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Hi to all of those joining at six o'clock. I'm just going to wait a couple more minutes to let more people join and we'll make a start in about two minutes time. Okay. Hi, everyone. Um, my name's Evie. I'm a doctor and F to doctor, uh, in Northwest London at the moment. I'm currently specializing on it and I'm going to be presenting about fluids and electrolytes, which is quite a common topic that you will face as an F one. Um, so we thought that we'd include it into our F one series for all of the, you that are starting in August and for also those medical students or maybe F two S as well, that might find this useful. Um, so clinically relevant to everyone in all realms really, but mainly aimed at the F one's. Um, okay. And can everyone hear me and see me and see my slides? Just comment a little. Yes, on the chat if you can. Ok. Brilliant. Fantastic. Right. So, um, what I'll do is it's going to be a pretty much a quick whistlestop tour on fluids and electrolytes given that we've only really got an hour to talk about it and it's a lot of content. I'm not going to go into a huge amount of depth on everything, but I'm going to try and cover what I found really useful as an F one and what hopefully you will too. I'm not going to go into depth too much about renal physiology. Um And I can't cover all the electrolytes, but if you find this helpful, I'm happy to maybe do a more extended uh talk on electrolytes or at least I can do one and upload onto our medal account. Um As I'm only able to cover a few in this session. Um So we've got some case based discussion's and questions throughout and some polls. So please interact and post any questions on the chat. Um I might need prompting if there are some questions on the chat because I'm not seeing it regularly. Um That maybe he's here to let me know as well, but mainly any big questions just say them till the end um and answer some of the case based discussion on the chat and I will let you know if the answer correct or not. Okay. So in this topic, in this presentation today, we're gonna be talking. So, first of all about IV fluids, so different types of fluid therapy, we're gonna talk about how you should clinically assess fluid status of a patient when you're asked to go see a patient. And I like to break down fluid therapy into the five hours. So are for resuscitation, fluids are for routine management for replacement and redistribution and to reassess as well, which is important step that a lot of people miss. And then after that, we're going to talk about some common electrolyte imbalances. Um I'm going to talk mainly about potassium, sodium and magnesium. I didn't have enough time to talk about calcium and phosphate and some of the others. But if you find this helpful, I can do a more extended talk at another date. So to begin with, um there are two really main types of fluid therapy that we use or two different types of fluids. So we have crystalloids and keloids. Some of the types common types of crystalloid fluids are shown here. And this table has taken for geeky medics and it's actually quite useful just to compare different types, different crystalloids and um compare there uh concentrations and tenacity to what the human plasma be like. So sodium chloride, not when I'm sitting on saline is a commonly used one. And as you can see here, it only really contains sodium and chloride. It's an isotonic solution. Isotonic, meaning that the salute concentrations inside and outside the cell are the same. There's no concentration gradient across the membrane. So water can pass freely throughout hypotonic means that are hypotonic solution is something with a lower salute concentration that inside the cell. So there's a difference in concentration gradients, meaning that there's movement of water between the compartments causing it to enter the intracellular fluid. So that's what the hypotonic deck saline and the hypertonic dextrose solution as well. Um So, um here you can see as well. Hartman's is the most similar to um human plasma. So it replaces sodium potassium chloride and bicarbonate, but it doesn't contain glucose. So, if you're prescribing maintenance fluids, someone's nil by mouth, for example, you need to consider their glucose requirements and you'd have to add something with glucose to this. Um One thing to mention about Hartman solution, um sorry about sodium chloride. And I guess with Hartmann's as well is that when you are prescribing a significant amount of fluid, you are going to be giving quite a lot of sodium and chloride. And this as we'll discuss later can leads to something called hyperchloremia metabolic acidosis, which is something that you need to watch out for when you're giving excessive amounts of IV fluid. Okay. So that's the first type of um fluid. The second type is something called colloids. And these tend to be used mainly in an ICU setting um and actually rarely used nowadays as routine um maintenance. Um and for fluid resuscitation um used to be used a lot more and it was so keloids basically can be either manmade um such as starches, decks, trans or gelatin or they can occur naturally. So, such as albumin or fresh frozen plasma. And because they are bigger molecules in the fluid, they tend to stay in um in the blood for longer before passing two different compartments. So they tend to remain in the intravascular compartment for longer. Um So initially, it was thought that this was better uh for fluid resuscitation and for maintenance fluid, but actually, as well come on to a study in the next slide. Um They've shown that actually, it doesn't seem to be much difference in the long term between keloids and crystalloids. And there are some cons of using keloids that they can cause an allergic reaction specifically if they're naturally occurring. So, albumin or fresh frozen plasma um or, and also the expense of them compared to crystalloids. Um And um so a study, a recent, um a recent um uh cock Rain review showed that actually using uh keloids as opposed to crystalloids had no significant difference in mortality. Um and also no or little or no difference for the need for renal replacement. So, actually the cons of using um a colloid as opposed to a crystalloid outweigh the extra expense and the risks of allergic reaction. So nowadays, and especially as your role as an F one, you'll be prescribing crystallized probably a lot more than keloids. However, in certain circumstances, such as in the intensive care unit, often they will use albumin solution. I've seen quite a few times uh specifically in those with low albumin. So it's a good album replacement. Um And sometimes in sepsis as well when they've got um kind of leaking of fluids into, into a well third compartment that you end up maybe using keloids a bit more than crystalloids. Um But for our basis, there's no difference. And I think for now, nice as recommends using crystalloids such as Hartman's or normal saline for main aspect of fluid therapy. So a little question for you guys now just post your, actually, I think we might have a poll for this one if we could set the pole up for which of the following fluids. Here is a colloid. Mhm. Sorry, I'll just go back one slide just going to count the pole. Um Sorry, showing you that okay if we could just get the pole up again or post in the chat with those. Okay. And so looks like the most of you voted on that one. Yes or correct. So Albumin human Albumin solution is the only call out there. The rest are as shown in the previous table are all crystalloid forms of fluid therapy. Okay. So, first of all, um in terms of fluid therapy before you're, if you're asked to see a patient or ask to prescribe fluids before going and prescribing any sort of fluid willy nilly, um You need to really go and assess the patient to see. First of all, what's the fluid stages? You want to take a thorough history as well. You want to find out why uh why do you need to prescribe fluids and if so, which is most appropriate? So in terms of assessing the fluid status, I like to kind of split into hypovolemic. So low volume euvolemic where they've got good fluid status and hyperkalemic where they're showing signs of fluid overload. Um So a good way of assessing this really as in everything you'll be doing really when you go to assess patient in as an F one is to do an A TUI plus a thorough history taking. So first of all, airway, I haven't put on here, but airway, you want to, when you immediately go see a patient, is there a way patent? Is there signs of stride or are you concerned about the gcs and then not being able to maintain their airway? In which case you have, if you have any concerns at this point, you'd be calling anesthetics, putting out a cardiac respiratory skull and um getting that sort of, but in terms of fluid status, it's not really relevant for this. So B stands for breathing. So you're looking at Festival, what their oxygen saturations do? They look from the end of the bed? Do they looked like a panic? Have they got a raised respirator on some on listening to their chest? Have they got by basal crackles? Something that might be a sign of pommery edema and fluid overload in the lungs. Um Or for example, if you've maybe heard a one sided cause crackles or crackles or if they're producing sputum? Is there a sign of infection? Are they septic? Um something else you want to move on to the next one? On to see you want to be assessing their cardiovascular status. So, what's their heart rate? Their BP? What's their capillary refill time? Do they have moist mucous membranes? Have they got called peripheries? So for example, a raised heart rate alot systolic BP, a sluggish capillary, refill, refill time and dry mucous membranes might suggest that they are hypothalamic and the need of urgent fluid resuscitation. If they're JVP has raised, that might be an indicator of um fluid overload of heart failure, right sided heart failure that's causing they're raised JVP. Um You're at the stage say that you want to put a cannula in, take a set of bloods off including a VBG. Um And what you want to be considering for your VBG. For example, festival is looking at the HB have they had a hemorrhage that might mean them hypothalamic. Have they all raise lactate, which might indicate that they are very dehydrated or maybe septic. Look at their electrolytes. Something you need to consider when you're replacing their fluids. Basics. S and Ph as well are the acidotic except in sepsis, maybe or if they got a DK but also uh contribute to your fluid therapy management here. You would also want to maybe do a lying standing BP, passive leg raise to see if their BP. Um, and to see if they're responsive fluid responsive. This is quite a good way to see if giving them fluid is going to help them with their, um, say, for example, they're hypervolemia. Have they got peripheral overload? Are they hyperbole neck as well? Um, you might want to move on to the next consider whether they have a low gcs, they drowsy. Um And if so why they drowsy? Is this a sign of sepsis that might have been missed? It's the sign of DKA that might have been missed, check their glucose and ketones at this stage as well and then on IV everything else. So, are they bleeding from somewhere? This might determine why the hypovolemic? Are they a patient, a trauma, trauma patient who may have lost a lot of blood, a lot of fluids, do they need to consider a blood transfusion and urgent blood transfusion? In addition to the fluid therapy that you're considering, are they POSTOP? And if they are, you might consider how much blood they've lost or if they're nil by mouth, POSTOP, uh this will obviously change your uh fluid therapy as well. Burns patient's require a significant amount of flow resuscitation and actually haven't mentioned it in this, but this will be different to your usual strategy to flood therapy. Um We use often use something called department formula here um to look into that as well because that's slightly different flow therapy for burns patient's. Um Do they have a rash? Uh This might be example of a ninja cockle kind of sepsis that you might need to urgently treat. Um If they've got a catheter in situ measure the urine output is something that's often missed in patient's in hospital is that they might be an uric, that no one has noticed they haven't past year. And if they don't have a Catherine, uh they got diarrhea, vomiting, stoma, these will all um effect and tailor your fluid management here. So next is what resuscitation for the first? Are, are we considering? So if from your fluid assessment there, you've seen that they're hypovolemic, this will require a bit more of an urgent approach. So if they're hypovolemic, some of these signs might be present a systolic BP of under 100 a heart rate of over 90 raised capillary refill time or cold peripheries. Uh res respiratory rate raised news. And if they've got a passive leg raise, suggesting fluid responsiveness, this might mean that they want their hypovolemic and responsive to flood management. So, um in this case, your first step would be consider prescribing a bolus of fluid. So 500 mil bolus of crystalloid over 15 minutes if they're fit and well, 250 miles. If there's maybe evidence of hyper hyperbole mia. If they're frail, if they've got home abilities, you don't want to be causing more damage by giving them too much fluid. Then nice guidelines for this suggests that you can give bonuses up to two liters of IV fluid. And then after that, if they're showing no response to fluid management, you'd want to escalate to seniors and specifically up to itu for consideration of Iron Atrix maybe or extra cardiovascular support as they're not responding to flood alone. But hopefully by this stage, you would have involved someone else at this stage. Um As always an F one escalate early if there's concern honestly on like whether it's your to your sho whether it's the med reg um get the nurses to give hands because doing an a to be by yourself is really difficult and you do need more hands than you often think. Um So yeah, so also if someone has complex comorbidities, you need a bit more of a cautious approach to fluid resuscitation. So I'd I'd involved seniors earlier in these cases. Okay. So routine maintenance, this is a table taken from a reference at the end that there's a really good, nice guidelines on IV fluid describing in adults in hospital. Um And this is a table really of everyone's routine requirements over 24 hours. And this is in a normal healthy patient who has normal electrolytes and not deficient in anything. This is what we would require. So 25 to 30 miles of per kg, over 24 hours, one minimal of sodium and one minimal of chloride per kg, over 24 hours, not 0.5 to one of potassium, over 24 hours and 5200 g of 24 hours. And we're aiming usually for urine output of not 0.5 mils per kg per hour. So in the 70 kg patient over 24 hours, their requirements would be as shown here. So this is kind of what you're aiming for in your routine management. Um And this is not necessarily taking into consideration uh electrolyte losses that would need additional cases onto this. So this is if they've got normal bloods as well, okay. And this is also given the fact that if they are hypothalamic, you have already done fluid resuscitation and you've already trialed bonuses. Okay. So next one, I think so, yes, the next one is replacement and redistribution. So if, if, for example, a patient has ongoing fluid loss or electrolyte loss loss is if they've got dire um vomiting, if they have drains in situ, if they have stoners or blood loss, you will need to be thinking about this in addition to your routine maintenance. So if they have any deficits in their electrolytes, you'll be replacing. You're adding these on top of your standard routine maintenance. If there are any abnormal redistribution, redistribution issues. So if they have significant comorbidities such as heart failure, kidney failure, liver failure, if they've got complex electrolyte, redistribute, electrolyte, different disturbances are not responsive at this point, seek expert help. Um And in the list below as well, just seek expert help early because these are gonna be slightly more complex fluid therapy. Um And you need to be more cautious, for example, in patient's with fluid overload, you don't want to be worse than that overload. So, gross edema, severe sepsis, hyper or hypernatremia, renal kidney, liver or heart failure post up or if they have re feeling issues which will be causing electrolytes stances as well. Again, you need to apply a bit more of a cautious approach in elderly patient and also obese patient's um when you're prescribing as you, that's going back aside. But prescribing routine maintenance for obese patient's, you want to be adjusting the prescription to their ideal body weight. So use a lower range for volume per kilogram because patient's really need more than three liters per day. But if you say have, you know, 100 plus kg patient, you should really be going for their ideal body weight rather than the actual body weight for this um to stop over prevent fluid overload, basically, okay, ongoing losses as well. So this is a good diagram which can show how you might lose excess electrolytes if for example, there's vomiting or if they have endured tube in situ if they have a biliary draining situa pancreatic drain, diarrhea or if they've got colostomy, these are all going to add to your um addition to your routine maintenance and these are some kind of figures. I'm not going to go into detail and you don't need to know off by heart. Um Often these patient's with complex issues will be, will need more of a special management anyway, but you'll be considering these losses in addition to your routine maintenance. So you might need to prescribe more potassium. For example, if you're giving fluids and they've got this loss. But as always involve expert help with this because these are complex patient's with complex fluid uh requirements and electrolyte requirements. Often, if they're POSTOP, post general surgery, patient might also be nil by mouth. And so you might need to be considering a dietician approach to this as well. Um So that's a slide again from the nice website, which is really useful just to keep an eye on that. And again, they've got a really good algorithm here, which I'm not going to go into too much detail, but it kind of has gone through the five ours um that I've talked about and there's a nice flow diagram to follow what um what steps you really need to take next. Also, uh as with everything you're not just treating the numbers. So for example, you always need to consider what's the underlying cause of fluid loss. Um If they're hypovolemic and their septic, you also need to be thinking about, I need to be doing the sepsis six and not just replacing fluids. So remember just keep an open mind everything. You're not just going into write a prescription for fluids, you're going to assess the patient and to find out why they have a dysregulated fluid status. So again, this is a good reminder, maybe have it on your phone when you're going to see a patient just to prompt yourself how to do that. And as always, I actually didn't put a slide on it, but every single time you prescribed fluid, you want to be reassessing. So say you give a bolus, you want to see after 10, 15 minutes after giving that bolus has their BP picked up, has their heart rate gone down, has their rest rate gone down. All of these things that will show you if they are responsive to the fluid you've given them. And if you need to be escalating to I two, if they're not responsive, for example, so don't just prescribe fluids and then walk away. You need to go back and reassess right? Case number one is a 50 year old lady that comes in with diarrhea and vomiting. She's been struggling to meet her oral fluid um and food requirements, she weighs 85 kg. So she was initially hyperbole in which came to any, she did require some fluid boluses, but actually she's now hemodynamically and clinically stable. She's got no concerning past medical history that might make you need to rethink your fluid therapy and these her bloods that you can see are pretty much within range. Um So for this lady, um what are her 24 hour fluid um electrolyte requirements if you remember the table I did then back then. And also what regime of maintenance fluid would you suggest for this lady? Uh as there's not a poll post your answers into the chapter this um And so I've just seen that question if patient is ongoing losses such as vomiting would be fine to possibly. Yeah, basically, again, such as vomiting, if they're still vomiting. Um, and you're concerned you involve a senior straightaway, you wouldn't, I mean, I've never known someone to measure exactly how much they are vomiting. But I guess if you are keeping an eye on output, input, output, it will help, you know how much to replace. But yes, always escalate when you're concerned. Um Right. So put answers into the chat for these questions. Um and we can discuss the answers and a reminder from her, those recent bloods they are all within range. Um So when they were thinking about routine maintenance, ok, waiting for small answers just for what her, I mean, you can round it up, you can Google be nice chart to give you an idea of if you got my numbers off the top of your head, what her uh electrolyte calm itself. You might want to whip out a calculator. I think I needed to calculate, to wipe this out. I'll give you a few more minutes. Okay. Okay. Right. So next slide is, so I've actually gone up with that. I went for the 30 mils per kg. Um, just because she's a bit, you know, I mean, either anywhere, anywhere in the range of 25 to 30 is fine, but just given the fact that she's probably not too much of a risk of fluid overload and, um, she has required IV fluid bonuses. I would kind of around it up a bit. If I was more worried that she's been more frail, then maybe I'd go back the lower end, but anywhere between that range is fine. So yet, so we're kind of basically going around 2.5 to 2.5 liters. They're really um sodium nice, 85 potassium fortitude to 85 chloride, 85 glucose, 5200. And you're not fortunate as well. So this is 11 a my mean one flood regime that I've put, you can kind of be quite flexible with it. Um I think as long as the one thing you need to be cautious with is potassium and how quickly you're giving potassium replacement again, something we'll get onto in a little bit as well. Um To be aware of is that you might not want to give too much Heartland or too much, not 0.9 a normal saline because you don't want to cause a hyper Clarinex metabolic acidosis as well. So, and also remembering that she's know, by mouth, she's not managing to eat or drink so that we want to be replacing high glucose as well. So as long as you kind of cover this, those requirements doesn't really matter so much what you do. Um I rounded it to 2.5 liters of fluid here. So I've gone for a regime of one m deck saline given over 10 hours and um 500 mils given over four hours. Um And obviously I uh potassium requirements is 85. So you want to, I mean, given that the bags kind of tend to come in 40 millimoles. Um you want to kind of round it up to the nearest 40. Um So I've said here just 80 given that she's got normal potassium, I'm not so worried about giving her too much potassium. In fact, because she's been vomiting, there's a risk of losing more potassium. So I guess we could probably go up to the 80 millimoles here. And as long as we're not giving, I might give the answer away tonight's question. But as long as we're not giving potassium over the maximum rate, then that's fine. And so again, yes. So as we said, if there are concerns regarding her fluid status, if she's hyperbole Mick or if she's got the signs of heart failure, kidney failure, she's a frail little old lady. We might go for the lower end of the scale here. Um And also something that we want to be cautious of is that if we're giving heart mints or 9.9% normal saline, we might be giving her too much slow demand, too much chloride and a few minutes from the previous table. Um We, and this can lead to something on the next side called, oh, in a couple of sites, I'm called hyperkeratotic metabolic acidosis. Right. So, just quickly for the next question, this is one for the poll you asked. So again, the same case, what's the fastest rate that sodium potassium can be transfused over? Given that she's also only got IV peripheral access if she had central venous access is much slightly different. Um So questions in the poem, wait a couple of a few more responses there. OK. Majority of you have got that correct. The answer is in fact, be so given she has peripheral either can, you know, we don't want to be exceeding the rate of 10 million miles per hour. If we're going over this, then she would need itu and central venous access for this. You can go a little bit faster with central venous access. But for our knowledge, for peripheral access, we stick to 10 mg per hour. We don't want to be causing ourselves issues with hypercalcemia which will come onto in a bit. Um Okay, fab any questions at this point? Um If they're quick, I can answer them now. If not write them in the chat and we can address them at the end. Okay. Moving on. So, as I mentioned briefly earlier, something called hyperchloremia, metabolic acidosis. So this tends to be in situations of patient's with diarrhea and vomiting. So they've already got bicarbonate loss from uh diarrhea. Um They've also say we've given too much IV fluids specifically, not 0.9% saline or even Hartman's is that we are giving it too much uh an ACL and by adding too many chloral island into the blood, we actually end up forcing bicarbonate irons into the cells. And if they're already losing bicarbonate from elsewhere, this can cause a normal and iron gap acidosis. So we want to be wary of this when we're prescribing fluids, I've never seen it happen in practice, but it is something to be aware of. Okay. Next question is another case. This is of a 70 year old male who has had a heartless procedure for an obstructing distal colon tumor. He's found to have an A K I following this and that's what his basement baseline, correct it is. And it's got 240 day one POSTOP. He on assessment is tachycardic. He has, he's hypertensive and has a raised as well, which is slightly raised respiratory of 24. He is catheterized and since the last six hours, he's only um produced 100 miles of urine. So, what is his current fluid status? And also what would you consider would be the first step, the flow therapy here, put answers in the chat for this and we haven't got a hole here. OK, great. You guys have got this spot on. So, yeah, he is hypovolemic. So, from our third assessment, from our A te tachycardic, he's hypo, he's hypotensive. He's all pointing towards hypomania. He's a small urine output as well. He's got an A K I, uh we probably think this is a bit of a prerenal like I, but we'd want to do some further investigations of this. Um And, um, again, he needs, first of all, first are, is resuscitation and given that we've said, um, well, I haven't mentioned any fluid overload and I haven't mentioned any past medical history. So yet I'd give a 500 mil Baylor's over 15 minutes. You're going to stay there with him while you have that done. Uh Given 0.9 Saline or Apartment solutions here. Yeah. Not quite nice. Aylan's what nice recommends and you want to stay with them and reassess his float response. So think about doing another 80 after 15 minutes. Has his BP picked up his, his heart rate come down as he maybe started producing urine. All of these things that you want to reassess. If not, you can consider giving another bolus. And further, again, following the assessment, you can give up to two liters. I would escalate if he's not really responding after the 2nd 500 mils. Um I would, I mean, if you're worried, just call people early and then when it gets to two leaders, that's when you're starting to have the discussion with the ITU team about what to do. Um, again, further investigations into why he's hypovolemic. Is this just that he's very dehydrated post up? Is it that he hasn't, we haven't been, he hasn't been prescribed any fluid since he's been postop nil by mouth. Is there something else going on? Has he got a sepsis here? That's come from being post up a lot of things. Has he had lost a lot of blood? Do we need to be transfusing him all of this? That when you've done your 80 you will be thinking about. So, as well as after you've done your initial bolus, you're thinking, where is this coming from? How can we replace it? And is there anything extra we need to be done? Okay. We're going on too. I mean, I'm going to have to run through electrolytes and as I said, I'm really sorry, I haven't been able to do all of the electrolytes here, but we're going to start with potassium. So plasma potassium levels are regulated by a number of things including aldosterone. So the run in um angiotensin aldosterone system as a base balance and insulin levels all effect uh plasma potassium hyperkalemia is what we're gonna be specifically talking about here. Um Your reference ranges are going to vary from hospital, hospital, the ones I've got here might be slightly different, but this is kind of the rough range. So anything over 5.5 is considered the hyperkalemia and it can be split into mild, moderate to severe uh causes of hypochelemia. These are just a few to list. Um I like to split it into renal drugs and other um renal causes. So a kickd or hypokalemic renal tubular acidosis. Uh any basically um the kidneys are responsible for 90% of potassium excretion. I think the rest is the gi tract. So as a result, any hit that the kidneys take can uh and is the most common cause part to Kenya um drugs. So either directly then nephrotoxic or indirectly by worsening saying AKI or Western CKD can cause a hyperglycemic. These are just a few. So potassium sparing diuretics. Um ace inhibitors are six foreign tacrolimus Heparin beach blockers and said's digoxin and the rest, I'm not going to go into too much detail about these if you have any questions as to why ask them at the end. Um but we did give a good renal therapy as a renal talk earlier this year. So I think that's on medal if you want to look into this further, other causes as well. So DK, I will talk a bit about DK actually just in diabetic keto acidosis. Um potassium, this can cause a potassium shift for two reasons. So, um firstly, in the daycare, they have a low insulin and um insulin actually increases the uh sodium potassium exchanger eighties exchanger causing. So low insulin means that there's less of um an extra set in cellular uh potassium shift causing higher extracellular uh potassium. So, raising the plasma potassium concentration and also in an acidosis um as a result of potassium ions leaving the southern exchange hydrogen ions to go in to buffer the metabolic acidosis. This can cause a hypokalemia as well um and Addisons as well. So, Addison's um is an adrenal causing mainly in this case, it's the low aldosterone. I think I'll go into this in a bit more detail later, but the aldosterone can cause um raised so increased. So, aldosterone causes usually helps with the acid excretion. However, if you've got the aldosterone, that's going to cause hypokalemia, tissue damage. So, anything that causes an intracellular release of potassium. So most potassium is stored within cells. Anything that causes damage to cells and causes release of that potassium will cause hypoglycemia. So, burns trauma, rhabdomyolysis as well as blood transfusion. When you are uh transfusing, a number of obviously red blood cells, you some damage cells can cause release of potassium into the plasma causing a hyperkalemia. There are also some other causes of a pseudo hyperkalemia. So that's where the actual plasma concentration of potassium isn't raised. But so for example, if you left the tourniquet on too long, that can cause increased cell damage, which can cause increased potassium um your main concerns about hyperckemia as well as the patient possibly feeling a bit nauseous, vomiting, muscle weakness. What you're really worried about is cardiac arrhythmias. Um So this will tailor your treatment of um hyperckemia. So basically any patient with a slightly raised potassium, you'd want to get an ECG on and whether there's ST changes or not, this will determine your management plan again, as well as taking a thorough history, want to see what their background is. Have they got CKD? Have they got a normal raised baseline potassium? Because some patient's can sit around a potassium of seven, some CKD patient's. Um and that is, you might not necessarily see easy gene changes, but if it's persistent hyperckemia, you, this is cause for concern and would need renal replacement. So your treatment, I like to split it into the aims of what the treatment's going to be doing. So, um if you've got a severe hyperckemia of over 6.5 or east, the presence of ECG changes, which we'll talk about what kind of things are looking out for. Um You want to be giving them IV calcium gluconate guidelines say give it 30 mils 10% over 10 minutes and reassess following that reassess ecg um as if there is any changes, you're escalating this immediately. If it's a 6.5 you would be calling the medicine at this stage. But this is the management important to note that IV calcium gluconate doesn't lower the plasma levels. It is purely to stabilize the members of the myocardium and protect the heart. Um Secondly, you want to get down, you want to basically reduce the potassium levels. And short term wise, you do this by shifting the potassium from the extracellular compartment, shifting inside the cell and insulin does that very well. But you give a insulin dextrose infusion, basically don't want to be giving too much incident in causing a significant hypoglycemia, which is why you give it in dextrose. Another way of lowering um plasma levels of sodium potassium is to give nebulizer, albuterol. Um just as beta blockers cause hyperkalemia, beat, agonists can help reduce it um longer term management. So this isn't going to be your immediate critical case, but eventually you will need to uh help with long term removal. You'd give something like calcium Vizzoni um which helps to bind and excrete potassium. Um enteral e so through the gi tract loop diuretics as well, can I produce uh potassium apart from, I mean, so you wouldn't give potassium sparing diuretic, obviously, but luke biotics about that and dialysis, um one of the indications for renal replacement therapy is a persistent hypokalemia that's refractory to any medical management. So many CKD patient's you might see will have high potassium levels and might not be responsive. In which case you're calling itu and U unless say you're already they're already on a diet, you know, whatever you're calling them for diabetes or your present further management, inpatient CKD, you want to be considering a low potassium diet as well. So, bananas, you know, all of that jazz to tell them to eat less bananas, um treat the cause as well. So we're not just treating the numbers here. We're thinking what actually prompted them to have the side, the clean ear. Are they on a Synod Bitters? In which case stop them? Have they had, they had a long live, they got rhabdomyolysis. Look at their CK and that would require IV flow resuscitation and monitoring as well. Are they on digoxin? Um Is this something you need to be considering? So, acute digoxin uh toxicity can cause a hypokalemia. Um So it actually inhibits the sodium potassium co transporter. Some cases you might need to actually give a digoxin specific antibody um as well. So you need any help for this. And this is a nice snippet from my hospital guidelines. Um We can send you outside afterwards or the this uh will be on our med. Also, I'm not going to go through what we've talked about this mainly. Okay, hypochelemia. The opposite. So moderate is 2.5 to 3, severe is 2.5 below 2.5. Again, these reference ranges will vary, causes can be split really into decreased intake. Um Increased losses tends to be the most common forms. So have they got diarrhea, vomiting fistula? Are they on diuretics? Loop diuretics. Um have they got aldosterone excess, something called con syndrome, a medical medical dries is the same. So all of these, you're considering might be causing a hypochelemia again, translated a shift. So in our closest can cause a hypochelemia. Again, coexisting magnesium deficiency can result in reduced potassium uptake as well. Um So considering that are they have, they got DK and have we just given them a an incident infusion that they wanna fix the insulin infusion that will drop their testing as well. Um And again, those medicines there that we briefly talked about, um these are all possible causes and something that you might um they might be complaining more symptoms wise. So muscle weakness, cramps, dizziness, nausea. Again, any potassium changes get an ECG have they got ECG changes? This is more of a worrying cause and will also determine your management of this. Um Yes, two, I think that was probably talking about entresto for hyperkalemia. Um I think so. Yeah, we'll come onto that later. Um ask that question again at the end of my one member. Um So yeah, whether they, I mean, whether it's moderate severe and whether there are insulin changes at EZD changes, sorry, will determine how quickly and what kind of potassium replacements you're going to give if it's moderate, mild to moderate. Um And they are able to takes me already. You want to kind of the preferred treatment is to give oral replacement. What you don't want to do is then cause them to have hyperkalemia via placing it too quickly or giving too much IV. If yeah, replacing potassium cautiously in patients with renal impairment because they will have a high risk of developing hip cleaner. You want to speak to the renal team really about this. Um, again, you'd want to be, if you are giving IV, you'd want to not put an absence saline, usually, um, 5% glucose can cause a transcending a shift check, magnesium levels. Do they need a magnesium replacement? This will also help correct the Hipaa cleaner. So these are again, these I think are taken from another hospital guidelines but will vary in your hospital and check anyone with unstable arrhythmia or ST changes. Well, first, well, anyone with these two changes, you're escalating anyone with an unstable with arrhythmia, you are putting out TTT to um easydew changes just briefly hyperkalemia. Your classic changes are your taught enter T waves P wave flattening pr prolong pr and a widened QRS. Um as the hyperkalemia worsens, you're going to start getting some conduction abnormalities. And in case is usually about nine millimoles, you can get ventricular fibrillation, pulseless electrical activity in a systole. So you're really worried about hyperkalemia causing these hypokalemia. Again. Um This causes the T wave inversion, ST depression. You waves start coming prolonged pr interval and an apparent prolonged QT. But actually, it's, it's apparent in the sense that it's usually due to a fusion of the tea and these new, new waves, it causes a nice pneumonic or not pneumonic but little ditty that I remember is you have no pot and ot but a long pr and a long queue tea is a way to remember it. So you for the waves. No partner. Potassium long pr long qt. Okay. Moving on rapidly because I'm aware it's already called to and I still got a bit more to talk about. So sodium um we're only gonna, I'm only going to talk about hyponatremia here. Um Just because it's quite common issue faced. Um And by F ones as well, and I'm not going to be able to talk about it in endocrinology level of detail. But just briefly, um we'll talk about here if you would like another feather talk on this, I'm sure we can do more specifically to um hyponatremia. But in any case, hyponatremia, you want to really involve the endocrinology team specialist here. Um It's a such a complex system and every hospital had their different guidelines. Um And also given the complications of hyponatremia and correcting it possibly too quickly. You don't want to be doing this alone. So briefly splitting hyponatremia into raised urinary sodium and a low urinary sodium. There are different ways to differentiate it, but this is just a quick way of doing it. So, uh first of all hyponatremia as anything under 100 and 35 and can be from different causes. Um someone with a urine erased urinary sodium who is hypovolemic causes might be um So this would be considered hypothalamic renal loss often from diuretics. So far as our loop diuretics or possibly Addison's disease can cause a low uh hypovolemic hyponatremia. Uh if they euvolemic and they've got urinary sodium of over 20 then you might think this is an SIADH and you also want to exclude hypothyroidism, hypothyroidism as a cause of this. Um So SIADH um would give you your classic euvolemic hyponatremia with a raised your nationality and a low serum osmolality in SIADH, you have an excessive excretion of ADH. So, anti diuretic hormone causing um extra uh sodium loss and fluid re uptick in the collecting ducks. So this is going to be causing this urinary sodium under 20. Um It's sodium repeating probably from renal loss as well, but they're still retaining that they're not losing it from there. Um Kidneys necessarily. Um So for example, this might be uh diarrhea, vomiting, sweating, burns if they're hyperbole emmick. Um There's a hyperbole emmick, hyponatremia for more to excess. It could be heart failure, uh liver cirrhosis nephrotic syndrome or a psychogenic polydipsia. So that's just a brief topic. I am not going to cover it more detail because I don't have time right now, but it is something we can go into later. Oh, at another date. Um Symptoms. So, what you're worried about in patient's with hyponatremia is usually the neurological causes of when you have an acute change in sodium, you can get cerebral oedema, oedema, which might cause fatigue, seizures, confusion, loss of consciousness and these patient's, you're really worried. Um So if they're, if they're showing symptoms from their hyponatremia or if it's an acute change within 48 hours, this is going to change your management. But for if it's a chronic over 40 hours and the nonsymptomatic, this is a little uh guideline into how you're going to be treating them. So, first of all, what's their urine sodium? Um this is taken from the hospital island. So the numbers are slightly different. If they've got a raised urine sodium, you want to be seeing, are they hypo or hyper polemic? The hypothalamic um with a normal urine sodium, are they, have they got diarrhea and vomiting? Are they dehydrated? Have they got a diuretic? In which case, you're gonna fluid resuscitate them with the uh 9.9% normal saline or apartments, they're hyperbole Mick. You don't want to give them fluid resuscitation, you're gonna fluid restrict them. Um So for example, if they've got heart failure, nephrotic syndrome, liver failure, you're gonna restrict them to 1 to 1.5 liters over 24 hours. If they have a raised urinary sodium, this will change your management if they are hypothalamic. Again, is this a primary adrenal failure in Addison's disease? In which case, you're involving the endocrinologists, you're also going to need to be considering replacing hydrocortisone here because this is a critical, urgent situation and you're gonna fluid replacement if they have a normal fluid status, if they euvolemic and they've got a raise during the sodium, you're gonna be thinking, is this SIADH or is this hypothyroidism for SIADH you want to flood, restrict them. Um And then I think I go into this and a little bit more detail in the next slide. Um You're going to um yeah, the first line fluid restrict them, treat the underlying cause of their say th second line. Um You can consider giving your ear or you can consider giving a vasopro press and receptor antagonist such as a captain, which basically directly block the action of a DH in the collecting ducts. So they reduce the water retention. Um but that really needs to be done under specialist management. Okay, if they have developed this acutely or if they're symptomatic, this is a concerning situation of cerebral edema. In this case, you'd consider hypertonic saline. Um But you're not going to be doing this by yourself. This is specialist management here and caution when you're correcting hyponatremia is that you don't want to be over corrected too quickly. You want to aim under eight millimeters per day. I think the research varies to the rate. Some people say 3 to 6, some people at age 12, but most it's under eight is required to prevent cerebral pontine myelin ISIS, which is irreversible condition and something you really don't want to happen. So, um if you're worried about the fact that you might be over corrected, stop giving them whatever you're giving them and get the specialist involved, the endocrinology might recommend something called desmopressin, but you won't be prescribing the stuff that will be under guidance. Okay. That was quick hyponatremia. I'm sorry if I rushed over that little bit, but final electrolyte here we're going to talk about is magnesium. Um Again, I'm only going to talk about hypo magnesium, magnesium, eah. In this situation again, um the range will very but I've put the range here is under not point some five as per BMJ gardens here. Um different types of causes. So um mainly, I mean potassium is sodium magnesium is um either lost through the gi tract. So I think it's absorbed mainly in the colon. So, um malabsorption because hypermagnesemia reduced magnesium intake, excessive pirg purgation also. And um eating disorders can commonly cause a hypermagnesemia as well. Renal. A bit less common than the gi causes impaired sodium magnesium re absorption. Some diuretics. PPI S TPN laxed is an alcohol can cause low magnesium and it can coexist, coexist with other electrolyte disorders like hyper uh selenium hyper hyper calcemia um and some metabolic disorders, symptoms. So, early symptoms, uh depression, vertigo, parasthesia, muscle spasms, a taxi, a hyperreflexia and then a bit later on confusion, seizures, hallucination and arrhythmias. Um again you're looking out for coexisting electrolyte disturbances. So you might also notice some potassium changes from potassium or calcium as well. Um ECD changes that you might see with the hypo magnesium eah are prolonged pr interval, is prolonged QTPT wave earlier signs and then predisposition to going into a VT and course a two point. And actually the treatment for torsade point is IV magnesium. So these are some changes that you might see here and, and uh associated hypochelemia, hypocalcemia. So I think I put hyper calcium on the other side, hypocalcemia. So calcium compete to magnesium uptake in the loop of Henle e. Um So increase in filtered calcium load can impend magnesium re absorption. Again, hypo magnesium can lead parathyroid hormone resistance, which can lead hypocalcemia. So they're very interlinked and a hypochelemia can also commonly be seen and coexisting with hypomagnesemia. Um Yeah. So just be aware of that and treatment. So again, hospital guidelines, um it will depend on the numbers and whether they're symptomatic or not, if they have a mild to moderate, moderate hypomagnesemia try and give it orally. So, oral magnesium comes as either or a magnesium glycerophosphate or aspartate. You're, you tend to aim for 10 to 20 minimal per day. Um Oral tablets can give quite significant diarrhea. So patient's don't really like having them. Um if they're know by mouth, you can also give it as IV um and routing replacement will be determined by hospital guidelines, but I think my, the ones I got on the next slide show maximum rate of eight minimize power um with routine IV replacement oral, you don't usually need ECG monitoring. However, if it's a severe hypomagnesemia, so under not point fiber of the symptomatic, this should be managed in an ITU setting with the CG monitoring. Um You're going to either correct it. Well, you like you usually, as we said before with routine, either you can give that for, for a peripheral line. Ideally with, when we're giving it this fast rate, we want to be giving it to a central line. So uh an example of the rating, you might give a B 20 minimal in 100 miles of sodium chloride over an hour minimum or if they need it really rapidly, if they've got. So you are a cute with me as you can give it a faster rate. But follow your guidelines as this next one shows this is from London Northwest, hostile trust. But again, reiterating what we've said, but these are some numbers for you um and follow what your guidance will say unless you're often really helpful in how you would dilute it and what to dilute it in as well. So I think you can usually dilute it in so employed or glucose, glucose 5%. Um And then after giving this replacement, you want to at least after two hours check what their levels are you want to be. Uh monitoring BP, heart rate, respiratory rate reflexes, a neurology as well. Um And ECG monitoring is recommended but not mandatory, mandatory for routine replacement, but it's mandatory when high doses and faster rates are required. In which case you want to be considering this in a critical care or an intensive care setting. Right? I think we're on to our final cases. Now. Um, a 67 year old male presents any with lethargy, vomiting and 24 hours of an urea. He's got a background of CKD and his most recent EGFR was 30 he comes in the hospital and these are his recent blood tests. Um, what are there any further investigations at this stage that you want to ask for post in the chat? And what are you mainly concerned about here? Nice. We want to get an ETG is what we're thinking of. Um, that's, I mean, a number of other investigations that immediately you kinda want to get an ECG when you see a potassium of 7.1. And here is a ZCG. What can you see that concerns you on this ECG? And what might this suggest? I'm not expecting a full analysis. The CDD. I just want you to point out the barn door signs here, post them in the chat. Nice. Yeah, a few other things that you can see a bit more subtle but might be all in keeping with the diagnosis. Yeah. Board, a widened QRS is correct. One more thing I think I mentioned in the first one of the sides. Don't worry if you missed it. It's kind of around here. Yep. And flattened p waves as well. Um So yeah, and I don't think I mentioned it there, but yeah, prolonged pr as well. Nice. And this is all in keeping with the hypercalcemia. He had a potassium of 7.1 and about going to CKD. So you are worried about this and oh, and what investigations? So what what would your immediate management plan B and slightly longer term management plan B put some ideas up in the chat will race through those. So initial management, what are you thinking most urgently with an ECG like that and then some further management as well poppel the answers in? Yeah, amazing. We're really worried about this becoming an arrhythmia going into a cardiac arrest here. So we want to give calcium gluconate to stabilize the myocardium and prevent that happening. So that's our first initial management. Once we've done that, anything else that we might consider to help treat the hypochelemia? Great. Yeah, insulin dextrose nebulized albuterol are going to bring down the serum potassium, calcium gluconate, gluconate is not going to do anything to potassium levels but is required to protect the heart. Great and then any longer term management bit later down the line you might suggest. Mhm Not really an urgent situation, but you might want to think about. Yeah, calcium Rizzoli. Um Perfect and yeah. Correct. Cause brilliant for remembering that what caused him to go into this. Um We've been told that he's got back on CKD. Is it just a renal impairment or is there something else? Brilliant? And then I like that you and we're not replacing the therapies that comes on possibly to the next one. So despite the fact that we've given him everything, um he, his potassium remains persistently high and refractory to medical management. What are we going to do next? Has been queried briefly mentioned previously. Brilliant. Yeah, we are calling it. You were calling the renal team. We're going to try and get him dialyzed. He might already be known to that dialysis team. He might already have a fistula or a Tesio line in which case we can just plug them into the dialysis unit or he might need to go up to itu for huma filtration. Great. But at this stage, you're getting your big, big seniors involved. Um Fantastic. I'm aware that it is past seven now guys. So if you need to nip off, I think we've only got one more case. Um But please fill in feedback form and don't miss our next sessions we want tomorrow one on Thursday. Um But I understand if people need to rush off, but if you have time today for the final case, um we have a 55 55 year old woman who's come in to the hospital following a tonic clonic seizure that was witnessed she, her seizures have now stopped but she remains italy well, well confused following her seizures. She's not known to have any epileptic disease. Her husband mentions that she's recently been diagnosed with lung cancer and she was also recently started on an antidepressant SSRI and since then, she's been feeling a bit sick, tired but just put this down to her depression, physical examination reveals that she is pretty much euvolemic. Um And otherwise she is stable. What are you thinking about when you see these blood tests? And what other investigations would you like to ask for from those bloods? What's really standing out to you? And what might you think of investigating next? Um a bit being a bit specific. Any answers? Oh yeah, we'll take them. Yeah. Jump the gun. I like it. Um We can tell by her flood station she's euvolemic and we can definitely tell that she's hyponatremic. Nice. Yes, great answers. We want to do a hyponatremia screen and given the fact you had a seizure, we want to do a CT head. She's got a background malignancy want to rule out any obvious Mets possibly might need further imaging and an MRI. Um But brilliant. I like the hypernatremia screen. So yes, you're in hospitality sodium urine, urinary sodium has not maliti. Also, we want to rule out other causes of hyponatremia. So we're going to get a random cortisol ideally, we'd like to have a 9 a.m. Cortisol's most accurate, but we can't predict when she's coming to hospital. So random course it was gonna have to do, but we want to rule out Addison's as a cause of hyponatremia, especially because this will require immediate management and also want to make sure she's not got hypothyroid which might be causing her hyponatremia. And we want to see if this really is what we think it is. So what can we see from this hyponatremia screen? Given these results? Um Shoutout obvious findings and what the diagnosis we think is. Mhm Shout out what these bloods are showing you and jump the gun and say what we think the diagnosis is and what might lead you to think about that as well? Nice. Brilliant. Yeah. Yes. Fantastic. Bang on Mustafa. So as we've said, we've assessed her fluid status. We know that she's euvolemic. Her plasma osmolality is low. Her urine osmolality is on the low side. Urinary sodium is high. So given this, we're thinking it's a euvolemic hyponatremia with a raised urinary sodium is pointing towards SIADH. And fantastic. We also know, well, I haven't mentioned some of the causes of SIADH, but there's a specific lung cancer post in what in the chat and what type of lung cancer for extra brownie points might cause this paraneoplastic syndrome. Um It's a specific pattern for a specific type of lung cancer. Yeah. Brilliant small cell, small cell can cause can produce a th which in itself then can cause uh SIADH inappropriate release. And it's paraneoplastic syndrome of a small cell lung cancer. And SSRI is one of the side effects is SIDH as well. So she's got a double whammy there. Um We also did want to rule out that this isn't a metastatic disease that would be causing the seizures and confusion. So we would want further imaging of her head and probably get a pan CT really to see if she's got spread elsewhere. Um Brilliant. Yes. OK. Out of the following um given that we think this is an SIADH picture. What do we want to do out of these? What's the best next step in management? Given her presentation pop on the pole. Okay. I'm gonna give you a couple more minutes and then I'm going to wrap it up. Yeah, I mean where the poll is slightly torn, but most of you have got the correct answer here given the fact it's a symptomatic. We're assuming it's an acute hyponatremia. Um We want to be giving a hypertonic saline as first line treatment in severe hypernatremia. But we won't be giving this ourselves. This is going to be in an ICU setting really or under senior guidance. You would be giving bonuses of uh or a small amount of hypertonic saline and then you want to be really closely monitoring this. Um And you want to make sure that you're not going to overcorrect that you're not going to be prescribing this yourself, you're going to be, well, unless it's under guidance, this is really what a worrying situation, what we don't want to cause put it in the chat or something, we don't want to cause of as a cause of overcorrection. Um If anyone knows the name of what we don't want to cause by giving over eight minimal crotch per day. Uh No, that's the other big name. Uh We don't. That is you're right in terms of giving excessive IV fluids for other causes, but specifically I'm asking for. Yeah, so cerebral pontine myelinolysis iss um desmopressin, you wouldn't be giving this situation. Um You won't be giving, you don't want to be giving more sodium because you're overcorrect it. Um Hyper hypertonic saline is the correct one flow restriction. Not really. That's either if it's an a symptomatic SIADH or if it's chronic or if they are hyperkalemic and a toll that time is when it tends to be in the kind of the chronic hyponatremia phase where they're a symptomatic and that's what they haven't responded well to flow restriction. And again, that's going to be guided by renal team and endocrinologists bit too specific for us. Anyway, that is everything that was a lot of content. I'm sorry if your brains are all hurting a bit. Are there any questions? I'll go through an answer a few that I think we mentioned earlier. Um Addie Dr addy can long term PPI treatment, lower magnesium. Yes, it does. PPI is a cause of hypermagnesemia and with consequent hypochelemia, they can coexist. Yes. And as you said, Valsartan Q petrol also risk of hypoglycemia. Correct. Um Any more questions? We'll put the recording up on our medal and um put in the feedback form if you want a bit more of a thorough session on electrolytes. I'm happy to do a recorded session or a live session. Um including calcium and phosphate. I don't mind doing that as well. I miss that out today and maybe a bit more in depth electrolyte management. Um It just is the potassium limit. Um I think mainly I think the damage like immediate damage to tissue. Um Of course, if you cause like an extra verse a shin injury. Um and I think the key issue is that actually you need central venous access as well as close monitoring when you're giving that much potassium. Because if you overcorrect it and cause a hyperkalemia, you are going to be needing cardiac monitoring, you're gonna be needing RTU setting or at least a high dependency unit. So both the fact that you don't want to cause an extra verse a shin injury and also because you want close monitoring. Thanks all, please remember to fill in the feedback form. Um And please stay tuned for our next um F one series. We've got some amazing speakers coming on with really relevant information. Um I found it so helpful last year. Well, year before when I started F one, if you again have any topic ideas you want us to address, pop them on a feedback form. We have already set our dates for this series, but we are happy to do some more teaching or at least maybe a pre recorded session that we could upload. Um Let us know and see you guys all. So there's an Australia talk uh for those interested in maybe working abroad tomorrow as well as on Thursday. I think we have our common things on Cool F One as part of our F one series and we have our ABG interpretation coming up on the fifth of July. Uh We will post on our Instagram close to the time, but stay tuned, posting the feedback forms if you want any more teaching. And it was lovely having your great questions, great interaction and see you all soon. Thanks very much. Oh And uh here are some references as well as there are some really useful websites that I've put up. The nice guidelines are great geeky. Medics are amazing. This was the review on keloids versus crystalloids. Um BMJ, I don't know if it was mentioned by Laura in the uh tips and Tricks for F one. But getting the BMJ Best Practice app is brilliant. I think you can get it through Open Athens or three, your institution. Um Really recommend downloading the app as a foundation, your doctor and beyond or as a medical student, it's got some really useful clinical information um and see you will soon.