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Good evening everyone. Thank you all for joining. Um I'm your host, I'm Viv and I'm one of the F one cos at mind the bleep. Um Just before we get started with the actual presentation, just wanted to go through a little bit of housekeeping before we start. Um So obviously, this series is aiming to give you some case based examples with lots of polls and opportunities to ask specialists, any of your niggling questions from on calls or in hour shifts. Um So I'm part of the team um with Manet and Ramea. Um We run the F one series and we help organize F one events throughout this year. Um If there's anything you'd specifically like covered, um then I'll put my email in the chat and feel free to email if there's anything you'd be dying to know about. Um So obviously, this series is all about supporting you with your out of hours and in hours work. Um And this evening we've got doctor, so tet he's an ST six endocrinology um reg and he's gonna be running us through some really great case based examples based on real life cases that he has encountered. Um And I think should be really helpful, especially if you've got nerves uh and concerns around insulin and insulin prescribing, which can be pretty hard to do, especially as you navigate into fy one. Um Just a few disclaimers that we try and say at all of our lectures. Um Obviously, all of the content tonight is to be viewed by healthcare professionals um or healthcare professional students. Um All of the cases are anonymized and any resemblance to actual patients is unint. Um We try our absolute best to make everything factual and accurate. Um But they may be sometimes errors. Um Do let us know if you have spotted any of these. Um But that is something to be aware of. Um And for our full disclaimers, you can check on the website. Um if you are finding F one difficult or you're looking for better resources. Um These are just some places to be aware of. If you follow us a medal, then you should be able to see a full list of all our upcoming webinars. We've got specialty specific ones and F one specific ones. So it's a really great resource. Um I've also just linked the fy one part of our website where we've got lots and lots of articles and we try and embed within the articles, videos um from events that we've held. Um And obviously whatsapp is a great resource. Um So I've just got a QR code there where you can go to the mind the Bleep page and it's got all of the whatsapp groups, including any Deanery chats for this year for 2024. Um, if you're not already on them, I think that's the end of my, um, introduction. Really? Um, next week we'll be covering, um, EC GS of the Raia and the week after we've got a surgical specialty we've got urology, um, just to be aware of. So I'm going to un share my screen and pass over to. So, um, fabulous. Hello. Hopefully. Uh you can hear me. Yeah, I can hear you all good. Oh, ok. All right. I'm going to stop presenting my cases. Um, I hope you can see my slides. Yeah, I can see and hear you. Oh, ok. So if they, um, if you look at the chart, if you have any questions or anything, just let me know. Um Yeah. Ok. So I'm gonna start now. Uh Hello, everybody. Uh welcome to the uh uh, uh, apply uh, appointment one series. Um Today I'm gonna talk about um endocrinology and diabetes which you normally encounter um, um, like problems when you normally encounter in the uh on course shift. So I'm currently working in an Exeter hospital. I'm currently uh ST six at the moment. Um So I'm gonna, hopefully you can see a slide and it's moving. Um, ok, so the content I would like to discuss about the, um, the first thing is we wanna talk about like hyperglycemia. So I think I'm sure you will have a lot of bleeds from the nurses. Uh like saying like, oh my patient had a high blood sugar and then you, you may, you may have a lot of calls and bleeds from the, from the nurses. Um And so yeah, I think that's, I will cover with the uh um few cases that I encounter. And then also I would like to talk about hypoglycemia as well. And I'm gonna talk about any like take home messages at the end of my diabetes. Um and talk and then hopefully you will learn something um from the, from this session. And so, so, and then after that, I will talk briefly, talk about endocrine case. Uh So when I think about endocrine cases, there are so many endocrine cases. Um So mostly when you're on call, you normally encounter mainly the uh electrolyte uh imbalance. Uh So I think the most common one you may encounter is the hyponatremia. You will get a handover from the uh uh uh D team saying like, oh, could you please chase the sodium level and then what will you do next kind of thing? And then, so we're gonna talk about some introduction and a classification signs and symptoms and the management plan. And then I will also talk with the cases so that uh uh to, to, to make it more interesting and more interactive and then, and we'll take it from there. All right. Um, so I'm gonna, so before let's move on to the diabetes session. So my first question is, um, because so when you're doing on call, so you probably need to know what would be the inpatient, uh blood glucose uh levels uh in the hospital. So I just would like to uh ask the audience and, and, and just would like to know your thoughts about what would be the uh target inpatient blood glucose level. And so, um, so you can put it in the pool. I think there is a pool questions coming up and then I just would like to know your idea as well. What's your target? OK. So I've got a few responses here. Good. So I'm gonna wait for the next uh a couple of seconds and then see. OK. Good. OK. Interesting. All right. OK. Uh I think most of the people answer 4 to 6 32% and then, uh OK. All right. Uh Thank you. Thank you for your input. Um So that's really helpful because um normally like in the hospital, um we normally aim for the blood sugar a bit higher than in the community. So, uh, so normally in the community, if you see a patient with diabetes in the clinic, you normally see that. Oh, should we aim for the blood glucose between 4 to 8, less than 10, basically. Um But in the hospital setting, uh we normally aim for like 6 to 12. So, um sometimes 6 to 10. So as I uh I think um this is because the hypoglycemia is the uh imminent um uh you know, danger for the, for the patients in the hospital. That's why we try to uh keep the target blood sugar as an inpatient, a bit higher than the in the community. So the an the current answer is ee obviously, OK, thank you for your input. Uh We're gonna go to the next slide. So, so when you get the uh call from the nurse that when patient had a high blood glucose level, uh don't panic. Uh because uh because whenever you said, like, make sure, make sure patient ask the, ask the nurse whether the patient is OK? Is he well, is she well and then ask the nurse to check the ketones? OK. So that is the first step uh that you have to do. And so if the ketone is more than 1.5 and then you probably need to consider, is it a medical emergency call? Like is, is that the patient is having a TKA? So I think that's the first uh especially when, when the patient had a type one diabetes or, or the uh or the patient came in with the uh TKA. So basically, you need to rule out whether this patient had ATK or not by doing the a venous blood gas. Uh check the ph and check the bop. Ok. Uh, so that is the first step. Ok. And I'm, I'm sure everybody knows that. Um, so, and, and then another thing is if your blood sugars is very high, more than 25 and the patient has type two diabetes and you need to consider about a, these are the two things that you don't want to miss, uh, when you're doing on call. Ok. And then make sure the patient is ok? All right. So let's go to the next one. So, so I think you rooted out everything. So if your blood sugar is like, not really high, less than 25 or keto is less than 1.5. So, so I'm not sure about uh uh other people do doing out of our on call. So normally I want to ask my junior doctors, uh I'm sorry, resident doctors, but not we call resident doctors. Uh They normally say that, oh, if the blood sugar is high ketones is nor normal. So, so what, what most of the junior do resident doctors do is uh give a, a rapid acting insulin like uh 2 to 4 units as a stat dose um uh which is kind of OK. But this is not the only uh way to manage uh the uh uh manage the hyperglycemia out of our uh setting. So, um so, so if, so there are a couple of things that you can consider. So in this light as you can see. So you can consider like, OK, you can continue monitoring and reassess. So if the patient had uh a long, long acting insulin or had an insulin previously, not long ago, you can monitor and reassess on the material is that you can titrate your existing insulin. But if you don't feel confident, it's ok, it's, it's, it's one of the options that you can consider. And the three is, um, you can also adjust the oral hypoglycemic agents. And, and also if the patient is not on insulin, if you think that the patient needs to be on insulin, you can, you can use the uh temporary uh insulin regime and, and then, and, and then, and then if the patient is like nearby mouth or like if they can swallow or something, like had a stroke and had high blood sugar during out of hour, if you don't know, just, just ask the nurse to start sliding scale, which is the stiffest we did you and then make sure that uh, you, you need, you need to refer to the uh diabetes specialist nurse. Uh uh because which is really important. They are the specialist who will be coming to see the patient uh uh uh in the morning. So especially, um, like if you, if, if we're struggling with the uh uh glycemic uh control. So, yeah, these are a couple of options that you can do. Ok. So I just want to talk about uh a case. Um uh hopefully, uh this will um make uh everything like more interactive. Um So, uh so this is a case, uh a, a patient with type one diabetes and, and patient had a blood glucose level of uh 22 MIOL. So, which was measured at, at night. So you, you've been called by the, the nurse that they, they concerned that uh his uh his glucose is he or his or high blood glucose is very high. And, and then, and then when you ask a couple of more questions and then the patient is uh on normal, normally on the basal regime. So he normally take normal uh 666 units with each meal and then he's taking Lantus tenderness at night. And, and then you ask that if the patient well, and then as I said, out, patient clinic can be fine. He does not have any symptoms of hyperglycemia. And so everything is ok. So, and then the next step, as you said, OK, let's check the ketone. OK. All right. So the ketone is very reassuring. It comes back at no 0.3. Ok. So, um, so, so you ask the patient like, what do you normally do if your blood sugar is too high? These are four units. And then, so most of the patients of type one diabetes, they know their correction ratio. So, and then you can ask the patient or you can make a decision of? Oh, ok. We can start uh let's, let's give a number four units because this glucose very high. And then, so um so I think you decided to give a number of it. That's the status. So, so my next question is, so, so, so what time will you ask the nurse uh to recheck the patient's blood glucose after you give your uh uh you uh after, after, after four units of Nova is given. So it's, it will take a couple of min minutes. Uh And so, so everybody can answer. So I just want to see chat. OK. All right. Uh uh We really appreciate your input and so just trying to uh be a bit more interactive because uh otherwise, you know, if I just talking and then everybody will get bored. So I just want to see what people will do uh after you give the rapid four minutes. OK. It's, I will give a couple of seconds and All right. OK. So very interesting. Thank you. Thank you so much for your input. Um Yeah, I can see that most of the people say 30 minutes after you give them the remember, you will recheck your blood sugar and, and then the next one is that 30% of the audience said 60 minutes. So an hour after. OK. Um So yeah, um just wanted to talk about this um because uh so for the recommendation point of view. Uh we don't normally recommend the nurses to recheck the the blood glucose level after you give the rapid acting insulin and know within two hours. So the correct answer is 100 and 20 minutes after you normally check that like two hours after you give the number, you normally check. So thank you so much for your input. I really appreciate that. Um So I will let me explain why you don't want uh to check your blood sugar level uh very uh within two hours. So when you look at the graph, so as you can see the red one and the yellow one, so the red one and yellow one, so normally the yellow one is the one that we we normally use the strong acting one. So usually the novorapid fall into that yellow category. So as you can see the blood group, the the insulin level will peak at a at, at around two hours and then it will take off after two hours. So the reason why we don't want you to check the blood glucose level within two hours is because it's not gonna make any difference. So if you check within like half an hour or an hour, the blood glucose may not be going down. It might be stay, stay high like 20 or 21 or maybe like 19. So in that case, that makes you worried that oh my God. But the insulin that I just prescribed is not enough and then you prescribe more insulin. And then this what what happened was like what we call insulin stacking. And so when the and then the patient will have a hyperglycemia and then you have to treat the hyperglycemia. So we don't, we don't want that. So, so we, we ask the nurses to instruct the nurses to make sure you check your blood glucose level two hours after you give them the rait because otherwise it will cause a lot of anxiety and the nurses will bleed you again. I don't know this person. Blood glucose is not coming down and then you, you become more anxious and then you give more uh insulin and then, and then you will end up, the patient would end up with hypoglycemia. So, so I think this is uh this is the landing point. Uh So we don't normally recommend to check the blood glucose level two hours after the insulin and just want to check for as you may know, there are a couple of like insulin um uh that we normally use in the hospital. These are the short acting, so like no rapid a hum and there are some premixed insulin as well as you can see, HumaLOG mix 25 to 53. You mix that and then there are some long acting or intermediate acting acting insulin and it's called Epis Lantus to Tresiba, et cetera. So yeah, II just want you to highlight that. So just be mindful about the insulin acting. OK? We don't want our patient to be hyperglycemic. OK. Uh So let's go to the next case. Uh Hopefully, hopefully, uh you will learn something from this case. All right. Um So let's go to another case two. So this case is very interesting and when I was a AAA registrar about two years ago and, and then I got a call from the junior doctors and, and saying like, what should we do? So? Ok, so the the nurses bleed you and and then the patient who is end of like pathways. So and then was found to have a blood glucose of only 3.1. Ok? And then the nurses said, and the ac a health care assistant checked the blood glucose accidentally uh because the ac a was not aware the patient is of life. So yeah, so how you do? So when you get the more information, what happened was so the patient is 82 ok? She got a background history of Parkinson's disease and then type two diabetes on human eye. OK? And then when you asked, oh, is patient? OK? And then the patient is alert uh but but confused but, but the nurses wasn't sure that it is is normal baseline or not. And so, so when you go and see and when you look at the notes and then see the note said that end of like decision was made today by the consultant uh because of uh repeated aspiration, pneumonia and then desaturation, not responding to the multiple courses of antibiotics. Uh And so that's why the the the patient may make end of life. So and so as usual like type two diabetes on normally on insulin, so that the patient had a human eye as a regular dose in the morning and before the medical go around, which yeah, before this end of like decision was made and then you got a call around like six o'clock and the patient is having high pull. Ok. And so the medical entry, so they say like the patient may pass away in the next 24 48 hours basically. Um So, but at the moment, patient is a little bit just confusion and he's requiring a bit of oxygen and, and he's a bit unsettled. Ok. So my question is, so how will you manage? Um So the next uh question is how you manage. The first one is, um, will you blame the ACL while you're checking the blood sugar for the patient who is on end of life? And the second one is uh where you ignore the hypoglycemia because the patient is dying within age 24 48 hours according to consult of nose or where you treat the hypoglycemia. Uh and, and then with these, uh maybe you can because patients seems to be just give sedation, make, make him comfortable or maybe you can recheck the blood glucose in one over time. OK. I'll wait a couple of seconds for the audience to respond to the poor question. Good, great. I'm greater than nobody, nobody selected. Thank you so much. OK. That's good. Uh Everybody is like uh thank you. Thank you very much. I think most of the people go for c uh Yeah, I think that is correct. Uh So um so uh uh because um patient might be agitated or, or like confused. Uh maybe because of um hypoglycemia. So if we don't know, so I think if she's eating and drinking, so we will suggest to treat the hypoglycemia according to the local hospital protocol. OK. And, and if the patient can swallow, you can give, you know, glucotide or like orange juice or things or maybe if the patient is uh nearby mark uh cannot swallow, you can give IV treatment. I think most of the people uh good to go for the uh right answer. Thank you very much for your input. So I'm gonna go to the next slide. The reason why I'm saying is when you look at the diabetes UK website, uh which is uh you can easily accessible uh this website which is really good for the patients also for the professional as well. So, so when you look up to the right side, the principle of high quality diabetes care at the end of life is in the duct bull as you can see, we will aim for to avoid the uh metabolic compensation and diabetes related emergency. And as you can see mostly frequent and necessary hypoglycemia, DKA and then hyperosmolar hyperglycemic state, which is called HHS and then persistent um symptomatic um hyperglycemia. Ok. So, I think this is, this is the main thing, like if you, if the patients end of like in the hospital, you've been bleed by the, by the nurses And then, um, and then, so patients hypoglycemia and very symptomatic treat the hypoglycemia. Ok. So we don't want um, the uh, patient to, to, to, to, to suffer basically. Ok. Um, so there are a couple of things that you can see, avoid with complications and you avoid the symptomatic clinicality. I appreciate everything. So, and then when you look at the left side, the definition of the approaching end of life is not just, uh, it very for like, so they are likely to die within the next 12 months. So, basically, so every patient, the end of life with the diabetes, you just want to make sure that they're not gonna end up in a DK or HHS or hypoglycemia. Ok. Because, uh, we don't want, uh, uh, and, uh, want the patient to suffer from these symptoms. Ok. All right. So, uh, this is also from the ref a reference from the diabetes UK. And, uh, so this is a brief summary of uh, what you can do. And so, so when you are on call and then when, when you're feeling so tired and then you, you can't think. And then there is that your seniors are busy and then they don't know how to you. You, you don't, you can't find any help immediately. So you can have a look at the website and there is an algorithm for the, for the uh for the diabetes care in the last days of life. And you can see type two diabetes normally on diag control, Metformin treated, you can stop monitoring your blood glu you going need to monitor your blood glucose. And then for the type two diabetes who is on other tablets or insulin or GLP one, you can stop the other tablets and then you can consider stopping the insulin if the individuals have a little small dose of the insulin requirement or if their blood sugars are less than 10 million more. Ok. So if the insulin stopped, you need to check your, check the blood glucose. Anyway. So if the blood glucose come up over 20 you can start treating the rapid acting insulin. And then if there, if they need like two, at least two, more than two rapid acting insulin in a day, you can consider uh long acting insulin as a or the Lantus. Um And then if the, if you decided to continue the insulin and you prescribe once a day insulin and then you can monitor and you can adjust the dose depending on the blood glucose level. For the patient with type one diabetes who is end of life normally, uh we just stop all the rapid acting insulin. Just give the long acting insulin just monitor. Ok. So if your blood glucose level is below eight and you can decrease the dose of the insulin by 10 to 20%. And if above 20 miol just incr uh increase the insulin dose by 10 to 20%. Ok. So the main thing is to reduce the risk of symptoms of diabetes, ketoacidosis. Ok. So, so this is uh also from diabetes uh UK website. And so normally for the end of flight patient, we normally aim for the blood glucose level a little bit higher than when as an inpatient. So inpatient, we normally go, uh aim for blood glucose between 6 to 12. So for the end of vibration, we aim for 6 to 50 you, we try to keep the test at minimum. So if it is necessary uh to perform this and because we don't want a lot of multiple blood sugar testing, so it's sensible to have a once a day uh blood glucose level checked. Uh And then if whether the patient is having any symptoms of hypoglycemia or hyperglycemia, you can check. Ok. So this is the reference from uh UK. Ok. So, ok, so diabetes still. So case three, so you're 44 year old uh Taiwan diabetes and patient was admitted to the hospital with the left leg cellulitis about 12 hours ago. Ok. Uh, not long ago. And he's now on the ward and then, and then he's normally on the 668 units with each meal and then Tresiba 20 units at that time. Ok. But the nurses believe you that he, he, he forgot to take it in short acting insulin and novorapid at tea time with food, uh, about two hours ago. And then, and then the nurses doesn't know what to do and, but she's not a diabetes nurse. Uh she's just a regular like what uh nurse. So she has no idea. So she's asking the advice from you. OK, so the current blood glucose is 12 miol. OK. So my question is, what would you do that? So first thing is do nothing. OK. Uh because, and glucose, as we mentioned earlier, blood glucose is 12 miol which is kind of acceptable. Uh And, and, and the option B is like, OK, just give eight units of no rapid and because this is uh normal t time and OK, we will give a little bit of less six units for C and then another option is D we will give four units of normal rapid on the E OK, we will recheck in two hours. So I will give uh a couple of seconds for the audience to respond to questions. Thank you and see 25 responses. II will give you a couple of uh seconds. Um ok, good. Thank you so much for your uh answers. I really appreciate that. I hope this session is useful. It's kind of more interactive, but I don't see your, I can't see your faces but like it's really nice to see people responding to their poor questions. Ok. Oh, thank you very much. Ok, you got 4039 response and 40 responses now. So most of the people the answer. Ok, we will recheck the blood in two hours time. Ok? And some of them is do nothing because BN is 12 million more now, which is acceptable to carry on. Um Yeah, a few people would like to give a bit of four units of the rapid. So yeah, good. Uh Thank you so much. Um So um, so the the the the rules and regulation is uh, so if you miss a short acting insulin and your type one diabetes, you don't normally have the insulin in your body, you need to rely on the insulin from the outside. Ok? We don't want that patient to be in a DKA. So option A and option option A is absolutely wrong because the patient had a, a active infection and then his blood sugar may be going up and then he had a meal without any insulin. He may have background insulin though. Uh but his blood sugar can go on. So the rule is if you miss your short acting insulin within two hours, you can give safely give the regular uh dose of the insulin. So at tea time, he take eight units. So basically you can give eight units. Ok. So eight unit is the uh correct. So you don't need to be panic about hypoglycemia patient is in the hospital, he's got an active infection. So if you don't give anything, he will end up in ATK. Ok. There's a risk and so this is the general rules for the missing insulin. Ok? So this, so the first thing is if your short acting insulin is missed within two hours after a meal, you give us your dose. So for the long acting insulin is you miss within two hours, you can give future dose if it is within two hours. So if missing short acting insulin after two hours. So what would you do? So normally what we recommend is use your correction ratio? Ok. So so just measure your blood sugar after two hours and depending on your blood sugar level, you will give the insulin, ok? The correction ratio for the patient with Taiwan diabetes, they have their own ratio. So you can ask them ask the patient or if they are not. Well, you can look at the diabetes um letter from the endocrinology letter see what the ratios are. And then you can also look at the GP record. What do you normally have? Ok, so the speaking of the correction ratio. I just want to ask one question to the audience. Is that OK? So, so how much does one unit of short acting insulin lower your blood sugar level? So A is one minimal, B is two minimal, C is three minimal, T four minimal E is five minimal. OK. So I will give bit of time. Uh I just want to, I just want to see the response from the audience. Thank you. Mm Yeah, I'll wait for a couple of seconds and getting to the response of 23 people responses. OK. Good. So far and most of the people think that um if you give one unit of short acting insulin, um this will lower the blood sugar by 2 million more. Mm Yeah. OK. Thank you so much. Uh Everybody uh I really appreciate your input. Um So basically uh the general rule you, you, you, you, you don't think about any, any any any other factors like body weight or like a BMI or whatever. Uh So, so general rule is one unit of the short acting insulin nor normally normally lower the blood sugar by three MIOL. So the current answer is 3 million more, but that is not always correct. OK. So that depends on the patient BM I and how resistant because if you have a high BM I, they might be more insulin because they are more insulin resistant because of the edible tissue. So, so that's why like uh so general rule of so one unit will bring down the 33 million more. But if you are a slim person, if the patient is very slim and then, and maybe, maybe they will be most insulin sensitive. And then um one unit of short acting insulin will lower the blood sugar full mi more. And then also you can also check how much total dose of the insulin this patient required uh for the daily uh for the 24 hours. And you can also see the drug chart and then see see how much insulin this patient is having. Uh, so I think this general result and if you don't know when you need by three me more. Ok. Yeah. And then, so we normally aim for the blood glucose around 12. So if your, if the patient blood sugar is about uh like um um maybe 18. So you can give maybe like two units if you don't know if you're not sure. Um, so just get two units. That's what bring down. Hopefully it will bring down to 12, maybe more. So which is the top? Ok. Thank you very much. So, uh, so this is my diabetes but hopefully, um this is quite useful uh when you're doing your on call, I know the medical onco are very, very busy and it's not just one thing. Um, so I really, really appreciate all the resident doctor Howard and you, you all deserve a good uh uh uh you know, deserve a good, very uh like a reward. OK? And you, you guys are very, very uh you are very hardworking and then you try to make sure that patients are safe and then, and, and it's really appreciated. Ok. Um So my take home message is um if you're hyperglycemia, so check the ketone immediately. Ok? And then if the blood sugar is like more than 25 and think about diabetes emergency. HHS DK. Um So another thing is uh be be, be mindful about the insulin statin, don't recheck blood glucose within two hours of no rabbit. OK. So there are other options possible, not just the no rait as a sta dose. Ok. Hopefully, uh this is my endo uh diabetes section. So hopefully this is useful. Um So I'm gonna go to the endocrine section. I think they have a good time. Um So yeah, hopefully this will uh you, you will learn something from this. Uh We OK. So as I mentioned earlier, so there are so many like endocrine r uh condition when you're doing on call. The most of the times that you've been called is uh to call to see a patient with hyponatremia, which is quite common. So which is about like 30% of the hospitalized patients according to the society for Endocrinology website. Um and then hyponatremia is very, very common. Um And, and then, and you know, one of the common disorder of the fluid and electrolyte imbalance. Um when you con daily clinic arris while you're on the ward, this, you know, despite regardless of your specialty that you work, you, you may see like postoperative in surgery and pediatric or whatever they join in your medical wards, uh things like that. So it's quite common like um so I think if we should talk about a little bit about how to manage hyponatremia. So yeah, hopefully this section also useful for everybody. So the hyponatremia can lead to a variety of the symptoms as well. Um So sometimes the patient is fine when you, when you ask the patient patient is uh ii don't feel anything. Um just settle, that's fine. I just OK, I'm, I'm good. It's OK. But sometimes the patient might be really, really uh very unwell or maybe like the hyponatremia is quite dangerous, electrolyte abnormalities and it can lead to life tricking. Uh uh OK, can lead to a horrible situation like even like life threatening. OK. So let's, let's talk about the uh uh definition. OK. So definition is um so if your sodium concentration is less than 100 and 35 mill per liter, which is defined as uh hyponatremia. OK. So hyponatremia is uh primary a disorder of the water burns. So that's what I see. So if you see a patient with the hyponatremia, you know you, what you think about is the water balance. So you, you, you have given a task how to manage, you know, hyponatremia by, by, by adjusting the water balance. Basically. Uh So I think what I normally like um think is like is this a water, is it overloaded or is it um very dry? So basically, the main, the main thing is if you get attacks, like if you see a patient with a hypernatremia, the main thing is the uh fluid balance is the key. So, so your clinical assessment is uh really important. OK. So, yeah, so um OK, so I think uh uh this is the uh based on the biochemistry m moderate uh um and severe hy hypernatremia. If you have severe hyponatremia, I think it's less than 100 and 25. And then also there's some classification on the onset if it is acute, less than 48 hours and then chronic condition is uh more than 48 hours. OK. This is a sort of a trans you can also have a look at the uh website. This is available to everybody. OK. Um So sorry to interrupt. I think um some people aren't able to see the slides. Ok. Um Shall we if you just un unpresented and then repres and then we'll just go back to the slides, hopefully that resolves the issue. Oh OK. Yeah, sorry about that. Uh OK. I'm gonna Trane. Um and you just wanna put in the, in the chat if they can see the slides. Yeah. Lovely. Oh, ok. So sorry about that. Yeah, thank, thank you. Ok, so I'm not sure which like insulin. Ok. Fine. OK. I'll just talk about classification. Hopefully everybody can see the slide. This is a classification based on the biochemistry and then this is based on the onset. Ok. Right. Ok. So we, we really worry if the patient has a severe hyponatremia less than 100 and 25 which is a cutoff. Uh And then, and then if it there's acute condition, so acute hypernatremia is uh is quite alarming. Ok. So symptoms wise there you severe symptoms. Uh this is also reference from the society for endocrinology, severe symptoms, vomiting, cardiopulmonary arrest, uh seizures, reduced conscious level GCS less than eight moderate symptoms, nausea, without vomiting, confusion, headache. So some people they find it's ok, just m or have some symptoms. Ok. So management of hypernatremia. So everybody will con confuse because do you get normal line or do you get diuretics or should we restrict fluid or do nothing or hope it will get better? So they are, yeah, this you might question like what, what should we do? So I tried to clarify what's going on. So as I mentioned earlier, the fluids uh assessment is the key. So yeah, you, you need to see the patient. Ok. If you got a referral, uh if you got a patient see a uh being handed over by the another person. Oh, this patient has hyponatremia. So I personally go and see the patient to assess your fluid status clinically. Um So, so depending on the fluid, it is that depends on the management of your hyponatremia. So basically, if the patient is dehydrated, uh and you need uh IV fluids, you just prescribe IV fluid. So if the patient is hypovolemic, we, we give um diuretics. OK. Uh So this is a, a brief guideline from the hospital which I work uh before, which is quite good. And so I think you, you whenever you walk there is a hyponatremia guideline in your local hospital, just follow, follow what test needs to be done. I know what medications are the contributing for that. We have to stop like any medication that can contribute to hyponatremia. So you just need to review the medication, whether you some some medication might trigger the uh hyponatremia. So you just need medication review, make sure all the blood uh blood are being done, make sure you have uh a full examination, a full history from the patient. Ok. So which is really important. So, uh I just wanted to highlight that because if you have like acute severe hypernatremia. So if you see a patients um severe hyponatremia with the uh drowsiness or like headache, some kind of like CNS disturbance CNS symptoms, just escalate and talk to the, talk to your uh senior person because this is a sign that the patient might have a cerebral edema OK. So the cerebral edema is the one of the main complications of this acute uh change in osmolarity. OK. So if your patient has hyponatremia just to be cautious. Um And then if the patient uh have these signs, you just need uh maybe you need ICU input uh or if the patient had seizures, like you need to give the hypertonic C line. But as the f one doctor's level, I think, um so you need to recognize the, the, the the patient clinical symptoms and then make sure you uh you have the full kind of assessment. And before you speak to your seniors, the senior can decide whether they need to escalate to ICU or not. Ok. So, and then depending on the fluid status. Uh so if the patient is neither hypovolemic or hypovolemic, um so, so we normally check the plasma osmolarity and osmolarity. So there is a condition called SI A DH, which is quite common in the hospital setting. Uh And so, so we normally check, make sure if the patient is due for me and the patient has a hyponatremia less than sodium, less than 100 and 30. And then if you check your osmolarity, which is less than 102 175 and the urine os more than 100 as, as you can see in the blue box and, and then, and check your urine sodium and check your urine potassium as well. So if your urine sodium is more than 20 anymore. So some guidance is more than 30. Uh So it is likely there is. So the S IDS, if you think it's the S IDS, the management is a fluid restriction. So everybody knows. OK. So, so I just need to go to the next slide. So, so don't, don't look at the left side, just look at the, look at the right side. OK? So if you si is suspected, has to patient has to be you to make. So they have to meet this criteria like serial os less than 100 275 0 more. 100 and then urine sodium with 20 m more. And then you, and you review your medication and, and then you can start making plan like restrict the fluid. OK? So I don't want to talk about this electrolyte free water clearance formula is I think it's, it's, it's, it's not uh really um uh not really a key, but uh if you're not sure, just restrict the fluid like or maybe like a liter uh first and then see how the patient goes and that's what you can do and then you can reassess. OK? And if your diagnosis is correct, the sodium level should be improved um uh within the uh within the next 24 48 hours. OK? And if it's not improved, if you, if you think that um you know uh the sodium is not improved. If, if you, you, you're very like, sure, like you complained that this is a hyponatremia. It's due to a DH. And you can speak to the, uh, your, your seniors whether they need some kind of medication called to 10 or t. Ok. So I'm not going to go through everything and then on the left side, um, and they are potential causes of SI A DH. And if you do them, if you are on the medical ward, you will see uh some like consultants register, they request CD scan for like you for any malignancy if they can find any precipitating factor for the SI DH. These are the possible list of um uh list of causes of uh S ID and some of the endocrine conditions such as hypothyroidism also can cause S ID as well. And so these are the things that um possible causes of S ID. All right. So let's go through a case. Hopefully, we, we still have a little bit of the time. Uh So for case one, this is a case that I encountered when I was a junior register. So 50 years, a female normally fit unwell came into, came into the hospital with a new confusion and patient was an ed at the time and the sodium they did uh on, on the uh venous blood gas was 100 and 20. She doesn't have any like significant medical history, only reflex esophages. Uh She's no, no normally independent uh medication, why she only take omeprazole, which could be the cause of hyponatremia. Ok. So, so the blood came back in the form of blood, came back to the sodium of 118 which is quite alarming. Ok. So we fall in the category of the severe hyponatremia. So when you checked the previous sodium over three months ago, it was 100 and 36 which is quite alarming. So you such the fluid status, which you may also stable gcs is 14 because she's confused uh blood glucose lipid profile, everything is normal. You follow the follow the hyponatremia guideline. Everything has been checked, everything is ok. But except that ultimately slightly low but the urine sodium also the state pending uh because uh patient is not able to read. So and then patient was transferred to the to the ward and then a few hours later, patient told to have a seizure. So the seizure is the one of the indications that you need to escalate. So patient is uh 50 years old, normally fit down. Well, patient needs a close monitoring of the sodium level and then needs to discuss with ICU for the hypertonic saline. OK. So this can be escalated to the uh HT U or ITU setting and then they can take it from there, they can find a course later. So make sure your patient is safe. So just escalate, ok? If the patient has seizures or comatose I think you should escalate that to the senior. Ok. That's my main message. Ok. This is the first case. So I've got the last case. Hopefully I just probably need to um talk a bit faster. I think time is about to run out. Um So this is case 278 years ago um and then admitted to the acute surgical assessment unit with pain and he had a two episode of a sub seizures in the unit and lasting for about oh sorry. Uh 15 seconds. It's not 15 minutes, sorry. Um It's, it's quite very brief and then just gone. Uh And then he's got have background history of hypertension or amLODIPine only and his previous sodium level is 100 and 36. Uh but only as how you assessment unit, the sodium came back 118 which is quite. So this is similar to the previous case. So you assess the patient as usual and then clinically you volume he is fine after a bit of like seizure, uh BP is fine, chest is clear, your heart sounds normal. But when you examine your tummy, like he's a little bit of tenderness in the suprapubic area. OK. So, so what will you do next? Um I just want to ask the audience um Do you do, do you want to do ECG as the next step or chest X ray or should we restrict the fluid straight away or maybe get a saline or we do beside bladder scan. So this is a rare case um um which I encounter before. OK. Don't worry, this is the last full question. OK. Uh I'm nearly there. Thank you for being patient and hopefully you will learn something uh new from the, from this session. Ok. Good. I wait for a couple of seconds. Um Good. OK. Most of the people want to do bladder scan. 43%. OK. Good, good. Thank you. Thank you so much for your uh input. Um I can see all the answer. Thank you. Good. All right. Uh Most of the people are correct. I totally agree. Like especially when you are in the surgical assessment unit with the patient came in with abdominal pain, the next test and then with the examination, findings of suprapubic tenderness. Um So you do the bladder scan. So yeah, everybody will. Um this is the correct answer. Um OK, let's go. So doing the bladder scan, what you found is um he's got bladder distension and he's got 800 nearly 807 80 I think as long as you remember, 780 males in the urine and blood. So patients got uh acute urinary retention. So why is that? Why, why the sodium is low? Why he had the ses? So when you think about it, so the this is one of the causes of si a da kind of thing because when your bladder is distended, uh your, your body is uh respond like, oh my God. Uh because, because we probably need to secrete more ADH an antidiuretic hormones because the body thinks that uh you shouldn't wean more because your bladder is so full. So that's why the patient had a hyponatremia. So, hyponatremia related to S IV potentially by the acute urinary retention. Ok. So what's the treatment for this? So the treatment is quite simple. You just cut it to, right. So yeah, just let the, just let the, let the let, let, let the urine come out and, and then if your bladder is uh not distended and then the sodium will correct itself. Uh And because in that case, I called the ICU because patient had a two episodes of either which is self. And uh but I told them that like the patient might not need uh hypertonic ide because of uh because he, he's OK at the moment, his GCS is fine, but there is a potentially that he might have another seizures. So if he had another seizure, then we need to record the ICU all night, you need to send the patient to the HD set to close, monitor the sodium. So after after catheterization, we check the sodium level and the next 12 hours, one time starting to improve and 24 hours starting to improve. So, so the main treatment is catheterize the patient. OK. So yeah, this is quite, quite, quite interesting. OK. Um So, yeah, so yeah, this is my last slide. Um My take home message is uh for the re all the resident doctors when you're doing on call. If, if you see a patient with hyponatremia, especially severe hyponatremia, acute onset thorough assessment, take a full history if you, if you look for the signs of the cerebral edema like G CS neurologically like patients comatose or she's confused or headache or. So these are the signs that, that, that, that, that they are the rle signs that you need to look for. So if there is one and, and, and then it keep to set, you should escalate to your see very young. OK? Before, before things get worse, just like the case number one. OK. So and then, and then, so another take home message assessment of the fluid state is vital. So this is uh this is really important because depending on your assessment and the management plan will be different. And also you need to recognize the importance of the investigations prior to the treatment just like urine osmolarity, serum osmolarity, things like that. OK? And you need me to make sure that and there are a couple of medications that can potentially cause uh the hyponatremia. OK? And then another thing that I forgot to mention in the um earlier was uh don't correct uh Overcorrect your sodium level, OK. Within 24 hours, we we normally aim to correct the sodium level no more than 10 MIU per liter uh because of the high risk of um what's it called the, the, the, the cerebral point myolysis? OK. So if you correct the sodium level uh quickly and then this can cause basically the brain damage. OK. So, so this is uh the end of my um presentation. Hopefully, um you will learn a lot. And so, yeah, thank you so much. I will stop presenting now. So, thank you so much. So, that was a brilliant presentation and I think when I gave so the brief, some of the, the things that come up around managing um diabetes in end of life, patients managing borderline BMS. Those are the things that can actually be quite tricky. They're, they're lower yield lower, yeah, lower acuity bleeps. But they can be quite confusing to deal with by yourself an out, an out of hour shift and then not the dramatic hypoglycemia, hypoglycemia is that are a little bit more obvious to follow. Um We've got two questions on the Q. Well, we've got one question on the Q and A. I've also just um highlighted someone's provided from the diabetes UK, um recommendations for managing diabetes and end of life. So, if anyone wants to see that link, it's highlighted on the Q and A, we've got one question around variable rate. If anyone has any other questions do put them in the chat and then say we'll go over them. We won't, we won't call your names out or anything for the purpose of the recording. Um There's a great opportunity to ask a registrar, any of your burning questions. Um But this question, so was around, can you simplify variable rate insulin infusions for me? I still don't understand it very well, especially in the context of DK management. What if BM drops below four whilst on the DK protocol? Um So, so I've downloaded just a uh A DK A protocol I found online. I think it's from Doncaster Hospital. That's not it. Um Yeah, I'll just get it up and then you can, maybe you can talk through that way. You've got a bit of an example. I'll just share my screen. Yeah, the very, very. So I think um so if the patient came in with the DK, um you, you start following like fixed rate insulin, right? Fix, fix rate insulin along with the IV fluids. And then, and then so when the patient, uh if, if, when the BTK become resolved, uh you can change it to the variable rate. I think there are simple guidelines uh from the test as well as is sharing as you can see. Uh So basically you just need to follow depending on the blood glucose level. OK. So, and then the nurses are really good at it. They, they know the protocol, they know when to check the blood glucose, when to check the ketones levels and then they will adjust the insulin syringe pump, depending on the readings of the blood glucose level. So all you have to do is make sure that you prescribe uh in a correct way. And then if you think the patient is tend to have more hypoglycemia, uh you can simpl uh you can decrease the insulin regime a bit. Uh Or if the patient is having more insulin need, if you think you can increase uh the for the insulin in a patient, you can increase the risk of the very low rate. So I II hope uh this uh slide that uh that we shared uh will be useful for you. Yeah, I guess just to add. Um So is it maybe worth just talking through the table? Cos some people might not have seen them? All right. Um I've just highlighted the two as like ABM of nine, for example, maybe it's worth talking through how you would actually approach filling the table out if you've not done this before. So, so normally if uh so as you can see in this table, like uh you can see like standard rate uh like green box and then the reduced rate in the yellow box and the increased rate in the red box. So, so basically if you don't, you're not sure, just get standard rate and then the nurses can give uh the the rate of the insulin that they can adjust according to the blood glucose level. On the left side as you can see if the blood glucose is 4.1 to 8, they will give one unit. Uh and then if the blood sugars is uh 8.1 to 12, they will get two units. Ok? And, and then, and then you can prescribe like the potassium as well. Uh So you need to give uh prescribed the glucose. Uh because if your blood glucose is less than less than 44 millim more uh you can prescribe the 10% glucose as a as a backup. Um So yeah, the these are the things that you need to prescribe. Uh make sure that um you know, like the nurses can adjust the insulin according to the blood if they need uh you need to, if they feel that this uh they are patient is very insulin sensitive, you can go to the uh yellow zone. And so for the use of the insulin sensitive patients, you can, you can use the yellow zone. So if you can see in the yellow zone, if the blood glucose is 8.1 to 12, the nurses can get only like one unit. So one unit per hour. Ok. So um yeah, I think so just to answer that second bit, what if their blood glucose is less than four? Should they still get insulin? So no, no, no the the less less than four as you can see here in the so you have to stop the variable rate, you have to correct the uh uh glucose according to the uh according to the protocol. Um So I think this variable rate is quite safe. So if, if the blood is like less than four, you, you, you need to prescribe uh the, the 20% G in 100 M and 200 mils in 10% glucose. OK. So these are the things. So because the rate is quite safe. So it's been designed uh to, to prevent hyper and hypoglycemia in acute setting, especially when you're on call. So basically, if the patient especially is useful when the patient is near by mouth, uh and then, and then if the patient has a type one diabetes with the recurrent vomiting, uh or when the patient has a DK now being resolved and if they still not eating and drinking well, so these are the things also other special circumstances like uh stroke. So patient cannot take orally. Uh but you don't know how to give how, how much you're gonna need the insulin because patient has a type one diabetes, he can't speak, he can't talk, just start the period when you start feeding. So these are the things. So it's, it's quite useful too. Uh So if you're not sure, uh and then, and if you're not sure, just have a chat with your senior and whether we should put on the distribution needs variable rate or just, yeah, because if you're not sure, just variable rate is quite safe. Great. Yeah, in my experience, you do get used to filling these out and it is less daunting, but it's hard when you first start working. Like as you can see in this, there is a sign and date and print your name so you can just sign and date. So make sure that they have an appropriate rate. Uh So if you think that the patient can be safe, will, will be safe with a green standard dose, you can just prescribe in the standard area and then you can just keep monitor and then if they worry, the nurses will, if they worry and then they will let you know, oh, this patient needs more insulin. Should we increase the rate? And then oh yeah, yeah, I think you look at the BM if they are still having like high readings along with insulin, just changes to increased R so we just safe. Great. Um I hope that answers that question. We don't have any other questions. So I think in that case, we will end the session and I'll just say a massive thank you again to. So for, for hosting this evening and for talking us through really useful examples today. Um The feedback form is in the chat, if you could all feed it in, um making sure just give so some specific feedback cos obviously, we're all in the portfolio grind together and that's really important. Um Thank you all for coming. Um I've added in the feedback form, an option to suggest any sessions you'd like us to host. That's an optional component. But if you've got any ideas or anything you're struggling with, just let us know. Um, have a lovely Tuesday evening, everyone and we'll see you next week for our session on EC GS. Thank you very much.