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Session 1: Introduction to the BNF and Fluid Prescribing Dr. Emily LongWhat we will cover Introduction to the PSA Navigating the BNF Fluid prescribing Disclaimer: The content of this teaching session is purposes only and is not a substitute forucational professional advice.Introduction to the PSA The PSA 8 different sections to test different aspects of prescribing Breakdown of marks per section At least one question on each of these! You will have access to the BNF onlineWhat can be tested? At least one question on each of these!Question format in the PSANavigating the BNF Can use either NICE BNF or Medicines Complete Navigating the BNF • Use ‘Ctrl + F’ to search for specific phrases • Use sub-sections to find information- e.g. about prescribing in renal impairment. • Search for clinical guidance in Treatment Summaries (list on next slide) • REMEMBER, use the BNFC for Children!!! Treatment Summaries in the BNF Topic Treatment summaries title on the BNF Anxiety/ OCD Antidepressant Overdose/ Dystonias Poisoning, Emergency treatment HRT Sex-hormones INR Oral anticoagulants Opioid conversion Palliative care Laxatives Constipation STEMI Acute coronary syndromes B12 deficiency/ anaemia Megaloblastic anaemia Notifiable diseases Antibacterial Gentamicin Aminoglycosides Excess bleeding Antifibrinolytics Endocarditis Cardiovascular infections Steroid conversion Glucocorticoid therapy Shigella Gastro-intestinal system infection, Antibacterial therapy Cholecystitis Gall stones Osteomyelitis Musculoskeletal infection Heparins Parenteral anticoagulants Diabetic insipidus Posterior pituitary Idiopathic thrombocytopenic purpura Platelet disorders Pneumonia Respiratory infections Smoking Substance dependence Antacids Dyspepsia/Chelates and Complexes“Appendix 1 Interactions”Prescribing Fluids Fluid Prescription Introduction to Fluids Resuscitation Fluids Maintenance Fluids • Fluids in the BNF • Calculating daily requirements • Daily fluid requirement • Adults • Types of fluids to remember • Pediatrics • Correcting electrolyte abnormalities for the PSA Treatment Summary: ‘fluids and electrolytes’ Navigating the BNF: Fluids • Useful breakdown of electrolyte levels in fluids. • Useful for electrolyte content of losses (e.g. gastric losses, biliary losses) • Not particularly useful for guidance regarding which fluid to use in different clinical situations. • 25-30 ml/kg/day of water • 1mmol/kg/day of Potassium, Sodium and Chloride Adult Daily Maintenance Fluid Requirements Per NICE guidelines • 50-100g/day of glucose (to prevent starvation ketosis) Example: 70kg Man - 1750- 2100 ml/ day of water - 70 mmol/day of Potassium, Sodium and Chloride - 50-100g/ day of glucose Types of fluid for the PSA 0.9% Sodium Chloride (NaCl) 0.9% Sodium Chloride with 0.15% Potassium Chloride Sodium 150 mmol/litre Sodium 150 mmol/litre Chloride 150 mmol/litre Potassium 20 mmol/litre Chloride 170 mmol/litre 0.9% Sodium Chloride with 0.3% Potassium Chloride Glucose Containing Fluids Sodium 150 mmol/litre 5% Glucose 50g glucose in 1000ml of water Potassium 40 mmol/litre Chloride 190 mmol/litre 10% Glucose 100g glucose in 1000ml of water 50g glucose in 1L 5% Glucose with 0.15% KCL 20mmol Potassium and chloride 100g glucose in 1L 5% Glucose with 0.3% KCL 40mmol Potassium and chloride All can be found in the fluids and electrolytes treatment summary! Prescribing Potassium Potassium can be given at a MAXIMUM rate of 10mmol/hour (on wards) Therefore: . Minimum time for a 1l bag of NaCl with 0.3% (40mmol/l) potassium is 4 hours . Minimum time for a 1l bag of NaCl with 0.15% (20mmol/l) potassium is 2 hours Timings of IV Fluids “Stat” Fast bag Slow bag 15 minutes 4 hours 8-12 hours Often to correct Resuscitation abnormality, e.g. Usually for hypocalcemia or maintenance fluids hypokalemia • Fluid status assessment before prescribing! - Peripheral oedema/Raised JVP/Bilateral crepitations Clinically important things to - Reduced skin turgor/dry mucous membranes/ remember when prescribing increased CRT fluids • Consider age, conditions such as heart failure or impaired renal function • Monitoring while on IV fluids: - Daily U&E’s - Fluid balance charts (input/output) Fluids in Pediatrics ) Resuscitation Maintenance Holliday-Segar formula for 24 hour maintenance fluids in children: 10ml/kg over 10 minutes 100 ml/kg/day for the first 10kg of weight 50 ml/kg/day for the next 10kg of weight e.g for a 25kg child 20 ml/kg/day for weight over 20kg 25 x 10ml e.g. for a 25 kg child 250ml 100ml x 10 50 ml x 10 0.9% Normal Saline 20 ml x 5 Total: 1600 ml Summary of Adult Fluid Prescribing Emergency Emergency Maintenance Maintenance electrolyte Fluids (No deficits Fluids WITH resuscitation abnormalities or fluid losses) deficits or losses Hypokalemia: 1l Monitor losses and chloride 500ml in 15 with 0.3% potassium 25-30 ml/kg/day aindividual approach, minutes chloride over 4 water less likely to be hours asked on PSA!) (In reality, may be Hypercalcemia: 1l 2heart of renaly, 0.9% Normal Saline 1mmol/and Ky Na 1l over 4-6 hours failure) over 4 hours. 20-100g/24h glucose 1L over 8-12 hoursPractice Questions Question 1 ) Case presentation Medication A 54 year old woman presents to A&E with lethargy. She has a two-day history of nausea and vomiting and as not been able to tolerate any oral fluids for the past few days. Weight 65kg. PMH. nil. DH. Paracetamol 1000mg PO Dose Route PRN. On examination Airway patent, alert and talking. Sats 97% on RA, RR 16, chest clear. BP 92/44, HR 125 and regular, HS I+II+0, cap Frequency Duration refill >3s. T 37.4, PEARL, GCS 15/15, capillary glucose 5.6. Abdomen SNT, no peripheral oedema. Prescriber Date Prescribing request Write a prescription for ONE IV fluid that is most appropriate to treat the patient’s current condition. Adult Resuscitation Fluids Answer: Sodium chloride 0.9% , 500ml over 15m IV Why? On examination Airway patent, alert and talking. Sats 97% on RA, RR 16, chest clear. BP 92/44, HR 125 and regular, HS I+II+0, cap refill >3s. T 37.4, PEARL, GCS 15/15, capillary glucose 5.6. Abdomen SNT, no peripheral oedema. Hypotension, tachycardia, reduced capillary refill or other evidence of Hypovolemia ( From the history, nausea and vomiting and no oral fluids) Note: On the wards, usually we would give a 250ml bolus in older patients (or other patients at risk of fluid overload) but for the context of PSA, prescribe a 500ml bolus. Question 2 ) Medication Case presentation A 19 year old man is admitted to the general surgical ward awaiting a laparoscopic appendicectomy for appendicitis. He is to remain NBM until his operation this afternoon Dose Route Weight 84kg. PMH. Nil. DH. Nil. Investigations Na 141 (137-144), K 4.3 (3.5-5.3), Urea 5.0 (2.5-7.0), Creatinine 63 (60-110), capillary blood glucose 7.1 Frequency Duration Prescribing request Prescriber Date Write a prescription for ONE IV fluid that is most appropriate for the patient at this stage? Adult Maintenance Fluids Answer: Sodium chloride 0.9% / potassium chloride 0.3%, 1000ml over 8-12h There are other possible answers for this, and in reality what you will use will depend on your hospitals protocol. But for the PSA, keep it simple! Could also have: Glucose 5% / potassium chloride 0.3%, 1000ml over 8-12h Or other variations, such as Hartman’s. Investigations Na 141 (137-144), K 4.3 (3.5-5.3), Urea 5.0 (2.5-7.0), Creatinine 63 (60-110), capillary blood glucose 7.1 - Electrolytes normal - Renal function normal - Blood glucose normal Question 3 ) Case presentation Medication diarrhoea. Viral gastroenteritis is suspected. Symptoms have been ongoing for 3 days and she has managed to eat and drink little during this time. Weight 60kg. PMH. Nil. DH. Nil. On examination Dose Route Airway patent, alert and talking. Sats 99% on RA, RR 16, chest clear. BP 120/72, HR 102 and regular, HS I+II+0, cap refill 3s. T 37.4, PEARL, GCS 15/15, capillary glucose 4.9. Abdomen SNT, no peripheral oedema. Investigations Frequency Duration Na 137 (137-144), K 3.4 (3.5-5.3), Urea 7.0 (2.5-7.0), Creatinine 100 (60-110) Prescriber Date Write a prescription for ONE IV fluid that is most appropriate for the patient at this stage? Adult Replacement Fluids Answer: Sodium chloride 0.9% / potassium chloride 0.3%, 1000ml over 4 hours (Could have between 4-6 hours, this is a situation for a ‘fast bag’ of fluids) On examination Airway patent, alert and talking. Sats 99% on RA, RR 16, chest clear. BP 120/72, HR 102 and regular, HS I+II+0, cap refill 3s. T 37.4, PEARL, GCS 15/15, capillary glucose 4.9. Abdomen SNT, no peripheral oedema. Investigations Na 137 (137-144), K 3.4 (3.5-5.3), Urea 7.0 (2.5-7.0), Creatinine 100 (60-110) Question 4 ) Medication Case presentation A 68 year-old woman is admitted to the medical ward with a 3 day history of diarrhoea. She has not managed to eat or drink properly since the symptoms started. Weight 71kg. PMH. Nil. DH. Nil. Dose Route Investigations Na 141 (137-144), K 2.7 (3.5-5.3), U 6.1 (2.5-7.0), Cr 110 (60-110), capillary glucose 4.9 Frequency Duration Prescriber Date Prescribing request Write a prescription for ONE IV fluid that is most appropriate to treat his current condition. Hypokalemia Answer: Sodium chloride 0.9% / potassium chloride 0.3% solution, 1000ml over 4h IV Investigations Na 141 (137-144), K 2.7 (3.5-5.3), U 6.1 (2.5-7.0), Cr 110 (60-110), capillary glucose 4.9 Clinical Context: - Follow the hypokalemia guidelines of your trust! - ECG- ECG changes include Long PR interval, Long QT interval, loss of P waves, U waves. - Re-assess after fluids REMEMBER: Potassium can be given at a MAXIMUM rate of 10mmol/hour (on wards) - Minimum time for a 1l bag of NaCl with 0.3% (40mmol/l) potassium is 4 hours - Minimum time for a 1l bag of NaCl with 0.15% (20mmol/l) potassium is 2 hours Question 5 ) Case presentation Medication A 45-year-old woman is in triage in AMU, having come in with abdominal pain, weakness and confusion. She has recently seen her GP for lower back pain. Weight 60kg. PMH. Hypertension. DH. Ramipril 2.5mg PO once Dose Route daily. Investigations Hb 99, Na 142 (137-144), K 4.5 (3.5-5.3), U 4.3 (2.5-7.0), Creatanine166 (60-110), eGFR 45 (>60), Ca 4.8 (2.2-2.6), Frequency Duration capillary blood glucose 4.6 Prescriber Date Prescribing request appropriate to treat her current condition.is most Hypercalcemia Answer: Sodium chloride 0.9%, 1000ml over 4h IV Investigations Hb 99, Na 142 (137-144), K 4.5 (3.5-5.3), U 4.3 (2.5-7.0), Creatanine166 (60-110), eGFR 45 (>60), Ca 4.8 (2.2-2.6), capillary blood glucose 4.6 Clinical Context Signs of hypercalcemia: Treatment: Aggressive fluid resuscitation initially, then medications including IV bisphosphonates, while investigating the underlying cause. Question 6 ) Case presentation Medication A 35 year old woman on the general medical ward is found to be sweaty, confused and drowsy. Weight 85kg. PMH. Type 2 with meals, empagliflozin 10mg PO once daily.wice daily Route On examination Dose Airway patent, drowsy but rousable, confused. Sats 98% on RA, RR 12, chest clear. BP 146/88, HR 100 and regular, HS I+II+0, cap refill 2s. T 36.9, PEARL, GCS 13/15, capillary glucose 2.3. Abdomen SNT, no peripheral oedema. Frequency Duration Would not tolerate glucogel Not responsive to 1mg IM glucagon Prescriber Date Prescribing request Write a prescription for ONE IV fluid that is most appropriate to treat her current condition. Emergency Hypoglycemia Answer: Glucose 20%, 100ml over 15m Glucose 10% 200ml over 15m On examination Airway patent, drowsy but rousable, confused. Sats 98% on RA, RR 12, chest clear. BP 146/88, HR 100 and regular, HS I+II+0, cap refill 2s. T 36.9, PEARL, GCS 13/15, capillary glucose 2.3. Abdomen SNT, no peripheral oedema. Clinical context - Known diabetic - Different eating in hospital to at home - Follow hospital guidance - BNF treatment summary: Medical emergencies in the community Summary of Adult Fluid Prescribing Emergency Emergency Maintenance Maintenance electrolyte Fluids (No deficits Fluids WITH resuscitation abnormalities or fluid losses) deficits or losses Hypokalemia: 1l Monitor losses and chloride 500ml in 15 with 0.3% potassium 25-30 ml/kg/day aindividual approach, minutes chloride over 4 water less likely to be hours asked on PSA!) (In reality, may be Hypercalcemia: 1l 2heart of renaly, 0.9% Normal Saline 1mmol/and Ky Na 1l over 4-6 hours failure) over 4 hours. 20-100g/24h glucose 1L over 8-12 hours PLEASE FILL OUT THE FEEDBACK FORM! Next session: 20 Jan (Monday), Calculations and Adverse Drug Reactions osceazyofficial OSCEazy osceazy@gmail.com OSCEazy osceazyofficial REFERENCES • Medicines Complete BNF • NICE BNF • Geeky Medics IV fluid Prescribing: https://geekymedics.com/intravenous-iv-fluid- prescribing-adults/ • NICE Guidance fluid prescribing: https://www.nice.org.uk/guidance/cg174