5I(O^M^T(
`##&11:(;+*F.&%T((6+#$%&(.5,(#+'&,(.*+,>4./&(,+/"3,&3/T(A$Z"0.1&T((
( F11$fHHLLLT2$1",.1&T*"#T$3"'ET%+43.3ET8.5,&34+%1T&,2H*"51&51/H/+#$%&>.5,>
#+'&,>.*+,>4./&>
ĚŝƐŽƌĚĞƌƐ͍ĚĞƚĞĐƚĞĚ>ĂŶŐƵĂŐĞсĞŶΘƐŽƵƌĐĞсƐĞĂƌĐŚͺƌĞƐƵůƚΘƐĞĂƌĐŚсĂĐŝĚнďĂƐĞΘƐĞůĞĐƚ
&,Z+1%&_Mm[`MU^\$3"8+,&3_5"=3"8+,&3(J()2I2/1(Mj:(O^MQK(
7.%$&3+5:(;+1*F&%%(]T:(c.#&%:(c.#&%(6T(.5,(Y"%,/1&+5:(;.3*(-T((JO^M^K(X%2+,:(`%&*13"%E1&(
.5,()*+,>-./&(=FE/+"%"IEf()(=3"4%&#(-./&,()$$3".*F:(X"231F((`,+1+"5T((
=F+%.,&%$F+.:(=)T(6.25,&3/(`%/&8+&3T(
c&%%2#:(d"F5()T(JO^^[K((0+/"3,&3/("G()*+,(-./&T((!3+1+*.%(!.3&(;&,+*+5&T(P"%(QU:(<"T(MM(
OWQ^>OWQWK(
;.3+5+:(dTdT(\(eF&&%&3:()TeT(JO^M^K(!3+1+*.%(!.3&(;&,+*+5&f(ZF&(`//&51+.%/:(X"231F(
( `,+1+"5T((=F+%.,&%$F+.:(=)T(((]+$$+5*"11:(e+%%+.#/(\(e+%9+5/T(
<&L#.5:(d"F5T((;@!A()!<=(]&*123&:(6$3+5I(O^M^T(
6D&3%+$:((7.3"%,(;T(((!7`6Z(!3+1+*.%(!.3&(-".3,(?&8+&LT(()2I2/1(OU:(O^MQT(
(
(
?&G&3&5*&/(
F11$fHHG+1/L&4T2*F*T&,2H/12,&51H/&%&*1+8&/HZ+#23Y3.F.#H!"#$&5/.1"3En3&/$"5/&/n
#&1.4"%+*n.*+,"/+/TF1#%(J()2I2/1(Mj:(O^MQK(
F11$fHH*"23/&/TL./F+5I1"5T&,2H#&,WM^H.4IH$"$2$n&'.#$%&6&1STF1#%((
( J()2I2/1(Mj:(O^MQK(
F11$fHHLLLTI%"4.%3$FT*"#H.4In.5.%E/+/TF1#(J()2I2/1(Mj:(O^MQK(
F11$fHHLLLT/*3+4,T*"#H,"*HMO^jUOWOH)*+,>-./&>7.5,"21>612,&51(J()2I2/1(Mj:(O^MQK(
(