Computer generated transcript

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

Hi, everyone. Thank you for joining so far. I'm just going to give it another five minutes. So we'll start five past eight just to give us some time for everyone to join. Okay, so that's five minutes past eight. Zetia. Are you okay with the slides just now? I'm okay. Thank you dot Hello, everyone. Can you hear me? Yeah, I can hear you. Uh, I don't think I figured out a way to share the slides with my video, so I will go with the slides on its own. Uh, I hope you can see them right now. Let's have a look. Yeah, that's fine. That's great. Okay, so, um right, I'm just gonna have a look. Okay, Right. So, um, you're welcome. Everyone to today's session. We're going to be talking about the acute kidney injury and hypochelemia. And this is another one of the mind a bleep urology sessions. So if we could move to the next slide, please? Right. So I'm just putting out a reminder here for everyone. We still have the 50% discount for COPD me. For those of you who can't be bothered putting their teaching on their portfolio every week This is a really good application you can use. Um, and it's designed for people who are registered with the GMC and the N, M. C and other healthcare professionals. And you can find it for free on your android and IOS apps. So if you're interested in that, go ahead and use the QR code to get that discount from mindedly. And, uh, now I'm going to go ahead and hand over to somebody who is going to be talking about today's topic. Thank you, Zakaria. Hello, everyone. Uh, this is me. I'm one of the core surgical trainee in urology, uh, university Hospital Air part of west of Scotland. So, uh, maybe I should have disclaimers to start with, uh, that this took will be focused from urology, perspective or surgical trainee. Uh, I'm not here to teach you, uh, physiology or basic biochemistry. I would like you to take over a message where you would like to be more comfortable managing acute kidney interest. So to start with simply an acute kidney injury or an a k, I is a sudden deterioration in a renal function to why it's important because it's common and it can lead to complications and, most importantly, early detection of, uh, an a. K. I is essential to prevent complications and hopefully achieve better results, such as early discharge from hospital or early recovery. Uh, study in 2012, uh, found that 30% or up to 30% of deaths from a K I can be preventable if earlier in remission was a sheep. So whether you would like to be an obstetrician gynecologist, surgeon or an I t u intensiveness. So this will be a common encountered during your daily life. Uh, and you will find it either, incidentally, if you're in a in A GP or primary care practice, performing some bloods or any post operative settings or if you are receiving annual patients in any or in the world. So as a definition from a biochemical point of view. So there is a criteria indicating deterioration of kidney function, which is basically a rise in serum creatinine of 26 per 2048 hours, and we're using the micro more per liter units here, or 5 50% or greater rise. Um, within seven days, uh, clinical definition would be here, uh, urine output falling to less than half mils per kilogram per hour for more than six hours. All right, I'll try to keep a scenario running with this presentation so you can be more clinically oriented. And I would like to invite you to imagine yourself being the S h o or the house officer, The doctor looking after this patient across this presentation. So Joan is 71 years old, gentleman who was admitted four days ago for an elective, right, total knee replacement. You were only reviewing the Bloods on a post operative day three. And he found a f r coming down to 45 where it was more than 60 and it was completely normal. So obviously you can see there's a drop of the E g f r to less than 25%. Um, this basically indicates an acute acute kidney injury. So now, uh, this is a common way for the acute kidney energy to be flagged up. Incidentally, on checking the bloods or post operatively, uh, now I will jump into back to the presentation and keep Please keep this scenario running in your mind. So how patients will present with the accused kidney injury. Either you will find this clinically from like how they look, uh, annual patients. They are drowsy or the complaint of weakness. Nausea presented to your GP to your GP practice. Complaining of feeling, uh, sick or weak. In the last few days, you've performed some bloods, and then they came back showing an acute kidney injury. Or they're just basically to, uh, telling you that there is, uh, they're not saying they are not having enough urine output. Or if they were in the hospital settings. The nurses can write this out mostly in I t. U or intensive care unit. Uh, in biochemistry. Uh, you will notice as our scenario, that your weight is trending up so you can see in a few days your sugar is coming up. Creatinine is trending up to, and HEFR is dropping down. So obviously, I, uh, put this is, uh, simulated like, uh, scenario for potassium where showing you that potassium is normal. But then keep in mind that potassium is one of the most important electrolytes to be linked with a k I. So now I'm going into the cause is I would like to define the causes as everyone, Uh, every year every text book do anatomically so pre renal renal and post renal prerenal meal means anything happens before reaching the kidney. And we are thinking here from blood supply point of view, you would think of the hypoglycemia decreased cardiac output. So decreased blood supply. Uh, just remember, we are discussing an acute kidney injury, So conditions such as renal artery stenosis are not considered the common Cause as this will mostly lead to chronic kidney disease in acute kidney settings. Just think about the increased blood out put going to the kidney in acute setting are the hypothalamic shocks such as in bleeding or maybe dehydration? Or maybe someone who sustained heart attack leading to heart failure and decreased heart decreased cardiac output. Now, renal, I think with any possible cause can happen in the kidney. This can be like infected or inflammatory or whatsoever, like can be nephrotoxic drugs. Uh, interstitial nephritis or inflammatory like trauma to it causes any infant to the kidney urgent waiting from the kidney itself. And when you think that I think about the knee from as the meal structure contributing to the kidney function now post renal, this is my nearly, uh, daily job where most patients with a K I I need, uh, have post renal causes. And that's why I do urology, uh, hopefully help dealing with such patients. So this is the least common cause and most likely come from obstructive uropathy obstructive uropathy has been mainly any decrease. Sorry. Any decrease, uh, urinary output from the kidney due to an obstruction can be stored as you see in this, uh, illustration stone just sitting at the pelvic ureteric junction of the ureter obstructing this kidney going down can be ureteric structure or extreme external pressure on ureters from maybe it's humor or, uh, urinary retention from prostate enlarged prostate, or maybe someone constipated or unwell with significant illness. So to sum up, causes are pre renal, renal and post renal. And this is something as a medical student or a foundation doctor, you need to keep in mind while assessing and managing the patients, because knowing the cause is basically your key to the right management to this slide is very busy. And my take home message from this that just to know which groups are usually at increased risk to sustain an acute kidney injury, and this will completely make sense. Elderly people Any people with previous acute kidney injury or kidney. Chronic kidney disease People with sepsis or, like neurological or cognitive impairment. Got dementia agitation, uh, chronic other heart conditions such as heart failure, liver disease, diabetes. So all of this makes complete sense. Uh, when When you see acute kidney is very patient, it happens. Invulnerability groups, people who are unwell, people who are co morbid people who can't look after themselves, too. And this is another important key message because you need to suspect where to find a huge kidney injury or to prevent it. So if I If I have one of those patients who was like cancer or they are comorbid, I would think, How can I prevent them sustaining an acute kidney injury? And that can be from doing simple stuff, maybe first thing to do for you as a junior doctor requesting routine bloods from them or make sure they are hydrate. Hydrating. Yeah. So, again, why Acute kidney injury is an important topic because it can lead to possible significant complications, uh, electrolyte imbalance and hyperkalemia. Although hyperkalemia is part of the electrolyte imbalance but you would find it mentioned separately as it's really significant and important, uh, to to highlight. Especially, it can lead, uh, too high mortality rates. So metabolic acidosis, volume overload, uremia or chronic kidney disease? Obviously an acute kidney injury or acute kidney insult can develop into a chronic kidney impairment or chronic kidney disease, and then an end stage renal disease to stages whatever. Like we mentioned, uh, organ failure. Most of our like most organs. There will be some certain staging systems, and this would be usually supported by biochemical investigations. Uh, in acute kidney injuries. Uh, our main biochemical market for staging is creating in. So I know now, in most hospitals or laboratory results, we it's easy to look at the g f r the estimated glomerular filtration rate, where it just give you a hint, especially if it's linked to people age or like gender or weight. So, uh, but then creatinine will give you merely, uh, the staging system we have. And, uh, I'm referring to my slides mainly to nice guidelines where, uh, acute kidney injury is staged into three stages, and that's based on the creatinine. It can be like 1.5 or more than normal, or the basically a baseline level, or it can be two or more or three or more. And the reason for this, uh, slide is for you to know that it's always like when you have mild, moderate and severe management. Uh, the urgency of management is always different, and the settings of the management is different. So if I was in a GP setting where I received a patient who complained from like being weak or having like, uh, some nausea with no known etiology and you've performed the Bloods and you've seen that the creatinine went like 1.5, uh, at times the baseline you can may be counseled the patient on more hydrating more. Obviously, after you rule out uh, causes, you are assuming that they are contributing to this acute kidney injury and maybe review the patient in 72 hours. It can make a sense, especially people who were dehydrated, dehydrated after sustaining a gastroenteritis. Why, if the patient, our annual or you were suspecting an acute kidney injury before the assessment, you might review this in 24 hours, and the reason, as you said there is a big road for prevention, uh, or early detection of acute kidney injury. And the reason is, as we mentioned in the first slide, it can decrease mortality rates. And the rest, uh, two stages have the same like, uh, flow and algorithm, where you need just basically to know exactly how urgent you need to deal with your patients, and how urgently need to refer them to maybe hospital or to the corresponding team for management to approaching patients with acute kidney injury should follow the system, and the system we use here is 80. And that's, uh, I would assume that you are familiar with this assessing acute annual patients. And basically, it's, uh, for people who doesn't do it's like a where you go for airway and breathing, and then circulation and D is like the neurological status and else else other. And obviously, this is a comprehensive review. You can you should be slick. You should do this in five minutes. Whatever. Like patients, uh, need, uh, some maybe slick review. But in patients who are completely and well, you might end up needing 15 minutes and repeating this twice, uh, until you are stable until your patient is stabilized and you have a clue what's on what's happening. So but then, uh, this is usually a common approach for patients who are in shock. Sepsis like having hypothalamic shock or cardiogenic shock. And those can all lead to a K I and, uh, most likely prerenal AKI. As you all know in shock, most of the time, you will have decreased blood supply decreased perfusion rate as the shock, the words the definition of shock stands for you have decreased perfusion, uh, to the tissue. And that would contribute to prerenal AKI. So bits at bedside data to imagine yourself assessing our orthopedic patient there. You would like to know the observations. Are they hypertensive? Do they have, like, a possible hypovolemia being hypertensive and tachycardic? What about the urine output? Is there any fluids? Starts showing the intake, uh, urine output. So are there not drinking enough? Um, is there like, uh, any urine output they produce in the last six or 12 hours? So and then try to look at the catheters or tubing. So sometimes patients can have catheter draining, and the nurses might tell you all right, this patient only had 200 mils in the last six or 12 hours, which is significantly less than they have. But then they can have the stoma and having high, uh, ileostomy output contributing to more fluid losses. So always have a look at the catheter tubing systems N G tube. Uh, whether they are producing more than usual or they are blocked and then look at the drug shots. Nowadays, some hospitals are having, uh, electronic drug shots. Please don't forget to look at them as I nearly like, uh, meat on a daily basis. Junior doctors not addressing electronic drug shots. So try to collect all the data you have from bedside and then proceeded. Simple investigations. So simple Investigations like urine dip. It can show you signs of infection, like having nitrites or liquid sites. It can show some RBCs. RBCs can be a sign of basically having some sort of severe nephritis or like synthetic syndrome or can be, uh, present in renal colic, kidney stones, bladder stones or maybe an obstructive uh, causes from possible humor's other in the ureter or the bladder. But they are not specific, but they can be sensitive, showing that there is some sort of implemented process happening. Their bladder scan. So it's a simple bedside procedure where the nurses can perform. I would usually, uh, call for junior doctors to do the bladder scan themselves. The best way is to familiar yourself performing bladder scan When patients are more comfortable or, uh, they are not significantly and well, or they are not deteriorating rapidly, try to familiarize yourself with such procedures when you have a good room of time and space and you're in less stressful environments. So bladder scan can basically show you if patients are in retention. Uh, the bladder empty is empty. An empty bladder flows with an acute kidney injury of like three renal renal code is where the patient is not. The patient is not producing enough urine. Why, uh, bladder scan showing more than like half a liter or retention picture close with the post treatment. Obviously, men as we grow older, uh, we would have. We would suffer from bladder outlet obstruction and that, most likely from a large prostate. A large prostate can be either from benign or malignant etiologies. So seeing a man who is like maybe more than 60 years old with an acute kidney injury and performing no bladder scanning is really a big mistake, which you would like not to do. Other other, uh, scenarios where blood scan is quite important. Big importance. Uh, in patients who are receiving strong analgesia post, like big procedures or, uh, significant orthopedic trauma or having significant, uh, pain, uh, pain killers can lead to bladder attorney and retention. And again if your patient is significantly and will do your, uh, important testing such as a BGS that will show you a picture of the lactic acidosis. Uh, what's the P h I V p gs? Uh, it can give you an idea of the bicarbonate if a B CS is difficult to obtain, uh, blood, E C G. And as you're 80 assessment carry on with your investigations needed. So back to the common scenario where our 71 years old John, who had his right total knee replacement four days ago, uh, I was just figured out to to sustain an a k i with an e jafar dropping from more than 60 to 45. So as you were attending this presentation, you remember to do your e assessment, and it was unremarkable. He is comfortable in himself. Sat, uh, sat up in his share. Try nibbling some crisp, and he looks fine. It's just a biochemist biochemical resident. But then you've looked at the observation shot, and it was stable. Obviously, there was no fluid shot as Joan was an elective orthopedic patients where we had no concern. So and the drug shot show that he is on an experiment. Post operative prophylaxis. Uh, metformin, uh, ramipril by supper rule. Ibuprofen, paracetamol Cody. Now again, because you are, uh, acting well and, uh, trying to remember, uh, causes of kidney injury. You've suspected an element of renal, uh, cause looking at the metformin, the ramipril, the biopsy, uh, maybe the ibuprofen. Sorry. So metformin, ramipril ibuprofen, our own nephrotoxic medications to. And I know it might be difficult for you as a medical student to try to appreciate which medications are nephrotoxic and which are maybe hepatotoxic. But this is something you would develop by time with experience. So don't worry. And don't panic. So your plan was starting fluid shots, and that makes sense. There was no fluid shots. You will start in there just to measure their intake and output. You will hold metformin, the ramipril and the ibuprofen, and you started some slow IV fluids and guess he's not drinking enough water. And that's what we usually call like a challenge of fluids. And you ask the nurses to perform urine dip and bladder scan as they are simple, easy to obtain in the world and their cost efficient. And you looked a lot for next days. So for now, this is what you're expected to do as maybe junior doctor on a ward over the weekend having know, Senior. So you need to assess the patient, make sure they are stable, and then again, try to find out what are the possible causes, as the patient, uh, is postoperative patients do it. As you know, like three renal renal causes are common again. Is an orthopedics having a significant surgery? Um, having a strong analgesia might lead to some sort of retention, and that's why you're doing a bladder scan. But then working this way, we make sure that you're not missing anything, and again the reason is to avoid significant complication. So now back to, uh, what we should do in initial management and again as you can read any situation be capable to organize. Uh, most of, uh, this, uh, follow the plan. And obviously, the most important thing is you should react to your initial assessment. So if a patient was septic, we need to address success. If the patient was bleeding or in hypothalamic shock, you need to address that. But then, in generally speaking, you should rehydrate patients, and it's not always the fluid. So I influence his ascension, especially uh, for patients who are not keeping up but even encourage patients to try to drink plenty of water. Oral intake is important as IV fluids. Obviously, you are aiming to prescribe the fluids for patient in case they are developing any nausea, or if they are more sleepy because of the pain being and well in hospitals, especially overnight, where you would like to make sure that they are hydrated. 24 hours, seven fluid shots. It's part of the diagnostic and monitoring, uh, data you need or mid nephrotoxic review the drug shots, uh, make sure they don't have any medication that can cause, uh, a K I. If you don't know what, uh, medications can cause a kid I used to be an application on your phone. It's really helpful. And maybe the first couple of times you would expect yourself sitting by the drug shot and maybe looking up every medication. That's fine. This is how we learn catheter. It's It's something you would like to consider in the patients in retention. And basically you should be able to put a catheter yourself without handing over this like another colleague or nurses. Because if the patient is in retention with a K, I most likely the causes retention. And that's an obstructive uropathy, so sticking a catheter is basically the treatment. A catheter can be for non obstructive uropathy causes if the patient is acutely and well with metabolic acidosis, where you would like to review to monitor their urine output and then obviously react to the blood so you correct the electrolytes and again mentioning electrolytes is potassium, our main important electrolyte antibiotics. If there's an infection, too, if you're suspecting an infection and that's usually supported with the patient's urine like clinical status or you're in depth or inflammatory markers, please have a low threshold to start antibiotics and try to start non nephrotoxic antibiotics to. No one will blame you for starting antibiotics for suspected infection, but you would be blamed if you didn't start antibiotic for patient having an infection and deteriorating next day Imaging. So ultrasound scan. Usually in the NHS settings. You won't find it out of hours, but then again, if you are overnight or over the weekend, you can book the patient for an ultrasound scan. Try to get ahead with that. It's always helpful with non Uh, maybe, uh, an achy are not responding to your management or very severe AKI, where you are worried on an annual patient to organize an ultrasound scan. Now, if you're suspecting, uh, an obstructive uropathy or if your patient is septic or severely and well, where you think, uh, the naked eye is within the context of more, uh, significant insult or disease, organize the CT K, U B and C T K U B is without contrast CT, kidney, urinary bladder without contrast, so it shouldn't cause any harm for your patient and again highlighting for who doesn't know from you. That contrast IV contrast we use during our imaging studies is nephrotoxic itself. So you you see usually radiologist performing CT scan without contrast on patients who are, uh, sustaining chronic kidney disease or a significant AKI. From a urology perspective, our preferred CT scan would be considered City K U. B. And the reason is it can show stones better and again. Don't forget to organize bucks for next day. You would like to monitor and follow up your management, hopefully reflecting an improvement next day and again, a k I is something worth to be mentioned in your in your hands, over for your colleagues and for the list. Uh, follow up. Obviously, you need to follow up your patient symptoms. If they had nausea, I would hope that you give them some like anti emetics. Because then this is something important for them to be able to drink water. Uh, if they were in pain, you need to address their pain. But maybe with non nephrotoxic medications. Remember, in our scenario, we committed the ibuprofen for our orthopedic sharp. So maybe, uh, we should prescribe something else, uh, and again, uh, monitor their signs. What is happening for the BP? If they were hypertensive before again, as we said, follow their blood's next day or day after, Uh, don't forget to discuss your management with your senior or our colleague. Make sure you are doing the right stuff and you didn't miss anything and then refer to the appropriate appropriate team and appropriate team can be renal, uh, wherever, like you have, uh, renal causes. Or it can be like intensive care if you're having, like, severe and acutely annual patients, maybe with metabolic acidosis and some other organ failure in addition to the acute kidney injury. And obviously you can refer to urology If there's an obstructive uropathy. Uh, and I hope you're not referring the retention, uh, as you should be able to put the catheter yourself. So back to our scenario, uh, where we were assessing, uh, from our orthopedic shop. So next day you have organized the blood and it came back showing HEFR 43. So that's nearly static. I wouldn't consider that drop. His electrolytes are still normal. The post void bladder scan is 70 million, so he was not in retention. His urine is showing plus protein, so there's no signs of infection or maybe an inflammatory reason. We know from his drug shirt he's diabetic as he was on metformin. So finding protein, maybe something may be expected to see. Looking at the fluid chart, you've seen that his 24 hour urine output was around 1.4 liters and this is 50 miles per hour. This number on its own make no sense. You need to know the patient's weight. So if drone was 58 kg, that's one mil kilogram per hour. It drawn was like 70. That's less. And obviously, if John was like 164 kg, that's half mil. Sue. My message here. You don't really need to calculate this accurately, but then you need to have a sense. Is my patient having more than half a mil? So you would like to You'd like to have more than half a mil per kilogram per hour. Uh, if you don't, if you're not having this, I would be worried. And it can be either from like the AKI itself or maybe dehydration. So you need to work hard to achieve some sort of improvement here. Suit. You decided to continue with IV fluids as, uh, nearly the patient, uh, did show an improvement. The Qvar is ecstatic, but he is again. He was stable and there was no, uh, post renal causes. You are identified and new infection causes. And he started to carry on holding the nephrotoxic. And again, you requested the bloods and the renal ultrasound for next day as he didn't improve. Now, back to your presentation. So I would like to make a pose here as we nearly been talking, talking for half an hour. So you guys, uh, this is what I usually try, uh, to explain, uh, to my fellow colleagues. I teach usually. So there is a comfort zone and you will find this comfort zone with any perspective in your life. Obviously, this is your medical or clinical comfort zone. So everything happens you are comfortable with is with a new comfort zone. If you are a foundation doctor, you will find writing discharge letter lying within your comfort zone. Maybe having referrals lies on the edge to if you refer. If you're comfortable referring to general surgeons, Uh, that's in your comfort zone. But if if you never refer to maybe psychiatry or, uh, neurosurgeons, that's outside your comfort zone. But then at least you know how to refer in a basic manner. I would like you to try to indulge AKI and Hyperkalemia in your conference. So I hope today the AKI and Hyperkalemia topic are status standing by the edge. But remember, later on, if you read more about it, if you address patients more about it, or if you discuss with your colleagues and unwell patients having a k I in your would you would try to make your comfort zone, including this in near future. And obviously there's some stuff which can be far from the comfort zone. But again, if you are part of the CPR or crush, keep, uh, your comfort zone can grow and grow by time. Uh, till it just become much more bigger. Will you be comfortable addressing everything? And this will happen with the experience so it will build up gradually, be patient and be persistent, and I would advise using virtual and stimulated training. And as a surgical trainee, this is a good way for like, uh, usually for US surgical trainee to improve our experience where you'd like to revise the step of a procedure in your mind before starting, Uh, revise it again. After finishing what would you make different and again you can train it. You can do it on a simulating setting using like, uh, simulated tissues or simulated machine. So mind your comfort zone and take care of yourself just to be better in providing your care to my next topic, which is just a few maybe slides. Five minutes talk on hyperkal India, which is, uh, very associated with a K I, uh, acutely in the injury leading to significant complications or maybe high more territory. It's to basically remember, uh, potassium is one of the important electrolytes in our body. Usually you would find it intracellular and just remember the word how I can It's just this is like usually, uh, us Emily Caplan. Uh, like a sentence having a friend called can. And you're just saying hi to him too high potassium insight to, uh, and try to memorize this normal potassium is 3.5 to 5.3. If you didn't know this before attending this presentation, I would be happy if you leave with this information on its own. Normal potassium is from 3.5 to 5.3, and there is something called pseudo hyperkalemia again as we said potassium is intracellular. So if that's the cell and you will have the potassium here if the cell ruptures Potassium Catholic. So if you are withdrawing blood in very difficult patient to bleed uh, the sample can him allies, Uh, and the red blood cells can humanize leaking potassium into, uh, the tube, Uh, and that will show false hyperkalemia soon. Uh, that's why important that that's why it's important to double shake that this is not pseudio hyperkalemia. Obviously, if it was me assessing the patient for hyperkalemia, I would like first to know the patient and the clinical scenario if you have. If you are having the hyperkalemia with an acute kidney injury, try to have a very high threshold to assume that this is pseudo hyperkalemia. Most likely hyperkalemia will flow with acute kidney injury, so don't assume that this is a pseudo hyperkalemia. All right, so classification again. It depends on the numbers. So this is why it's important to know this, and it's important to know this to try as your patients because most of the time the lab will call you while you are performing another task or reviewing another annual patient telling you that the potassium is abnormal being 5.5, and that's just slightly above the upper limit. So would you worry and leave your annual patient and deal with that or leave it once you are done? This is why it's important for who for who are being on call and maybe, uh, surgical or medical wards carrying the sleep. This is maybe something you've encountered nurses or the labs calling you for hyperkalemia, and it will. Usually you will receive this phone call while performing another task. So try to memorize this so you know how to try As you're patient and later on, you need to know how to classify your hyperkalemia so mild hyperkalemia is 5.5 to 5.9 to obviously, you need to review those patients. You need to address why this is happening. Try to treat them as soon as you can and prevent further deterioration. Moderate hyperkalemia is between six and 6.4. This needs agent review and treatment, and obviously, uh, you are requesting an HCG for all patients with hyperkalemia and then severe hyperkalemia is more than 6.5. This is a life threatening condition if you have a hyperckemia more than 6.5 or with BCG changes. This is a severe hyperkalemia where you need to try at it as a high priority. Like this is your priority. One patient to see. All right too. Now, speaking so again, my message if you are receiving the bleep of abnormal potassium northern normal potassium level and try to have a counter attack reflects to ask the nurse who is bleeding you from Hyperkalemia to perform an ACG on that patient until you walk in and review that patient. Obviously this again flu with the virtual training. So if you just close your eyes and imagine the nurse calling you for hyperkalemia, you tell him. Thank you. I will come and give you the patient. Please do an EKG. True. What would you see on an ACOG? You would see signs of bradycardia p wave being absent or P r prolongation or any funny arrhythmias. Uh, you would see significantly tea with a P T waves or attended t waves or widen your complex or fatal arrhythmias such as V T or, uh, ventricular fibrillation or ventricular tachycardia. You can see an EKG strip here showing maybe attended t wave. So you don't need to be a cardiologist to identify this family, Rise yourself with HCG and again, As we said, try to memorize yourself with HCG when you are comfortable. Maybe, uh, reviewing very stable, comfortable patient with your senior colleague, where you can have a look and discuss the HCG for more training opportunities. Because the last thing you would like to do is carrying and holding up this CCG strip, assessing an unusual patient and then see nothing So you can see here it tended to be with like you are complex is not, uh, widen. It's just normal. And then, uh, I can't see any Like the P wave is faint, but it's still here. So the only finding I can see I spot myself is attentive to be Well, I don't need to be cardiologist. So with this, I can see hyperkalemia EKG changes. That's enough for me. I have hyperkalemia blood results, and I have an EKG changes so that will classify my patient as severe, having severe hyperkalemia despite the results. So if anyone has a CD changes, this is a life threatening emergency condition, which you need to address. So obviously I'm referring to North Bristol guidelines, and I'm referring to them just to code this were to go the last sentence, if there is an acute changes more than like, uh, half uh, 0.5 million more in 6 12 hours. This might be significant. So if your patient, like, had a potassium of four in the morning and for a different reason, you repeated their blood's, uh, in the evening to monitor the acai and their potassium came in the evening like, uh, at four point, maybe seven. That's potassium. Um, so that's still within normal limits. But this is a significant trees. And then, for that reason, you would like to address this AKI in more urgent matter. So back to our patient, John, who is 71 years old with diabetes as we know from his metformin hypertension, has his, uh, total knee replacement a few days ago. So you came after seven days. Once you finished your uncle back to the world and you found that you found out that he sustained wound infection, post surgical site infection, and he was started on antibiotics. He had a normal ultrasound, but he's a k I deteriorated. I believe this makes sense. He is a comorbidity 71. Uh, and he was unlucky to sustain this complication. Having antibiotics for an infection doesn't help. An achy I, uh, setting. And suddenly, uh, the nurses called you for the potassium of 6.2. Again. My take home message. Try to organize the BCG before you arrived, the patient you would like to have try adding of the patients yourself. So, uh, once the nurses called, you ask for the HCG. You plan to do an HCG, and then obviously you are doing always a reassessment. And you are still asking yourself, Is that a CD of hyperkalemia? But then again, because, you know, that bone had a key I viewed as soon. It's not to If June was someone who is like, 25 or 30 years old who had just walked into the hospital to have regular blood test, and then he had normal blood with no Okay, I have hyperkalemia. Maybe this is something you would consider, but not in this setting. All right, so you've done the EKG. You've seen the attentive way of you know you're gonna have, like, some sort of plan the plan. I'm not planning to teach you this today, but you need to check your local guidelines. Uh, every NHS trust will have local guidelines on the Internet or share drive where you need to familiarize yourself with those guidelines and trying to go over it with a cross them. When you are having free moment and again, it's just building you comfort here. Uh huh. The main idea treating hyperkalemia is you need to get rid of potassium and try to buy some time shifting potassium from X extra cellular to intracellular. So you're targeting the main course to treat. So if they were like, uh, having an a k I. You are already managing the way. I, uh it can be with IV fluids or simple as having a catheter in patient with retention so hydrating your patient is something which completely makes sense. You will dilute their potassium so you would use fluid without potassium. So Hartmann's is a favorite, uh, surgical fluids. It contains potassium. Every liter contains nearly four million more. So another take home message. Don't use Hartmann's in patients with hyperkalemia. If your patient was already on Hartman and that was prescribed by your consultants. Feel free to cross it off. Cardiac stabilize. So example, calcium gluconate. Some other trust you some other forms of like calcium, uh, gluconate. Or maybe if you read, uh, basically, uh, they will decrease the threshold. Uh, arrhythmias and usually drug like calcium gluconate can last from 60 to 90 minutes. So that would use you will give you a good window to drop your potassium, The potassium levels, two more safer rhythm. So basically cardiac stabilizers, like calcium gluconate and not like I mean treatment. They would just buy you more time. Insulin and dextrose. They will shift potassium from out to intracellular again. Check your local guidelines. Usually they will be IV insulin and IV 50% dextrose. Giving subcutaneous insulin would help, but not in, uh, an acute setting. So you will try to, uh, you are targeting the insulin intravenously, and that's why you need to give dextrose to avoid hyper, uh, glycemia salbutamol again. It's one of the medication which help shifting the potassium from extra cellular to intracellular. Calcium. Reason is the potassium binder, which the patient take orally and that basically will help the patient by the potassium, uh, from their GI tract and then, uh uh, defecated. So if you're giving customers only, um, constipated patient, you would consider giving them laxatives, they need to open their bombings. Uh, again, if this doesn't help your potassium going back into safer or normal levels, you need to consider dialysis. And obviously, this is a referral to renal doctor. So long story short, if patient does, the best way is for the patient to to correct or to get rid of their potassium is either to pass urine or to open their bowels. If they're opening their bowels and passing urine, you have a way to get rid of your potassium. Otherwise, you need dialysis. Um, to buy yourself a time, you can use some medication to shift the potassium from extra cellular to intracellular. And again, don't forget using Cardura stabilizer in patients with moderate or severe hyperkalemia or patient definitely with patients with COPD changes and again, please shake your guidelines whenever you have, like a moment that will help you maybe knowing exactly where you find them or you can download them to your account or two like you drive where you can use them whenever you are in such a scenario. So that's me trying to address an achy I and hyperkalemia from a urologic perspective. Please feel free to ask any questions. I hopefully, uh, I will try to answer all Thank you. Thank you very much. So maybe that was an excellent presentation. Very informative. I'm just going to have a look. If anyone would like to pop a question in the chart box and I'll relay them to somebody, um, I've got one question here for you. So someone Nicola White was asking for you to clarify pseudo hypochelemia in relation to AKI. Oh, sorry. Yeah. So, uh, hyperkalemia is a is a term as it says. Like it's false hyperkalemia where we would usually like assume that the results we had from the lab is wrong, mainly because of hemodialysis, uh, main, mainly because of hemolysis of blood while being withdrawn from the patient. Uh, my key message was, if you have patient sustaining an A k, I don't consider pseudo hyperkalemia as a cause. Take any hyperkalemia in an A k I settings seriously, as a true one. Obviously, you will send more blood. Uh, the blood, uh, bottles you send. It will come back to you within one hour or two to confirm that. But no one will blame you for managing the patient's most likely AKI and Hyperkalemia are through, uh, concurrent conditions. Okay, that's great. I hope that makes sense for you, Nicola. Um So there's another question here. What e g f r do you rule out using I donating? Contrast. Uh, usually, uh, radiologist will have certain criteria. They usually try to avoid IV contrast, uh, for PDGFR below 50. But then, guys, uh, the thing here is is not from a contrast or achy. I point of view is you would like to put the full picture all together. Do we need the CT scan urgently? So if it wasn't a CT scan for suspected cancer, the cancer will not grow in, like, a couple of days or maybe even three or four or five days. You can delay it while if you are performing a CT scan for someone who might just have a ruptured aortic aneurysm, you won't really care about their Egypt or Hyperkalemia. So try to put the pictures altogether. Uh, but then answering the long story long uh, answer short. It's 30 is usually what's followed. Great. Okay, that makes sense. Um, so there's another question here. Um, still not quite sure. So why is creatinine used as a diagnostic tool for a K i e g f r is used for chronic kidney disease? Doesn't create and disregard the context of the patient in terms of age and sex. CTC. Oh, yeah. So, to be honest, this is a tough question for a surgical trainee. Uh, not, uh, physiologist, but I would assume that usually creatinine is more sensitive. So again, your it's from mathematical point of view. You would, you would see, like a big change in creatinine with maybe sometimes a few change in the far. So someone creating it can move like from 50 to 60 without affecting the G fro. Especially if it was normal HEFR so. But then again, creating it is sensitive, and it can be an early detector. I would assume it's mainly from the mathematical like, uh, reasons just from how the formula is calculated. Okay. And I think we have one more question. Um, so someone asked What is the role of diuretics in Renal AKI? So again there is. There is no role for diabetics as a treatment for a k I. But then they have a rule in treating overloaded patients. So it's very common to see, uh, doctors, especially in I t u prescribing diuretic for an overloaded patient, uh, sustaining an achy I. But that's the diuretic was not mainly for an achy I It was for the EKG. It was for the overload. So if the patient having desaturation or significant like, uh, pulmonary edema, you are giving, uh, diuretic to basically to keep them alive. Uh, as you are following following an algorithm of, like, a B C. D. Obviously, the briefing is much more important than than the kidney. So otherwise you would intubate them. Uh, but then, uh, I think you would. You would see this wrong practice, especially. Sometimes it used to be like given, like from old, uh, maybe or like old train doctors, where they used to give, like IV diuretics to challenge the kidney and make it produce more urine. But then this, unfortunately, most of the time I end up causing, uh, stress and overload and deterioration of the A. K. I, uh, you don't give IV diuretics, except the patient is overloaded. There is no role of IV diuretics in a car. Okay, that's great. Um, there was just one more question. So, uh, any advice for pre hospital clinicians like paramedics? Etcetera? Sure, sure. So basically, uh, you would you would try again to think on the algorithm, uh, 82. Uh, if the patient is having hypoglycemic shock because of bleeding, Uh, stopping a bleeding point will help to keep the patients circulation. Uh, just like, uh, sustaining it's volume, uh, as much as it can. So you can do a lot from point stopping the bleeding, trying to obtain a cannula, maybe starting some IV fluids as you do and rest resuscitation. Or, like, maybe if you are having a patient with sepsis trying to identify, like sepsis as a cause of, uh, deterioration. So, actually, I don't know Zakaria. I do remember myself being part of the trauma team. Whenever, like, we used to receive patients. Uh uh, part of the trauma cools. I think the main, uh, I think, uh, our treatment would usually start with a good hand over from paramedics. And I do really remember the faces and the names of the paramedics who used to deliver the best hand over ever. I think this is a good way to start with. Great. Thank you very much. I don't think we have any more questions at the moment. And that's just over time. So I'm probably going to go ahead. And if we move onto the next slide, I'll just conclude our presentation now. So thank you, everyone for joining us. We've had a great attendance today, and the session was really good. Um, in my opinion, So I hope it was useful to all of you. Um, if you could all go ahead and use the QR code on this slide, um, and fill in the feedback for me just so that we know what we did wrong and what could be better? Um, that would be great. I'm going to pop the link to the feedback form in the chat box once we finish. Um, I also note that a few of you have been asking for the slides as well, so I'm happy to send them your way if you send us an email at the address on this slide. So urology at my end of the week dot com If you just send us an email asking for the slides and I'm I'm happy to send them across to all of you. Um, and I hope that you can use that urine use, um, in the future. So be sure to join us next time as well. So we'll have a session on flank pain and renal colic. Um, next Thursday. So thank you very much, everyone. And I'll just go ahead and pop that link in the box now. Thank you, everyone. And I hope you have a good night. And thanks to you as well. Thank you. Thank you. Thank you, everyone. Thank you. Thank you.