脱水( dehydration) 是指体液容量的明显减少。脱水按细胞外液的渗透斥不同而分为高渗性脱水、低渗性脱水和等渗性脱水三种类型。

(一)高渗性脱水

高渗性脱水(hypertonic dehydration) 以失水多于失俐，血清铀浓度> 150mmollL ，血浆渗透压> 3 1 0mmollL 为主要特征。

1. 原因

( 1 ) 单纯失水:任何原因引起的过度通气都可使呼吸道茹膜的不感蒸发(纯水)增加，导致大量失水。

(2) 失水大于失铀: ①胃肠道失液:呕吐和腹泻会丧失含例量低的消化液;②经皮肤失水: 例如，在发热或甲状腺功能亢进时，通过皮肤的不感蒸发每日可失水数升。汗为低渗液，大汗时每小时可丢失水分800ml 左右;③经肾排出低渗尿:反复静脉输注甘露醇、尿素、高渗葡萄糖等时，因肾小管液渗透压增高而引起渗透性利尿，排水多于排制; 中

枢性尿崩症时因抗利尿激素(AD H) 产生和释放不是， 肾性尿崩症时因肾远曲小管和集合管对ADH 的反应缺乏，肾脏排出大量水分，其中只含很少量的例。

(3) 饮水不足: ①水源断绝，如沙漠迷路;②不能或不知饮水，如频繁呕吐、昏迷、极

度衰弱的患者等; ③渴感障碍，如中枢神经系统损害、严重疾病或年老体弱的患者可因渴

感丧失而造成摄入水减少。

iI伍床上，高渗性脱水的原因常是综合性的，如婴幼儿腹泻引起的高渗性脱水，其原因除了丢失肠液、摄入水不足外，还与发热、出汗和呼吸增快等因素有关。

2. 对机体的影响

( 1 ) 口渴:因失水多于失铀，细胞外液渗透压增高，剌激口渴中枢，患者有渴感。

(2) 细删兄水:由于细胞外液渗透压增高，使水分从细胞内向细月包外转移，引起细胞脱水。

(3) 尿的变化: ①尿量:除尿崩症患者外，细胞外液渗透压增高， 剌激下丘脑渗透压感受器使ADH 释放增多，肾重吸收水增多，尿量减少而比重增高;②尿铀含量的变化:早期或轻症患者，由于血容量减少不明显，醒固自同分泌不增多，故尿中仍有铀排出，其浓度还可因水重吸收增多而增高;晚期和重症患者，可因血容量减少、自主固自同分泌增多而致尿铀含量减少。

(4) 中枢神经系统功能障碍的症状: 由于细胞外液渗透压增高使脑细胞脱水引起嗜睡、肌肉抽擂、昏迷，甚至导致死亡。脑体积因脱水而显著缩小时，颅骨与脑皮质之间的血管张力增大，因而可导致静脉破裂而发生蛛网膜下腔出血或局部脑实质出血。

(5) 脱水热:见于脱水严重的病例，尤其是小儿，由于从皮肤蒸发的水分减少，导致

散热受到影响。

3. 防治原则①积极防治原发病; ②补充水分，不能口服者静脉给予5%- 1 0% 葡萄糖溶液。应当注意，高渗性脱水患者也可丢失$内，故还应补充一定量的含纳溶液，以免发生细胞外液低渗。

(二)低渗性脱水

低渗性脱水(hypotonic dehydration) 以失纳多于失水，血清饷浓度< 130mmol/L ，血浆渗透压< 280mmol!L 为主要特征。

1.原因

(1) 丧失大量消化液而只补充水分:这是最常见的原因。大多是因呕吐、腹泻，部分是因胃、肠吸引术丢失体液而只补充水分或输注葡萄糖溶液。

(2) 经皮肤失水:①大汗后只补充水:汗虽为低渗液，但大量出汗也可伴有明显的纳丢失，若只补充水分则可造成细胞外液低渗; ②大面积烧伤只补充水: 大量体液丢失而只补水时可发生低渗性脱水。

(3) 肾'性失铀:可见于以下情况: ①水肿患者长期连续使用排纳性利尿剂(如氯唾嗦类、映塞米等)j ②急性肾衰竭多尿期; ③Addisoll 病，可因为醒固自同分泌减少，而肾小管对铀重吸收减少。对上述经肾失俐的患者，如果只补充水分而忽略了补$内，就可能引起低渗性脱水。

2. 对机体的影响

(1)无口渴: 体液低渗状态而使口渴中枢的兴奋'性降低。

(2) 血容量减少:细胞外液容量及血容量明显减少， 导致心输出量降低， 易发生低血容量性休克。

(3) 尿的变化: ①尿量的变化:低渗性脱水的早期无明显尿量减少，严重的低渗性脱水患者，尿量可明显减少; ②尿纳含量的变化:由于细胞外液(尤其是血容量)减少，以及血铀浓度降低，可导致醒固自同分泌增多，使肾小管对Na+ 重吸收增加，尿铀减少。

(4) 脱水征:因为血容量减少、血液浓缩和血浆胶体渗透压增大，毛细血管有效滤过压降低，组织液生成减少，同时促使一部分组织间液向血管内转移，所以组织间液的减少比血浆的减少更明显。患者可出现皮肤弹性减退甚至丧失、眼窝凹陷、婴儿囱门内陷和体重下降等脱水征。

(5 ) 中枢神经系统功能紊乱:由于细胞外液低渗，水分进入细胞内增多，细胞内液容量增加，导致脑细胞水肿，严重者可出现中枢神经系统功能紊乱。

3. 防治原则①积极防治原发病; ②根据病情及时补充NaCl 溶液，以恢复细胞外液的容量和渗透压。对轻度患者，一般给予生理盐水即可。对重症低渗性脱水患者可给予高渗盐水;③如患者出现休克，要按抗休克方法积极抢救。

(三)等渗性脱水

等渗性脱水(isotonic d ehydration) 的主要特征是水与纳按其在正常血浆中的浓度成比例丢失，血清铀浓度维持在130-150mmol/L ，血浆渗透压保持在280-31 Ommol/L 。

1.原因①大面积烧伤:烧伤时创面血浆大量渗出引起等渗性体液丢失;②小

肠液丧失: 从十二指肠到回盲部的所有小肠分泌被以及胆汁和膜液的纳浓度都在1 20- 140mmol/L 之间。因此，小肠炎所致的腹泻、小肠瘦、小肠梗阻时的呕吐等可引起等渗体液的丧失;③大量胸腔积液、腹腔积液形成。

2. 对机体的影响细胞外液容量减少而渗透压在正常范围，故细胞内外液之间维持了水的平衡，细胞内液容量无明显变化。血容量减少可通过自主固自同和ADH 的增多而使肾对锅、水的重吸收增加，因而细胞外液得到一定的补充， 同时尿铀含量减少，尿比重增高。如血容量减少迅速而严重，患者也可发生休克。若不予及时处理，则可通过不感蒸发继续丧失水分而转变为高渗性脱水;若只补充水分而不补饷盐，又可转变为低渗性脱水。

3. 防治原则防治原发病，输注渗透压偏低的氯化铀溶液。

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