Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

everyone. Welcome back. Thanks for coming to those who were here last time on for those of you weren't here for part one. This will still be useful. There's a couple of follow on cases from last time, but it doesn't really matter if you weren't head see them in the first place. Let's quickly run through how this all happened. So because we haven't met me, my name's Tom Granger. I'm enough to you working in Somerset, applying for gyny. But this is very much a general medicine in general surgery session entirely led by you guys. You will decide exactly where we go and when. Let's get started. Let's have a look. So you are the FBI one on call. You started your night shift in the session the other day. You're up four hours into the night shift, and it's really been quite busy. We've seen a few different cases. This session is gonna take it from about one o'clock in the morning through the morning. Hand over 9. 30. We've got S h o n a med ridge, also on call, but they're mainly focused on Clark new patients. So the words of your responsibility, but there's a bit of help there if needed. Set some ground rules during this session. As I said before, you are in charge of the body, See, patients is entirely up to you guys, is the viewers. You'll be frequently us to decide where we go. Next on. I will follow the majority decision. You'll not be given all of the relevant information for the patients in the stem. You need to ask for it. They're examinations you want. If there are observations, bedside tests, blood or imaging you what you need to ask me for it. And this is so that we can simulate a really encore. You have to think about these things dynamically as you go through. Feel free to use your phones if you want. Antibiotic guidelines. MG cow. Any APS like that that you would use in the real world? Absolutely. Go ahead. Open those up and use them. You might find them useful in some of these scenarios. You're welcome to take notes as we go, but think of this more is an on call. So one good way of doing it is to get a piece of paper, fold it into eighths and maybe write small bits about each patient on each of these but detailed note. So probably not as helpful you as helpful in this session as I'm just cracking on and joining it. So recap of our last session. So we have three jobs outstanding. Unfortunately, they carried on and followed through for us. We have got Andy Miller, who needs a decision about treatment, escalation and the treatment escalation form filled out. Now we've got Brenda. All right, you need to start on her. Fur is my prescription on. The nurse is waiting for you to come and prescribe it. And Ramona Flowers needs her gentamicin reassess to potentially replace scribed. So let's get started. So start the session. The bleeps gonna ring one o'clock and it's the site manager next. I'm really sorry about this, but the surgical team are tied up a horrendous laparotomy and feel better. They're absolutely all hands on deck. I know you're supposed to be in a medical F one, but the surgical wards have quite a few jobs piling up on. We'd be really grateful if you can help out with some of those. Unfortunately, because this is the NHS. We're just gonna take it and we're gonna get on with things and decent medicine and surgery in this session. So immediately after that, of course. Surgical ward rings on Have got another case for you to add on to your jobs list. So they've got a POSTOP patient who they need some help with. He really wants a cup of milk tea, but his POSTOP plan says free fluids only. Can you come and take a look at him and let me know whether he can have his team with milk place on? Guess this is the kind of question that does somehow crop up. But one o'clock in the morning, on down the way to your job to get another phone call and they say, Oh, hi, Doctor. I've got a patient awards seven called Muriel Cherish. I'm just gonna rub on her heart rate 150. Ignore what it says. There is 150. I've done any CD. Can you come and review our place? So let's have a look at our jobs list. So we've got a few jobs here from before, and we've got two new ones. So what? I'm going to do is pull you guys on. If you could please let me know. Option. They will be that we can go and see Birenbaum drawer right about her. Freeze might option being we can go and see Ramona about a gentamicin option c we can do with this tachycardia patient, Muriel Option d We can go and start this treatment. Escalation plan for Andy Miller. Option the We can go and see Castle Tyson Sort this fluids out. So I'm just going to give probably about 30 to 40 seconds, right? Fairly comprehensive. You guys want to go and see Muriel? So that's going to be bureau. So, um, you're really cherish. She's an 83 year old lady who was admitted with the UTI as she's been managed with or piperacillin, um, for an uncomplicated UTI on. She was only kept in hospital because she was struggling to manage on her own with her activities of daily living. She's been on antibiotics for the last three days, but now developed tachycardia on the nurses would like you to come and review her, please. So she's lying on bed when you're in the bed when you arrive on the Ward's She's can't just but confused, telling you that she needs to get to the bus stop. So anything you ask her, she's answers quickly. But then she says she needs to go and get to the bus stop and she's sweaty and she's tacky. That has a regular pulse when you palpate it. She's got a palpable bladder when you palpate her abdomen and she's got some super pubic tenderness. What else would you guys like to know about this lady? Tell me in the chart. Me. What's our BS? Sorry, Assad. Blood sugars. Yes, I have blood. Sugar is normal. BP. What? We've got some ops. Lily, can you write me where the obs are? Yeah. Hopes is be So. Here's the cephalosporins guys. So she's tachacardic that so is tachycardia. She's Parexel a 38 quid to her. Pressure's 125 over 74. She's talking 150 or respiratory rate 16 on her SATs. 97%. That's gone, Remember? Totally play. So just second bloods yet? Honey, what bloods would you like? Yeah, CRP and white cells is good. Starting point isn't Yeah, for blood count and crp. It probably gonna be in our most useful, anything else that would be really useful in this patient and see if some cultures about Yeah, it's also really sensible. Suggestion, dipstick. I mean, she's treated for a UTI, said Hope that already done is steak. Yeah, definitely. Yeah, where we got blood. So I've got some bloods in here that so she's got a white cells of 18 today. Yesterday they were 21. Her hemoglobin's 110 for your ear is 7.4, and it was 6.2 yesterday on her creatinine is 148 and it was 86 yesterday. Her CRP is 65 on yesterday it was 82 a sodium is 134 and her potassium is 4.4. So what you guys make of these bloods resolving? AKI? Um, I have another look. So that's 148 going up from 86 That cream in, but definitely you're thinking about the A. K. I would say, Yeah, it looks like the infection is resolving of it doesn't, But certainly I think the creatinine is is the thing that stands out as well. Yeah, someone else asked for a year in microscopy. I think we've got that somewhere. Um, yeah, it's s So her urine sample was sent on admission, and it's grown some gram negative rods. They are resistant to amoxicillin and the cylinder. Um, intermediate sensitivities to ciprofloxacin on, Sensitive to nitrofuran and gentamicin, Right? What do you What do you guys know about Gram? Negative rods. Any any examples of gram negative rods? Any thoughts on how that might improve your antibiotic choices? Iko? Yeah, that's the commonest gram negative rods in terms of uti. Definitely on. We know equally has very high resistance rates to amoxicillin. So yeah, it could be. Could be any kind. Like what else did you guys like to know? So we're off to come and see because she was tachycardia. 150 sed. Yeah, we got the CD someone haven't made. I think that he you got it museum and I'm not a little bit for you. Tell me what you guys make the HCG. Thanks. I'll give you a bit of time in this one. We've had one option is one of her Sinus tracking. Hear anything else? Any other thoughts? A fit? Yeah. So what makes what makes people say it's a F Nope. A ways. Yeah, well, swirls do you normally have with atrial fibrillation's so you normally have absent P waves? There's something else you have atrial fibrilation. Oh yeah, irregular. Do we think? Is this irregular? Do we have unequal or an unequal our our ratio? Here, kid PSVT a CT normally that quicker than 150 but it's good thing to think about. It's certainly a narrow, complex tachycardia. I would say that this our our interval is regular on BCG. I suddenly pick this easy to be a regular 11 thing in terms of thinking about peewee is of atrial fibrilation. It's really important to think about, um, how rate effects that so with the tachycardia. What you can often find is that your P waves could be buried in ST segments because you're not really having enough time for full relaxation of the ventricles before the next atrial contraction. So what's what's? There were no clear and obvious P waves here. I think you could potentially argue for some of these before the complexes being P waves. Certainly there a regular regularity between the are are complexes on but it's it's only look more regular than irregular. So I think this is a Sinus tachycardia, as opposed to in atrial fib. They're necessarily make out the P waves. I think that's a really nicely consistent our our ratio on which is much more in keeping with a Sinus tachycardia. But certainly if it's something to think about for those you thinking about SPT it's a good thought. But usually it would be quicker than 100 50 for an STD and only thinking of 1 60 to 200. Anything else you want to know? Guys? Yeah, urine output. Really good point. Anyone with the ETI? She's got an A k I. So she's catheterized, which is helpful this year in in the Catheter Bag, and it's dark yellow and it's got heavy sediment in it. It is something you really get used to seeing in their patients with UTI. I take it if you do any sort of medical or Jerry's job. So she's on. Put a total of 400 mils of year in up to midnight, and there's 400 mils in the drainage box. She's been drinking or fluids only. It's not clear from the input chart. How much she's drunk So again, Unfortunately, this is quite a common reality is that you get partially completed. Fluid balance is sometimes if you put yourself in the nurse's shoes. So many people are very quick to criticize nursing staff or not completing for balance charts. But just think how difficult it could be to make sure that every single hour you're going to your patient and checking that they have, how much they've had in and how much they found out. It's quite a lot of work, actually, so it's very common that you'll get spotty year fluid balance Charles outside by to you, whether you normally very good at it. But we know she's had about 800 mils, at least over the last day. How much? Assuming of body weight of about 60 kg, How much fluid should she have in over 24 hours? Certainly unleased a litter, and she's only 100 year, certainly at least a liter, probably more likely 1.1 point 2 to 1.5 thinking to 2 to 2.5 mils per kilo, right? Sorry, 2025 miles per kilo. Now then, um any other information you'd like to know about her or we happy here, I think. What makes the the things that I'd have highlighted allergies? Yeah, someone was here the last session. She's know Granny allergies from that. So what we do about her antibiotics? Then we can leave her on the insulin and we can change her toe nitrofurantoin 50 mg Do yes or really we could give a gentamicin 280 mg stopped and then measure the trough levels and 12 hours we could change it to IV ciprofloxacin. 400 mg IV ts What we could call med region have a chat with them about Yeah, that shows. All right, Great. I think there's a There's a few good old press is going on here. So there's if you have gone with option being nitrofurantoin. What are we thinking now? What? What do you like nitrofurantoin in this situation? So it's a good thought, actually. Interned Say we've had, like, year sensitivity. Absolutely. So that's a good thing to think about or or nitrofurantoin. She's got some sensitivity to it. That's good. Those of you who were thinking about the ciprofloxacin. Why do you like the ciprofloxacin. That's fine. And whoever gets my son what we think, imagine my son would be like. So gentamicin was one of the other sensitive options here. Those of you who went with nitrofurantoin over gentamicin on what made you lean away from gentamicin rather than I was going for the 93 interns. My sense nephrotoxic she's got increased creatinine. Yeah, less side effects. Yeah, all good thoughts on those of you Wanted to call the metric what you're worried about with this lady that's made you call the Med Ridge. How would you summarize what's happening with this lady? So bromine? Often when we're making nursing women making notes, entries for patients we often like at the end of our our at the end of a systematic review, we often like to put in impression. So yes, someone suggested possible year. Except it's so that's your sort of headline is your impression. So, yeah, you're worried that she's septic, are you? So I think it's no unreasonable to be contacting. Um, it registered by Certainly if you're if you're sort of new to write for one job, you're doing your first set of them called. Absolutely. Imagine the Medrol would be more than happy to discuss the lady like this. So we've gone with that. Let's let's have a look and see what the matter of just that's for us. Yeah, So they've said, I think the a k I could be because of the UTI and dehydration. A stab dose of gentamicin could be really useful in urosepsis, particularly with Grandma negative agents. So gentamicin aminoglycoside really good against gram negative bacteria. Gentamicin also is particularly effective with one off dose is the problems with gentamicin tend to come with accumulation, so most of the nephrotoxicity with gentamicin comes from accumulation by having either inappropriately high dose ing or keeping people on gentamicin for too long. So if you've used a good weight based dosage for gentamicin and you are reevaluating that prescription rather than just giving it, giving it giving it, then it can be really sensible even in people with a slight a k I, so that the Med Register Gestion is let's give her a step dose now repeat her using these in the morning and document in the notes that the dating needs to review whether she needs to carry on that gentamicin So you often hear people using terms like a shot of gentamicin because giving it a one off dose can be really helpful for people with success, especially if it's from a gram. Negative source. So we'll do that. Then we'll give us and gentamicin option to you. What about this tachycardia? Then we've got a few options here on. We could give us and say lines down to 500 mils. We could give her 250 miles of Salen. We could give her some saline and with hold her for his mind, we could give her a stat dose and stop prolong what we call the Mezrich. That's one of the things you guys didn't ask for actually, was her medications. Or if you did, I missed. It's all right. So she is on a few medications, including Frusemide. She takes 40 mg. Media freeze might also guys, we've got a few options here. We can give us influence and given your range of options of fluid there. But we could give us and fluid and withhold that for his might. We could give her a stat dose of his operable if we want to try and bring down the heart rate a bit or we can call the Mezrich. I'll say. I pulled this question against a number of different clinicians of various grades, and I've had a few different answers. So if you're really struggling to choose between two answers here, know that there are a few good safe options there. But yeah, than shop Great. So some of you have gone with 250 mills of fluid. Why do we want where some of you thinking about that conservative amount of fluid? Because I can think of one very sensible reason why unsure. Fluid intake? Yes, it is difficult to know, isn't it? Giving a small amount of fluid could be really useful in that you can reassess someone after a small amount of fluid on. Then, if you think it's still not enough, you can always give some more after. So, yes, the seven support thought isn't it? What else are we worried about? Is making us go with the 2 50 rather than 500? Bring him on 250 miles is a glass of water, whereas 500 mils a pint of water. That's the way I tell you sort of describe it to people. Is she in urinary retention? Yes. You can be a powerful bladder, but she has got She has got a catheter, and I suppose it could be king. Present it. Someone else has made a really sensible suggestion. Has she got heart failure? Is that watches on the freezer? Might? Yeah. So let's have a little look back. Uh, so if if you'd examine this lady if that would be one of the things you said, if you don't have fluid status assessment, I would have told you she's got sunken sunken membranes. She's got quite dry skin. She has got some pitting edema to her ankles, and she's got some crackles on her chest. Um, she has got heart failure. What do you do about that? What do you do in someone who's got evidence of heart failure? But also, there's evidence of an a k. I'm dehydration. Difficult, isn't it? Yeah. The sensible thing to do in people like that is to give, um, small amounts of fluid, listen to their chest, see if it's worse, but actually is an f y one who is new to the job. If you've got someone. This is something you'll find. It's really, really common in medicine. Is what do you do about someone who's intravascularly dry and deplete but peripherally or peripherally or thoracic? Clear, Really wet and it's really difficult situation. But actually I think on the whole high it high creatinine like this. No evidence of respiratory difficulty. Remember her SATs were quite high. I think it's sensible to think about fluids. Those of you who wanted to get some pus opera while we're thinking that what's the thought process behind the flow and this and sensible thought behind so below What, what? What makes some people sick so things I can think of. Her BP was about 140. Systolic is high enough that she would be up to tolerate some bizarre. It's going to reduce the metabolic. Yeah, it's gonna bring a heart rate down, isn't it? But it's really important to think of why someone's heart rate is high. If if it's a physiological elevated heart rate because your heart was saying, I need to work harder to refuse tissues which is struggling with infection, then the way of reducing it. The reason why we want to reduce that tachycardia is actually no, not anything to do with the metabolic demand on the high itself, necessarily. But it's because we want to treat whatever is causing that tachycardia. So if you've got something like sepsis, what we really want to do is treat that sepsis and let the heart rate do its own physiological correcting on rather than in if it inappropriately correcting it potentially. So if you get those operable to someone who's heart rate is high because of sepsis, what you're then doing is reducing the heart's own physiological response to that infection. And you're stopping the heart from doing those natural processes needed to fight infection. So I think this, uh, prolong it would wouldn't be my option here. I think, actually, any of the fluid options is is sensible in this lady on for is, um, idea. It's a difficult one, isn't it? So when I spoke to a message, this is what they said to me when I gave him this exact scenario. They said, Yeah, she sounds subject. You definitely need some fluids. Holder for his mighty because she's got good going. Okay, I that make sure it's well documented that it needs to be reviewed in the morning with repeat bloods. This is a well, also the kind of person I would like to go back to shortly after. I have a listen to that chest. So if you prescribe someone's and fluids and you say, Okay, I want this a half hour, make an effort to get back in half and hour, listen to their chest, make sure they're not suddenly got flash pulmonary edema is a result and then need more for his might. So, yeah, good thinking, guys difficult one, this is is exactly the kind of scenario you come across on. It is exactly the kind of scenario it's think about speaking to the Med Ridge with pretty clear. If you're not very confident in this scenario, what about her catheter? So we said her cat has not drained anything since midnight, so there's a few ways we can handle this. We can ask them to empty the drainage bag and reassess that urine output in two hours' time could ask him to do a bladder scan. They could flush the catheter. They could remove it and replace it, or they completely take out because it could be the source of your infection. What do you think? Just quickly? Someone mentioned a little while ago thinking about colloid fluids in this lady. I think that's a very contentious topic. It's a good thought. Currently, the nice guidelines in the UK don't recommend using colloid is in sepsis. I think the evidence basis for keloids tends to follow this cyclical tract, where they go into an out of favor quite frequently on Colin's can also worsen. Then, okay, it's it's a difficult one. Um, most of the time that I've seen keloids used to be the been in very specific scenario. Such a replacing loss is from acidic drains or in intensive care when they used with very good fluid monitoring. How long is Captain in situ? Yes, it's been in for about three days. Great. Now show those results. Yes, really good thought process is here. So if the drainage bags hasn't had anything new in it, waiting two hours probably isn't going to change. The fact is not draining. We've given her some fluid, so I suppose, waiting time to see if actually it's a little pre B. Know what and that's going to get some more. Free it up is one way of thinking about it. No one's asked for a bladder scan. The bladder scan might be useful to be fair. If the blood if the catheter is kinked or blocked, it might show a buildup of year in within the bladder On that makes it more easy to think that this is a post renal rather than a pre renal condition. If the bladder scan shows nothing in the bladder and yet you've not got year and out and you've got a high creatinine, you can think right. This really is someone who is dry, and I definitely need to give her some fluids. However, if the bladder scan shows that there's a liter of fluid in her bladder that actually you think, Oh wow a year and output really isn't is a little higher than I thought. Maybe she doesn't need much of that fluid. Flushing the catheter with some saline is a really good idea. On would be my first step. I mentioned that it's a very heavily sedimentation urine sediment. It urine has a has a habit of cramping and catheter tubing on block them off quite easily. So often the nurses will do this without you needing to ask them, but it's certainly worth asking if you flushed it. If you flushed it and it's still not working, then you can think about replacing it, possibly using a wider bore catheter. We have a tendency to go to for smaller catheters for comfort, but actually, if they're gonna keep blocking mean, you just need to use a big one on removing it completely as a source of infection is a good thought process. And the problem is this person is second septic, and we really do need that. Urine output measuring through bottles and bedpans just tends to end up being wildly and after after not very long. Great. It's a good thought processes. Guys say, Let's do that. Let's give us and fluid Let's change your antibiotics. Give us, um, gent, and let's try and get that catheter working. That sounds like a really good plan, right? So now is that first section done? Now we've got a we've got two o'clock and they say, Oh, hi, Doctor is pediatric would with the and the order in. He's had his appendix out earlier today, and he's in a lot of pain this evening. I've given him some, um, parent settlement. I propose. Um, but I think you need something stronger. Would you come and right, Um, are more fun for us, please. So now when we have seen Muriel Cherish So she's out. Wilder. We've got option A Will be. We can go to seek, has worlds heists and sort out this question about what free fluids means we could go and see. And the Miller option being sort of his treatment escalation plan, we could go into Ramona's gentamicin is option c option day. We could go and see this pediatric patient saw. How is postoperative pain or option? We could go and start this fruits and my prescription for Brenda. All right, where do you guys want to go? Yeah, greatly, Shelagh. So, yeah, most of your thinking. We want to go and start this child out. Who's in pain? No one likes to leave a child in pain. That's good thinking. I think some of your probably thinking well, a gentamicin might be quite quick to sort out saying With the fruits of my prescriptions, we could maybe do those on the way or so those drugs are not going to be given if we don't review them. So yeah, good thinking. But we're going to go and see this child in pain because he likes to leave a child in pain. So and he presented this morning with a two day history of abdomen pain. The AB, loose stores, reduced appetite and nausea had the laparoscopic up in deceptive me earlier this afternoon. And he's now in quite a bit of pain. This is 10 years old. He's got down syndrome, but no other medical conditions or surgical history. When you go to see me, something bad crying, his mom tells you, managed to eat a little bit and drink some fluids after the operation. He's kept those down on, but he's been steadily increasing pain. His cheeks are quite flushed. He's pushed away all these toys. When you ask him about pain, you told me his tummy hurts. What you want to know about Mandy? Yeah, Hope so. I'm sure we got some up somewhere is and Oh, yeah, no, no, that's all. So temperatures 36 6. His blood pressure's 114 over 65. Heart rate's 92 recipes or 12 and accepts 100%. What you guys think about these ups? One over normal. Any other schools? Not too bad but noncommittal here. Appear normal. Those on the heart rate Horace Low for a child? Yeah, his his 10. So 92. Probably reasonable. But yeah, that's that's the point I'm trying to get at it. Is remember, the heart rate is typically a bit higher in kids, so 92 is reasonable in a 10 year old child, but it's very easy. When you first started one, some units, the General Surgical met the general surgeon collect ones will handle pediatric surgical cases on when they're a little bit doing far between. It's easy to forget that what makes it might make you really set up and think your patients to protect Kartik and an adult could be entirely normal in a child. So remember to take that context into account. So yeah, I think it actually, this is a normal set of ops. Well, it's two in the night. Yeah. Blood says he open this past. It hasn't opened about his day zero post op. Have we got some blood on here? Uh, I think. You know, he's only He's only a few hours after his operation. He hasn't had any repeat bloods. Yeah, and actually, a lot of the time after an appendicectomy. If you've taken away the cause of the pain, often you don't really need any blood. As soon as they start getting better, send them home. But we'd like to have a look at his would. Yeah, that's a good idea. Surgical ports, that's all look healthy. Yeah. Anything else? Yeah. Medications and civil court medications. He's heart. She's had doses of both paracetamol in ibuprofen two hours ago while he was in recovery. Had a stop date of 5 mg of warm or five o'clock, but is not written up for any further or more. Anything else? Yeah, we got up to exam. Um, no. No. So, yes, when you feel like he's got a tender tummy is quite sore is not liking you touching him, but he's not pertinent. Ick allergies. No allergies. Oh, great. Let's have a look and let's make management plan. So what you do about pain, then, um, we could give him or um or 50 point so previous medical histories got down syndrome. and nothing else. So we could give him two more. Um, or 2.5 to 5 mg. We could give him 5 to 9 mg. Four hour early. We could give him some codeine. 15 mg max. Cute. Yes. We could call the anesthetist and ask about patient controlled analgesia device. Or we could give the surgical rhetoric and ask them what they think you guys want to do. Yeah, great. Let's fellows first. We've got a few options and those if you have gone with the 2.5 to 5 mg of remorse, how did you come to that? What were you thinking? That How did you decide on that dose thing rather than the 5 to 9 mg? How do we dose or more in a child? Did you give her more from the child to toe any Any thoughts by way? Yeah, So that's something you could have asked me for. Remembering Children is really useful to have their weight helps. You is guiding drug doses and the B N F. C will tell you for almost any drug store it will give you all of the doses by weight on. Then you can use simple calculators to work out the weight. So never guess, especially with controlled drugs. Things like Morphines open your eyes. Never guess. Always think about using a calculator. Using you Be NFC to work out your room Your makes me take, um, a couple of people suggesting patient controlled analgesia. Yeah. What's the thought process that? What do we like about it? Or those if you didn't go for a patient controlled energies and what we know, like about it? Okay, pounds? Yeah, What's what's downs? I'm playing into the the decision making process. What's the risk with the patient controlled analgesia? How did it work here? My overdose. So patient controlled analgesia normally is hooked up to something like either fentanyl. Yes, someone said, Is it appropriate to Children? So nothing to do with the dancing during more about the fact is, a 10 year old child on patient controlled analgesia is on the very strong medications It can be. They could be morphine. It could be fentanyl. There were some other medications you can get through them as well. They do have a lock out time out to try and make sure that it safely dosed. But it is still possible in some people, particularly smaller people where weight come very so much. Does it come very so much to push yourself into a respiratory depression on Children? I'm gonna have that same understanding that an adult would on. They often will leave a press it too much or just not press it enough is the other option is. Well, some Children could be quite scared of that idea on. I think this is something where Children need a slightly more paternalistic approach compression to try it analgesia. It's just not suitable for Children, really. But the most common on so you guys had given is we're gonna call the surgical rich. Yeah, let's call the surgery wasn't a says. Well, I'm in theater is an emergency and yeah, that's that's something they connect commonly say, but quick. Bit of us, he says. Oh, yeah, please, Absolutely. Let's give him some more more check with the NFC. So does anyone want to have a quick look and be NFC? I'll tell you his weight, what, Whatever his weight. 30 kg. So does anyone have want to have a quick look at the NFC and tell me how much normal. We could give a 30 kg child. So give you guys a minute. Was whoever gets there first and let me know. No. And this is a kind of thing you'll find yourself doing in real time. Sometimes overnight, when it's quite tiring. Your gentamicin dose. Easy, vancomycin days, years yet analgesia for Children. And it's it could be really quiet. Quite tough for a walk in the morning. To do what? Really A simple math. So 3 mg per day this year. So that 2.5 to 5 doesn't sound unreasonable. Great. So that was two o'clock. Gets to 40 on. We've had an emergency call come through on. Say hi, Doctor. I need you to come straight towards six. I've got a patient who was admitted this evening by the S H O. On. They asked us to repeat, uh, VBG and the potassium 7.1. I tried calling the S H over there in recess, and they said they're not. Could be able to come up for it. Least 20 minutes. Can you come and help, please? Yeah. Got Toby Johnson. He's an 88 year old patient. Was admitted with an infectious exacerbation of COPD on It's Got a background of heart failure with reduced ejection fraction. He's got moderate COPD. He's got steep CKD Stage three is got anxiety and he's got mild dementia. And he's been having daily using these for monitoring apart failure cause he was in pulmonary edema. After initial fluid results, the lab lost his bloods in the daytime and he was replaced this evening. The potassium is dangerously high. So the lab it phoned the ward and said, Well, you need to do something about this. So course the nurse is giving you a call. What would you like to know about it? You see, GI good saw was a refugee place. Really? Toby Johnson's know on a crib. She Oh, sorry about that. Ah, sorry, guys. There's RSCG. Tell me what you guys think of that. Anything on the CT that stands out to you. Told he weighs Yeah, This is what told entity waves look like Exactly. And that's a common finding. If we see GI Common STD finding in hyper hyper khalidiya what would be the next stage of severe hypoglycemia? That would worry. It's even more than tall tented T waves was the next change that you see with high, dangerous hyperkalemic. Yeah, the FOBT. Yeah, they're so if you were arrested, a result of hyperkalemia it has to be a CT or a PF arrest. But before that that some of the oxy toss odds Your size, I think is usually more associated with magnesium. With hypo magnesium here, but correctly from wrong. Yeah, I think that's normally hypokalemia flounder inverted P waves you can't have. Yes. And the thing I'm thinking about widened QRS complex really broadly widened. QRS complex is a really worrying Simon on. I think if you look at the rhythm strip here, there's evidence of acute arrest complex starting to widen a little bit. Absolutely. This is certainly in the CT. We need to do something about what else would you guys like to know? Ob see a subset. Months of a BG. Someone said, I think maybe No, I Well, let's give you a DVD. Any We'll come back smoked. So VBG we repeat and we'll see a pH of 7.32. We've got appeared to 7.1 pcr to 6.4, sodium. 131 potassium we can confirm is Yep, 7.1 lactate. It's 1.6. The bicarb is 22 in the base. Excess is three. Would you want to tell me about this DVD? How would you summarize BBT in a short praise? Metabolic acidosis? Yeah. Decompensated metabolic aspects that someone's going to even further. Yeah, I agree with that. It started to burn off all of Iraq if there are bicarbonate. Yeah, well done. It's a metabolic acidosis. What do we think about the purity in PCT high piece here. Too low piece here to your normal piece here to you. Same question for oxygen, p 02 very low. Remember, it's a maybe Jay common comment about the oxygen PCR to. Actually, you can get a general impression from a VBG because it will go. It will go up in it in the severe respiratory acidosis on someone who's hypertechnical will go up in the VBG. But you certainly can comment on the oxygen on there on the DVD, so those gases are really interpretable from this. But just important thing to think about. It's very it's very easy sometimes to be startled by low P a two on the BBC and the you just remind yourself that it's venous, But yeah, we've got a metabolic acidosis. A little bit of danger here on someone wanted ups. Let's go find the Mary out found the opposite Lost. So temperatures 37.2. But Pressure's 106 over 58. How raised 112 respirations 18 and the sets, or 89% comments on those. Any comments on those abs? Tacky. Low such? Yeah, or is it about the sex in this situation in this kind of emergency patient? That's his. Okay, given back. Growness COPD. Well done. Good thinking. Good thinking. Yeah, always remember your context, guys. So Saturday, 88 to 92. Absolutely appropriate COPD on. It's also important. So you don't need evidence of chronic low to retention to make that decision about changing someone to love saturation scale any. Uh, the British stressing society suggests that any history of COPD is adequate to reduce their oxygen scout on. Actually, there are. There's a trial going on now called the UK Rocks, which is looking at reducing the oxygen saturation target to 90%. Even people healthy lung parenchyma and certainly if any so too. Although a lot of places. That decision has to be someone above the left. One's just double check your local policies, but yeah, we can go to, but they are attacking. The BP is a little bit wobbly. I'm sorry. Because of no written things down. I'm just gonna give you the rest of the information on this one. So you've seen the GI seen a VBG medications importance. Think about so really common reasons that people get hyper clean making medications. He's on Coach Mock's old on This is for his COPD is on ramipril. It's operable. Spironolactone frusemide salbutamol on Trelegy. Which of these medications? Compassion? Sure. Toxie Um hum Rama grow? Yep. Spironolactone yet potassium sparing diuretic clues in the name I'm a pro. Definitely X inhibitors. Yeah. Yeah. History is my duty. Potassium Up, down, down actually, yes. Oh, Frusemide is one of the is not a potassium sparing diuretic. So it pushes it down. Yeah, but yeah, and co-trimoxazole actually compress your potassium was Well, that's the other one. It's have a little thing about bloods from nine o'clock this morning. Um, have finally come back. Actually, the lab did find them in the end and they were lost. But they, they they found them on. The potassium wasn't as bad then, but the creatinine is 285 in the area is 16.4, even with a CKD of three creatinine a challenge in eight. If I would really give me time to sell something and there's a chest X ray because he's got a an effective exacerbation of COPD, that's something else we might want to know. Anyone want to make any comments on the chest X ray? Bilateral pneumonia? Cardiomegaly. Yeah, I would agree with the cardiomegaly. It's important to be able to know whether it's an a p o p A. Films. Comical, not pulmonary edema. Yeah, attention looks a little bit on the West Side. Patron for traces. Good, actually, for for a patient of 88 years old is probably quite good. Chest X ray. Actually, there's definitely no clear consolidation. Remember, with pneumonias and consolidations, you're looking for solid areas without these air spaces within them. So these patch infiltrates is not what you would see in a pneumonia. This might be a little bit of fluid overload. There's certainly some up alot deviation. This looks like back winging looked it. There's definitely no clear consolidation that there's no evidence of pneumonia. That's the main thing I wanted to get from that. So what's the first thing we should do about this potassium? And so we've got all that information we know. Potassium 7.1 has got a severe AKI. What do we want to do about it? Let's give you a pole for that. Uh, can we restart a PPO from things that we go, guys? So option A, We can get some counseling. Blue connects. We could stick a second cannula in and get some fluids. Take some repeat bloods off that we could give some backdrop it plus some glucose. We can get some nebulized. Albuterol. Mezrich. Yeah, we all like the calcium gluconate. Good idea. Let's do that. Everyone's answer for that. So let's get some constantly connect. Definitely. So you give some of that. What do you want to do next? Stabilize the cardiac member? Yeah, it does so realize that also we can give 10 units of backtrack did. Now, with some glucose, we could repeat the EKG. Repeat, the VBG could give some nebulized albuterol. We call the metric, right? Oh, already on some beautiful Someone said it's good Thought is already on Prn inhaled salbutamol. Do you know how much sub you tomorrow is? In? One puff of a Ventolin inhaler. Didn't use a 200 micrograms. And do you know how much I'm so beautiful? We give five nebulizer. I'm going to get 2.5 to 5 mg. The air, 5 mg is It's sort of magnitude higher than than what you get from a couple of puffs of the albuterol inhaler. Great. So let's share those answers. Yeah, some of you want to repeat the CT. What's the thought process with that? Ideally, should be on some cardiac monitoring. Yeah, really good for process. A situation like this is definitely something you want to escalate on. Yes, you. Well, no. The high pick hyperkalemic practical, and we can always Well, I say we'll know that by the time you're at the end of your F one, you could have done this enough times that you'll be able to recite it off road. And usually you'll know all the doses as well. Yeah, this is Somebody needs cardiac monitoring. What's the quickest way to get cardiac monitoring when he said he doesn't give you live. Cardiac monitoring gives you a snapshot, but we can definitely repeat. I think repeating that STD is definitely a sensible option. Echo isn't really Yeah. What do we think about putting out a double to double to emergency call for a patient with a potassium of 7.1 and EKG changes with someone gonna come in and lot for you. No obvious reason. But what do you get when you put a double to double to call out what gets brought to you? What? Really useful. It's a kid. Get brought to you. You go and you pick up the phone. You put double to double to you and you say at all cardiac arrest. Ward nine. Who comes in? What comes? A different related. Yeah. What can you do with the defibrillator? You can do well. You can do, um, you can do shots. You could look at the rhythm. Yeah, a different related will give you continuous cardiac monitoring. So even even if you don't put the cooler, even if you just say to someone, can you come? And can you bring me the emergency? Try the the research trial. Hopefully, if you're on the right ward, that will have a defibrillator. If know, if you put the tubes out, you're definitely gonna get defibrillated thoughts. You either by a porter or will be on the trolley on your in your ward, but yeah, certainly think is a reasonable for process, but minimum we should be repeating that ECD because there were changes. At some point in reality, the more hands you've got. Another reason why you wanna double to double to potentially the more hands you got. You could have the nurses repeat. The EKG were always someone else is setting up the after Apidra. Yeah, those are definitely the two things I would do on. Why would I not repeat the DVD at this stage? Having given just the calcium gluconate so I wouldn't repeat the BG? Because calcium gluconate doesn't Yeah, it doesn't decrease the potassium. Someone said so it stabilizes the cardiac membrane, but it doesn't do anything to the potassium, So let's give him act rapid. Good idea. Uh, as you start giving the atropine med rec, a piece of your shoulder on the Mezrich says someone else escape me a call about this one. I think it's definitely important for me to be a well done, really good management plan. So far. Let's also give some nebulized salbutamol. Let's write up some calcium was only, um, on. I'll have a chat with the I see you team, because what's this patient going to need, really to deal with that, a k I and that potassium dialysis? Yeah, exactly. Yeah, I've kind of just given out the answer to this next question, actually, by mistake. But eh? So this next question with the patients stabilized, measuring Russia's off CCU to deal with another stemi on what we would do past the danger zone is actually most of these things, really So I would give calcium was only, um, with the lactulose. You could call CCU. So your cardiac unit, wherever they send us, Demis, that's gonna have cardiac monitor beds, which might be a good first step stopping those nephrotoxic drugs. The ramipril the well, not the bisoprolol, but the ramipril. The coach marks on the spironolactone. Yeah, and definitely we should someone probably ideally a register. I should be calling. I see you and this situation. I've told you that that they're running off to deal with the stomach. But in reality, a patient who needs to go to I see the med Red should be ringing. I see you to make that referral for you. That's what the patient's going to need. In the end. This is hemodialysis. But again, this is the kind of scenario brought in to just make you think about escalation guys, because when this happens in real time, it's really quite stressful worrying on. Remember, whenever you put a double to double to out the brilliant thing that you get is hands not just people who can make decision, but people who can do things for you. You often have, like an emergency call. We'll get you people who could do good cannulas it will get you. Could people who complain ultrasound cannulated We'll get you people who can draw out medications quicker than you can wink or even prescribe them on. Gwen, you haven't emergency call put out, you know, lots of things all at the same time. And in a situation like Hyperkalemic. A, especially with this higher 7.1, that would be really helpful. Being able to get off those things done at the same time. So well done. Good. Safe management plan. World on guys. Yeah. So two fourty We just, uh, managed to get past that we know of for a clock on DA. We've got another phone call. Sorry, guys, that I missed one. Of course. Hi. It's a surgical ward. I've been trying to bring you for ages, but you've been tied up early. I've got a patient, has an open his bowels, and five days is really uncomfortable. Can you come to prescribe something? So now we've seen your ears. So our options are option is going to be to go and see Castle tight about these free fluids. Option B. We can do with this constipation for Barry. Option C. We can sort this gentamicin option deal. We can do the tap for more options. We consorts. Um, frusemide guys want to do. I can't share it yet, but we got split 50 50 most to popular answers. So if anyone else wants to vote, not be super helpful. Perfect sharing that Brill. So most common option is we want to get and see Ramona's gentamicin, and if you know, she could do this point we've given you this big list of jobs. Anything else? You might be thinking that 10 past for having just been a real big emergency. Could we have a break? Would think. Is this a safe time to have a break? Have some food. Four o'clock in the morning. You've been working since nine PM So how many hours has been on shift now? 37 hours without stopping because you didn't know you asked for a break in the first session. None of these patients are emergencies. None of these patients sound like they're really struggling with severe pain. I think this is a good time to think about having a break on. I would encourage you to make sure you take breaks even on the busiest of nights. You need to take breaks because tired doctors are unsafe doctors. Okay, then. Your busiest of night shifts. You need to find five minutes somewhere just to sit down, have some water. If you If you like to eat all night shift, have some food. Okay. Make sure you take a break at some point. I think now would be a good time to do so. But let's let's say you've had a break and let's go and see Ramona Flowers about this gentleman, such a 72 year old lady being treated for urosepsis, which gentamicin. She had a stat dose of 360 mg yesterday, and she's do another dose. Her level came back and no 3600.8, and the nursing staff would like you to describe the next dose. Onda, I think, on average on my night shift is an F one of probably prescribed somewhere between six and 12 gentamicin doses per night. Eso bit more information searches for a 72 year old lady. She's relatively fit in. Well, she's got some hypertension and a rose. Other medical history of notes, actually on amoxicillin and gentamicin for your a success, and she's improved considerably overnight. What you guys want to know about it before we make a decision about it's gentamicin? What's gonna help you to repeat scribe this gentamicin I'll make decisions about re prescribe this gentamicin medicine allergies, yet have a good medications on here. Really? Uh, no. No. So gentamicin levels. No 0.8, we said medications. We've just got the to be honest, we just got a couple of anti anti hypertensive. She's on warfarin on, but she's got these antibiotics. No allergies. What we worry about when we dose the gentamicin culture results A good thought. Yeah, I got a culture on here. Yeah, and so urine cultures got a grand positive uti sensitive tonight for you and tell you in with no allergies. A renal function. Yeah, I'm sure your renal function a renal functions past correctly. 75 at baseline. Anything else? Oh, see, I did have some bumps on here. Uh huh. No So ashamed. Normal upset. Great. So, what we do about this? That's my seven. So the level is no 0.8 creatinine 75 part. So we can, um, it the dose and reduce the next one. We could, um, it the dose and increase the dose in interval from 2.24 to 36 hours. We could give the dose as it's been prescribed. We could increase the dose to 400 mg. Or we could change gentamicin to an alternative antibiotic. What do you guys think? Yeah, let's show up there where we thinking about changing the gentamicin? The most common answer is to change the gentamicin and what did you? What made some of you guys go with that? So we we saw that it's sensitive. Yes, a sensitive to another medication. And remember, earlier I was saying that gentamicin is really good as a stat dose is a one off, and the problem with gentamicin often occurs when we're giving it over longer periods of time, potentially but in judiciously s. Oh, yeah, Actually, she's got a better with the stat basis of Jen, and we know that she's sensitive to another antibiotic and it's nephrotoxic exactly stopping over tonight tree. And so it might be a really good idea. Omitting the dose. Do we know where the normal the toxic trough level of gentamicin is? Hers is no. Her levels, no point. What level above, what level do we need to hold it? It's a really easy one to remember. One of gentamicin is if you gentamicin levels above one, then you should hold the dose. So no 10.8, we don't need to hold it. We could give it a prescribed. I certainly wouldn't increase it. If she's getting better, then there's no need to increase the dose. But yeah, we can get I think we give the dose has prescribed a. We can swap it to an alternative. So remember, oh, overnight. Your job is not to give the ideal management plan for everyone. Your job is to give a safe management plan for everyone, leaving her on that gentamicin re prescribing it. It's safe. You could leave that decision to change the antibiotic to the dating because it's it's their patient on D. Depends where you are. Some consultant make a bit picky about that, but absolutely, Yeah, I think you've got perfect, perfectly good reason to justify changing her antibiotics, but it's also a safe option to leave it. So I think either of those two options is is absolutely safe and reasonable. Personally, I would change it to the Nitrofurantoin. But But again, you know, there's different ways of approaching different patient. There's different ways of approaching the same patient. We've sort of Ramona. Yeah, we're making a bit of headway now way I have just noticed. I've designed mix with a 15 minute gap. There apparently is taking us 50 minutes to go and change a change. The prescription. Now let's Repola on with No, had any more jobs. Come through, which is an absolute godsend. So option A, We can go and see capsule twice about these free fluids. Option B, we consult the freezer. Mind option D we can get that option. C Sorry. We can detect form for Andy Miller. Option d. We can see Barry content of ice constipation, Which guys want to do. Okay. Oh, great. Yeah. So, um, most common option is we're gonna go and see these guys. Constipation, bro. Let's go back. So Barry is a 65 year old man. He was admitted with PR bleed. He's been on the surgical five days under investigation That hasn't opened his bowel since admission on me, struggling sleeps. You feel bloated and fill it, too. And he would really appreciate some help. Not a pleasant situation to be in. Constipation's pretty nasty. So you had a CT scan on admission? Unfortunately, it's shown a legion highly suspected for a T four sequel. Carcinoma was due to be operated on yesterday. Was bumped do to emergency laparotomy that came in. That's the laparotomy that the surgeons was still in theater with. By the way, he's been squeezed into a theater list for tomorrow afternoon. to have a right hemicolectomy. He's been kept in pre procedure in order to medically optimize him. What did you guys like to know about them? Okay. Yeah. After examination, I think we've got one of those somewhere. Sorry. Oh, examination. Is he so Yep. Thoughts on those abs have intensive here. Joined anything about the hypertension? No. Right now. Now, it's not a dangerous hypertension, is it? Certainly not something you want to fast around with the five o'clock in the morning if you start giving. So lots of people love to give status of amlodipine because it makes the nurses happy and it brings the BP down. But if you give that start dose of amlodipine and they end up being really said stiff calcium channel blockers now you've got to go back to the BP is 80 or their blood person that higher. But they're behaving really weirdly, and they're not peeing in the not mentating because they used to running a really high BP. Just don't mess around with a high BP unless it's about 200. Or if you've got any evidence of any evidence of malignant hypertension such as changes in the retina or severe headaches or signs of signs of hemorrhagic stroke, that kind of thing. But really, unless the BP is above 200 or you've got good signs, just just leave it alone. It's bit on. The higher side might be high cause he's in pain. Might be high causes. Constipated. Might be high because he's worried about an operation in the morning and he's still up at five o'clock in the morning. So you have good leave it alone. Abdullah Exam was the wasn't it, So he's not nauseous. C hasn't vomited. He's bit bloated, his abdomen soft but mildly distended, with some discomfort on power Patient. But no tenderness, if you because his abdomen. It's a bit more resident unusual, but there's no pain, and it's about sounds present but a bit sluggish. What else would really like to know? PR exam you have over in the P. R. X from anywhere on know you happen. Go. It's a really good full process, actually, Yeah, absolutely. Can anyone tell me the to country indications to PR exam the doctor not having a finger in the patient, not having an anus? Um, it's very people love to Dodger PR exam. It's didn't get away with it. But in a patient like this is constipation. You really need to do so. Yes, actually, you know fish is is something to think about If someone's got a nail Fisher, if there were reasons why it might be really painful, then you said we need to discuss that with him first. You might need to be really gentle. Make sure you've got plenty of lubricant for it. But in a patient like this is worth seeing because an empty rectum versus the rectum impacted with hard stores is going to affect your choice of your choice of laxatives. So the way I think about is being constipated from the top end versus being constipated from the bottom end. So if someone's got heart store, they need start softness on, such as cholesterol in suppositories or placement depositories or things like Doctor State. If someone is constipated with an empty rectum, it might be they're not stimulating there about enough, and they need something like a center or a. It's a stimulant, like a center, or, if they're constipated from the top end with an empty rectum, they might need some lack Cedo or some sort of automatic bulk forming like great Well, so we want to know meds. Yet because medications no now find. So let's say he's not. So what kind of medications are you thinking about money that might be contributing to this opioids? Codeine? Yeah, so many people is really common something you'll find. It's people with really bad abdominal pain of Scott is more and on old easier and and so people come a long way, and I had a bit of Cody on. Then they they abdominal pains getting worse, or someone adds on morphine. And then something else comes and increases the morphine cause the abdomen is getting worse sometimes what you need to do. You just have a pause on the opioids a week meeting. Moderate whatever, Have a pause in the opioids. Think about other right now. Other things I can't see. Inflammatories trying to have. Actually, all that pain is because of constipation that needs really good explaining to patients because it's going to stop the medication. For someone who's in paying, you need to make sure you rationalize that with them. Explain to them. Look, I think your pain might be because of constipation. I think these analgesia, some of them are making it worse. Going to give you a different one so that we can stop the ones that constipate you. Great. Um, find in the interest of time, I'm gonna move things on a little bit. So what do you guys want to do about it? Uh, his constipation. That Yeah. Great. Let's share there. I'm not gonna wait too long. These ones, guys, because I don't want to keep you too long. You can really patient with it so far. And so yeah, things to think about. So phosphate animal? Absolutely. If someone's really struggling, there been in for five days. That probably got a lot of poo in there on an Animas. A really good option. Chest X rays are good for worry about perforation, and he's not pertinent thick, so it's a bit less likely. Abdominal X rays really know particularly useful in bowel obstruction. If you genuinely think someone has a bowel obstruction, they need a CT scan because an abdominal film is going to tell you that they got some dilated loops, but you have dilated loops and constipation as well as obstructions there. Really? It doesn't add anything you didn't already know. If you've got a good reason to suspect a bowel obstruction, just go straight for a CT. Obviously, that's not a decision. You're gonna make it an F one at four o'clock in the morning placing an n g tube in case he starts commenting. Well, it's not the worst idea in the world if you're going to be. If it is bad enough that you're gonna be putting him Neil by mouth and you think he needs our rest, then certainly. But I don't think he's necessarily got signs of obstruction here. I think it's more constipation rather than obstruction on forming. Emmanuel. This impaction. I think you need to try other things first, which why don't you have a headache, which is good? Unfortunately, at some point during your afford, you're probably gonna have to manage you disimpact at least one person. It's not a pleasant job, but it really does benefit patients if their constipation severe enough that they need it. And then it's a very therapeutic thing to do. Um, fluids were about to run out. Uh uh. Right. So I'm just going to quickly with back through three days and give you other information. They're still chart no bowels for five days, which is why we've given it a minimum. Bloods there fairly stable set of bloods with maybe a slight decay. I yeah, um, so we said the normal but hypertensive fluid balance. So because the other thing to think about in anyone, he's been waiting to theatre. He's on. Sorry, I just remembered something about why I've got this in here is that patients were nearby master long periods of time. They're not getting electrolytes, and that can worsen constipation's if he's been know by mouth since the previous night because of cancer operation, he's had some Harmon's maintenance fluids and produce 1.2 liters of urine in the last 24 hours. So is a reasonable fluid balance, actually, two liters in 1.2 hour. Allowing for insensible loss is that's recently good examination was spoken about a laxative. He's been having some laxity on center, and that's why we've gone to a rare. That's what we've got for the enema. So what would you want to do about fluid in this guidance, he's been know by mouth four day, he's had two liters of Hartmann's. It's five o'clock in the morning and it's fluids of run out. So we can either say that he's had a flu. It's already and we can leave them alone. We could give him another bag of Hartmann's is. Actually, it's five o'clock the next day now, so maybe we need to stop thinking about the next day's fluids. We could give him some saline with potassium. We could give him some glucose with potassium, or we could give him some heartburns with him Would he goes Monday, So he's had two liters over the last 24 hours. But we're now into the next day what you guys want to do about these fluids, so maintain so we're thinking about fluids for maintenance. They're not fluids for resuscitation. They're not fluids for treatment of dehydration is a maintenance fluids for someone who's know by mouth. What what floor do we like for Neil by mouth patients who need maintenance? And this is something that will be really useful when it comes to the P. S. A. I know you guys probably have just sat essay. If you're in a 20 year in the UK and, hopefully fluid to something that went over the PS A prep sessions. But I think for you it is something that a lot of white ones get wrong. Um, and not just have one is actually a lot of people get from his wrong but by know, thinking about why you're giving the fluids, what patients needs are on how you go about it. So that's why I wanted to cover this quickly. Yeah, that's stop had. So the way I think about fluids, I'm gonna give you a little bit much bill here is they even need it for resuscitation, in which case they just need a crystalloid fluid this quickly as you can give it to them. So either saline 500 mils stop through a bag plasmalyte 500 step right back. We don't people don't like giving Hartmann's a stat dose often because it's got a small amount of potassium as a physiological amount of potassium solution actually be problematic even when given really quickly. But anyway, that's what you do for resuscitation for maintenance. What electorate? What does someone need? What are the electrolyte on day water needs for human being you don't need to give me numbers. Just tell me what electrolytes and fluid contexts someone needs. So water, I've already told you. What else do we need? Electrolytes. Do you need him? Sodium, Potassium and chloride? Yeah. How much? Sodium glucose. That's the other thing. Yeah, Coast. He's had two liters of Hartmann's over the last 89. Any clickers talk? He's not eating. You need roughly 1 to 2 g of glucose per kilo per day. Well, so how much? Potassium Dean, how much sodium do you need per day? Right, It says 1 to 2 millimoles per kilo per day. So if you're 75 kg and you had two liters of Hartmann's, it actually already doubled your day. Requirements of sodium on How much potassium is in the leaf is in a liter. Hartmann's for yes, four or five minimal Andaman E millimoles. A potassium. Do you need in a day? Yeah, so it's no 0.5 to 1. So it's a It's a roughly one. So you need about one minimum of calcium a day because they're two liters. Hardness is that 10 millimeters potassium? I suspect he probably weighs more than 10 kg and does anyone? Can anyone think of any obvious things that happen when you're not having enough potassium elephant in this scenario? Low potassium, uh, contribute ideas. Yeah, well done. Over. Yeah. So something people, is it really commonly forget? And one of the most common reasons why your post surgical or near by mouth patients get constipated or go into our list is because people are giving them through it without any potassium in the So if you're giving someone maintenance fluids and make sure they're getting one millimoles potassium per day And actually I had this problem where a lot of the nursing stuff would go to Jesus Christ, Doctor, you're getting so much potassium and it's saying no, actually, I'm giving the physiological amount. It's just Unfortunately, lots of people are not giving the right enough anywhere near enough. So you think if you weigh 60 kg, what he really needs is one bag of fluid with 40 millimoles potassium in it, and he needs one bag of food with 20 millimeters of potassium in it. So one way you could do that is to give a liter of 5% glucose with 40 millimoles potassium and then you could give 500 miles or a liter of saline were $29. That's really important to think about what the human body needs if you're prescribing maintenance fluids, and I think that's the element of fluids that tends to be done most poorly is that is very easy to quickly just scribble some saline scribbles and heartburns without thinking what you're giving it for. If someone is eating, they, then they're going to give themselves the right amount of electrolytes and a physiological fluids such as heart burns or plasmalyte is good, because what you doing in someone who's eating is you're trying to keep their electrolyte levels. The same is the one he's not eating. You're actively trying to top thumb up on the thing that people always forget is to give adequate amounts of potassium. Um, well, don't guys, I know that's been really long. I'm going to leave the last two sonorities because I think they're slightly less important. Some of the other ones, I think they're good ones to have left towards the end. The point of the tip form was that this was gonna be a really complex young cancer patient and exactly the kind of person is not appropriate for you to be making escalation decisions about in the middle of the night on the free fluids. One was just quickly to explain that a lot of people don't understand what the different scales of eating and drinking after an operation are so lots of people. So the way it works, you could be know by mouth. The next step is to give someone sips of water or clear fluids on by clear fluids. We basically mean water. What's he with No milk free fluids is the one that encompasses. Quite a lot of people don't realize when people talk about free fluids, you can have milk. You can also have soup jelly and I scream that counsels free fluids. Since one. A lot of people don't realize that the nurse tells you that patients diet includes free fluids. They can absolutely jellies, and I screams. Then, from there you would go to the soft meal and then from there you go to formula. So those were the tubes, sort of learning points from those last two because we've already run to an hour and a half. I didn't want to drag this out any longer into some of you to lose concentration and not take much of that. And the world are guys think it's really good section. I think it prioritized really well. I think you've made safe management plans would be really grateful feedback guys, especially because it's a smaller session. If you can take the time just to do that, to spend a couple of minutes doing some feedback is really useful for me. It's also useful to help me know the changes I need to make in future. If anyone's got any last minute questions, just let me know. Otherwise, we'll end it in a minute. Brilliant. Thanks, guys. Have a good evening. Oh, sorry. Did you have a question? I'll be, uh no, no. I was just going to say thank you. Um, I don't know if you want to show that you are code. Oh, yeah. If I if I scroll on your coat. Yeah. So, um, the fluid fluid you given your behalf so personally the way I think about until by mouth patient, the fluids, they need our maintenance fluids. So they need fluid to replace electrolytes that they're not getting from their dietary sources, and they also need a glucose. So the proper way to prescribe fluids is thinking about in three different ways. Do they need resuscitation, in which case you're replacing water? So it's a low know plasmalyte, quick as you want to give it if they need hydration that they are eating well, say, in someone who has septic and is increasing their water losses. If you want to just increase the amount of water someone has in their body, then I I would give them a physiological fluid, such as heart mons or plasmalyte on dust. Give that over in appropriate amount of hours that you think is matching the rate they're losing. Water maintenance fluids is the one where you need to give a bit more thought, because that's when you're replacing electrolytes, so you need 1 to 2 millimoles of sodium her kilo of body weight. So for someone who's on 100 kg, they need about 100 to 150 miles. Millimoles saline. One bag of sodium one bag of saline has 150 minimal of sodium in it, so one liter of saline is already maxing out. The amount of sodium someone needs if you give them or they're just going to pee it out. What you need to think about is potassium, so potassium is about one millimoles per kilo. So 100 kg person actually needs about hundreds. Millimoles of potassium, which is loads really 80 should be enough, especially if they're not know by mouth for ages. And if they are now by mouth or more than a few days, you need to be thinking about things such as TPN or parenteral nutrition. But in the meantime, you need to make sure you're keeping those electrolytes up. I think a really safe way of starting in the average body weight person is to give them. Lots of people talk about the whole one salt too sweet or two to start once we whatever that's that's a no over simplification. The important thing is to make sure you are giving them some potassium on. Really, you should be giving them some glucose. Okay, so 5% glucoses are normal. One liter of 5% glucose has 50 grounds glucose in it. That'll do it. That's that's a starting point. So give him give, think about a liter of glucose with some potassium in it. Probably 40 millimoles on. Then think about Are they normal body weight, In which case they probably need another liter. Um, so you can give that a liter a saline with your 20 millimeters of potassium unless they're a big, heavy person. In which case maybe it's another 40 millimoles potassium if they're small. If they're afraid, old lady, just give a 500,000,500 mL bag instead of a second later on. Give that one year. You're smaller amount of potassium unless they're really small. In which case, maybe the 40 millimeters potassium is enough. But the key crux of this is Have a look at the nice information. Make sure you know what normal electrolytes people need to make sure please, when you're giving people maintenance fluids but, you know, by mouth, just make sure you're thinking about their electrolyte needs and ideally, calculating the mask for their body weight high. That's helpful, guys. Thanks. I'm gonna go and I enjoy your evening dice. Okay?