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Yeah, it's going live now. Okay. Yeah. Whenever you're ready. Okay. Hey, guys, can you guys will see the slides? You can just mention the chat. Um, I'll get started when everyone can see Perfect. All right. So how you guys? Good afternoon. I hope you guys are having a nice relaxing. Um, Saturday afternoon. Um, my name is still be on one of the ones, um, currently training here in east of England. Um, I'll be going through some basic IV fluids. Um, prescription, um, both for your PS exams coming up and for more like a real life situation. Uh, that will become useful once you start doing, um, what was it called? The assistant ship? The clerkships later on or after graduation? All right, so the structure of the talk today will be Well, uh, cover some of the theoretical background. So the the information that you need to know the all the knowledge parts, and then we'll work through some ts a examples, Um, some of them from published, um, guides and textbooks. Um, some of them from the official PS, a problem bank, and some of them made up by myself and then also some talk about some more interesting real life scenarios. And, uh, I would really like this, um, session to be a little bit more fun and interactive. I promise that. You know, it won't be like this. I'll really try to make this interactive. So if you could all participate through the chat function, really appreciate that. Right? So, um, let's start off with the interesting scenario. So you're working as a chef. One clerk in the emergency department. You're handed over this patient from the E D staff, which they've taken a basic history, sent off some blood, done some observations. So it's a 70 year old lady, um, presenting after a fall. And in the in the working diagnosis is Corey Vasovagal Corey Orthostatic. So they did a line standing BP, and it showed a drop of more than 35 which is positive. So now you're trying to get into the system trying to log on and start to see a GP summary which has all the information like her past medical history or the drug medical, Um, repeat medication she's taking, but a nurse comes up to you with the same patients. Um, flow charts in their hands saying, Hey, doctor, um, so are you looking after this patient? Yeah. And, uh, the IV fluids just prescribed by the staff previously just ran out. So the nurse just wants you to prescribe the next bag. So, um, if you could just all type, what kind of prescription? You right here. What would you do? Okay. Anyone else? Okay, someone said recheck volume status. That's actually the right answer that I was looking for. Um, it was a bit of a trick question, because the worst case scenario is a junior doctor. That you could do in this case would be Oh, um, So the doctor has prescribed one nature to run over one hour. That's really fast. And, um but as a starting junior, you're not really comfortable with things. So you might think, Oh, they must be doing something right. So let's just continue whatever they're doing now, the correct answer would be you have a look over the GP summary that you were trying to access. So note there, background what? They're on what kind of medication you're taking. You go into the other system to look at their blood's, especially their kidney function. and then you can have a look. And on examination, the patient is fully alert. Set up in bed, she is slightly short of breath but doesn't require any oxygen. At the moment you have a listen with a stethoscope, so you get some very thin crackles bilaterally, with some mild pitting edema. So this patient had a background of heart failure. And if you had continued that fluid, um, 1 m over over one hour, that's really fast. And you would have, um, fluid overload that this patient, which would have been very bad, so important to take a message from this is before you prescribed fluids. Don't just blindly follow what has been prescribed previously. You know, it's a strong temptation you'll feel once you start working and always review the patients, opts Bloods. Before you do that, do do the prescription and urine output. Sometimes it's it's not always there. Um, if the patient has urine output, heart have to look into it. Um, make sure you know the fluid balance, and obviously, sometimes you're so busy. Sometimes it's not just possible, but obviously try to see the patient examine the patient before you sign the prescription All right. So about the exam itself, in terms of fluid prescription, um, you can sort of categorize the questions on P s A into three broad categories. First being resuscitation, fluids and replacement fluids. And then, lastly, the maintenance fluids. You could argue that resuscitation fluids is sort of like a subgroup of replacement fluids, but it's more done in a more acute setting in a slightly different fashion. So I just so that might be better to mention is a separate category. So first thing is, we need to decide what kind of fluids that we're giving the patient so most of the time is quite straightforward. Um uh, most of the time, you can just give them normal saline, Hartman showed. Here it's like it's usually for surgical patients. The difference is that Hartmann's has some other electrolytes, such as potassium, but it has been sort of pre titrated to meet the the daily requirements in terms of the medical patients. Um, I think the we prefer to run a separate bag of, um, that's employed so that we can sort of more precisely just the potassium levels. Um, but usually, um, surgical patients tend to be let's complicated in terms of their, um, using these. So, um, that's what Hartmann's prefer. For surgical patients, it's almost like a welcome back onto the surgical ward. So you get given Hartmann's you get given Kevin met. It's like the the usual Welcome back. Um, in patients with shock, they advise using keloids. Um, if you can find one, Um, but I haven't really seen colors being used in real life yet, but that's because I'm currently on the medical placement 5% dextrose you can use in hypoglycemic patients. Hip in between patients. You obviously don't want to give them any more sodium, and you run them alongside. Very rate or fixed rate initial infusions. There's some urban myth, um, saying that it's really good for hangovers, but I personally haven't tried that. I tried out, so Okay, so first thing, resuscitation, fluids. So tachycardia. Um, so we're talking about over 100 and 20 so it's when people get start to get worried. Obviously, you need to know their baseline. Same with BP. BP tends to be more late, um, sign of dehydration of fluid volume loss. So if you are ever an award with telemetry, where you can see the patients observations on on the monitor. And if you see four numbers instead of phone numbers sharing the BP, take another look at them and make sure they're okay. So again, it is really important to know what the patient's baseline is. It's not uncommon to see, like marathon runners with a baseline heart rate of 40 some people might have like a longstanding, essential hypertension, so something like 100 and 50 or 100 might be normal for them. Say so. Just bear that in my mind it's not an absolute marker. Once you decide that you need to give resuscitation fluids, um, as you may Well, no, it's 500 mL bolus over 15 minutes. That basically means just crack it open all the way. Um, so just give it as fast as possible and then reassess the patient. Um, so, following the first molars, um, you would ideally assess the fluids. The patients first that status again check their background, their medication, and you could decide to get a smaller dose of 250 say if the patient has heart failure. Um, so with the bolus is usually, um you can give up to four bullets is before you start thinking about some more sinister causes. So roughly as a rule of thumb in real life after giving like the third molars are probably going to find someone someone more senior, like a probably a Reg. Okay, replacement fluids. So, first of all, to detect how much fluid a patient has lost, um, urine output is the most sensitive for early or mild fluid depletion, so it could detect up to, like, 500 mils of fluid. Push in and then you start getting decreased urine output. So obviously it's it's best if the patient is catheterize, so we can exactly measure the the urine output. But at the very least, check if the patient has, um, urinary retention or or any sort of obstruction before you give fluids. Um, and then once you once the patient starts getting more fluid depletion, um, we're talking about over one liters around two liters. You start getting tachacardic, and then once you get more than two liters of fluid depletion, only then we get start getting a follow BP. So one thing to keep in mind is that, um, following BP is a late sign. It means that the patient has lost a lot of fluid volume. So this is you would need to treat it quite aggressively, um, and consider giving you a bolus now, in terms of urine output. So, um, for a normal sized human being, um, you're looking at around 800 to 2 liters, 800 mils to 202 liters per day. Um, now, if the if your patient is particularly small or particularly underweight, particularly large, then you can use 0.5 to 1.5 mils per hour per kg, and then you can work out the math. Okay, So in terms of what to give for replacement fluids, so the first bag you run it fast over 2 to 4 hours. Obviously, it would depend on the patient's fluids that studies as low as well as their background and their medication. And obviously, ideally, we should assess the patient between each bags. But, um, it is absolutely necessary that you go and assess the patient after after running two bags. And then, you know, it's just not recommended that you prescribe more than two bags in one go. Okay, Now, onto maintenance fluids. So, um, the background, sort of the mechanism of how we came up with three liters and one sultan. Too sweet rule is quite complex, and you could look it up. Sorry. What was the food for? Kilogram. Um, I think you meant the urine output. So the normal year now put a 0.5 to 1.5 millimeters per kilogram per hour. Yeah, so going back to maintenance fluids. So, um, yeah, so there's complex, um, calculations behind it, but so feel free to have a look into it, and I guess, verify this information. But the rule of them that you really need to remember is that first of all, normal average sized adults require three liters over 24 hours. Obviously, um, if they're very elderly and very frail, give less, um, potentially two liters over 24 hours. And, um, just for body size, their cardiac function, renal function. And they're fluid status. So, um, for a normal adult requiring three liters over a day, you know, the typical sort of maintenance routine you give is one salty and too sweet. So one liter of normalcy line that you run first and then you run the next 22 liters of 5% extras. Now, obviously, um, you need to justice if the patients diabetic and, um, you'll be monitoring the BMS but that I think will be covered in a different topic. Um, potassium, obviously. You need to replace the potassium. Um, so you're looking at around 40 to 60 million holes of the requirement over 24 hours. Now, if the pain that is assuming the patient is within normal range. Um, but with replacing potassium, um, it's always useful. It's always better to be a little bit on the aggressive side. So if you have a patient who is sitting on the upper limit upper zone of the normal range, I would still run a bag was usually like a small plastic tube more than a bag of potassium chloride. Okay, any questions so far? Am I going too fast? Okay, just let me know in the charts and in the case of flu electrolyte imbalance, um, fluids do take a big role. So, in case of hyponatremia, obviously, you need to really check. Okay. When do you use rule number one? Over rule number two. Now you use both. So Rule number one says you just need three liters of something over 24 hours. And that three liters is made up of one salty bag, 1 to 2 sweet bags. So you use them in conjunction, right? Okay, So going back to hypernatremia. So, um, this again will be more under chronology related, so I won't be going to too much detail about this. But in the case of hyponatremia, um, really thoroughly examined the patient, assess their fluid status, and your management should depend on the fluid status. But the management that you can do, um, with regards to fluids is first of all, fluid. Restrict them. And if they are really hyponatremia, you can start giving them slow IV normal C line. And if you don't see any change after getting slow IV normal saline, um, you switch them onto a hypertonic saline only after, um, senior input. Now, if you correct hypertonic treatments so quickly, there's a risk of Central Pantene. My like my myelin, you know, like this is, uh and obviously you want to avoid that and the same principle really for hyponatremia. So you correct that with slow IV of normal saline. Obviously, if you give a normal saline too quickly. In this case, um, you get, uh, cerebral edema. Um, hypochelemia hypochelemia so hypochelemia you'll see quite often in the emergency department setting. So you get that shows which drives the the potassium into the cells and calcium gluconate, insulin and salbutamol to protect the myocardium. And the insulin also works to keep the blood glucose down. Because obviously you're pumping the patient for dextrose in terms of hypochelemia. Um, you First of all, it says how big deficit is if it's not really big, and it's not symptomatic. You just give them some sand. Okay, you can be quite generous with the sand. Okay. Um I know like potassium sounds a little bit scary, and you give you always get told you give too much potassium, get arrhythmias, but sand Okay, if you look into it only contains about the same amount of potassium as a regular banana. So you're basically giving the patient and bananas, so just consider, like, how much harm could it does? So you can be a little bit more generous, So I think the usual dose is two tablets, Q. D s and now, Obviously, if they're quite symptomatic, you can give a replenish with Slow IV. But I'll mention the details about, uh, potassium replacement later on in the slides. Now, for all these fluid electrolyte imbalances, All right. Um, the important thing is to treat the cause and some things that I haven't mentioned here. Um, sometimes you get patients with phosphate or magnesium, um, imbalances, and these can be replenished with IV fluids. And, uh, you just need to refer to the local guidelines. Look up. How What's the concentration and the rate they give these fluids? Okay, So important factors to remember. So never give potassium fast, so the infusion rate has to be less than 10 millimeters per hour. Otherwise, you run a risk of getting cardiac arrhythmias, and the concentration also should be less than 40 million miles per liter. Otherwise, it's very irritating to the veins. And, like I mentioned sodium when you correct them, you should be You should be doing it slowly. Okay? And just before I move on to the questions, some special fluid infusions. So, like I mentioned, you have the insulin infusions used for different situations. You have total parenteral nutrition so, um, they won't be run through. Your IV is most likely. They will be given for, uh, for a central line, either a PICC line or central venous line and medication infusion. So things like, um, your your infusions first, my infusions, um they could also be written up in the fluids chart. But before you do that, make sure you have, um, you have the access because things like a meal during the infusion you never want to run through a regular cannula. It can be very irritating. Okay, so first problem. Um, so it's a 40 year old female brought into E d following a road traffic accident. Um, she has a respirator of 20 for heart rate of 120. Fasting at 96% on air BP 70 or 50. Temperature is normal. E C. G shows Sinus tachycardia. Um, so I did a fast can with the ultrasound and showed some splenic injury. So can you guys please please prescribe the appropriate fluid in the chat? I'll give you guys a couple of minutes to work on this, and then we'll move on. Okay? Yeah. So most of you went for recess fluids giving her 500 mils bullets, and that is the correct answer. So the important thing is recognizing the patient is in shock. So we have a really low bp. Um, she's tachacardic. Um, she's take it as well. So the correct answer would be giving them the bullets. All right, so yeah, this case was internal bleeding from a sporting injury. All right, so next one, you have a large 43 year old who was admitted for elective cholecystectomy following a previous episode of Prostatitis. She was first on the theater list tomorrow. Um, it is midnight, and the nurses call you to prescribe fluids because she's never been like from midnight. She has not had any routine biochemistry performed. And previous results are not available to you. So Bit of a bad situation. Tricky situation, but somewhat close to real life. So I'll give you guys another couple of minutes to work on this. So just post in the chart, what do you think the correct answer would be? Okay. Looks like we've had some ds one e some some something be So it's the correct answer in this case would be be. So let's work through this together. So basically, this question is asking you to prescribe some maintenance fluids for this lady. Um, you don't know the reason you use the knees, So it's really not possible to, um, estimate the the renal function. Obviously this exam sitting so you can't really go and assess the patient. So there's not much information given to you about the current status of the patient, but obviously she's due for elective operation, so it's safe to assume that she is normal in terms of our renal and cardio function. So with that in mind, um, she's a normal sized person. She would require, uh, as we've mentioned in the maintenance fluids, going back to the rule number one. She will require three hours of 24 hours. Now, she's first on the list for tomorrow. So you just need the first bag prescribed until she reaches that 1st. 1st thought in the theaters tomorrow. So you're looking at one liter bag and over divided over 3/24 hours. That would run over eight hours. So that's sort of gives you gives away the clue here. So you're looking at eight hours. You could potentially think about doing 12 hours since you don't know the fluid ST status. But the infusion for the 20 the potassium will be too low for these. So the correct answer here would be, um, one liter of 0.9 cc line with 20 million holes of potassium chloride over eight hours. Okay. Any questions? Okay. So why not dextrose and streets nearby? Mouth? So, um, the Dex. Okay. So Okay, let's go with the okay. I don't understand what you meant by one liter three. Okay, so she requires three liters of fluids over 24 hours. So if you want to figure out how how fast you run the first one liter back, you just divide 24 by three, and then you get eight hours. So if you're running, um, running of fluids with three liters over 24 hours, um, one liter would run over eight hours. If you're running two liters over 24 hours, you have one liter running for 12 hours. And the reason why dextrose is not the answer is well, you could give either dextrose or normal saline. In this case, it's just the rate of the infusions too low or too high in this case after six hours. Okay. Any other questions? All right, if you have any more questions, just keep posting in the in the chat, we'll come back to them as we go. All right. So lastly, a little bit of an easier question. Do you give dextrose at the same rate as saline? Yes. Um, the answer is, Well, if if it's the same patient with the same influence that say this with the same cardio renal function. Yes. Oh, sorry. Sorry. I'm talking about 5% obviously, for 20% extras. You talk about a different, um, infusion rate, but we'll cover that in detail. All right, so third question a little bit easier. So, um, this patient comes to you with a potassium level of 6.8, which is quite high, and then the BCG looks like this. So what do you do, give you guys another couple of minutes until half past one, right? Okay. It looks like most of you got this right. Um, so quite a straightforward question. So this is hypoglycemia. Um, So the cutoff for the treatment of hyperkalemia is slightly different, depending on the trust. I think are trustee is 5.5. So But even if the potassium count is below 5.5, um, if the patient has EKG changes or symptomatic, you need to start the treatment. Um, the option a he has shown here, Um, so if you have a random, high potassium count most of the time I would say human lives on the on the results panel, but sometimes it will just have a rogue, um, high potassium that came out of nowhere. There's no sense whatsoever in the patient. Then you might suspect that there has been a license, so it might be grounds to repeat or you sneeze. But in this case, you have EKG changes showing, um, showing, um showing hyperkalemia. So it's definitely smart to start the treatment. All right, so a little bit more interesting stuff. So we have a real life scenario. So first scenario, it's a 62 year old male, um, with a background of type two diabetes. He had gastroenteritis from a take away since about three days ago, But now that he his diarrhea and vomiting is worsening with some actor pain, um, only relevant past medical history is his diabetes is well controlled, and he's taking metformin and empagliflozin for that. So what would you like to do? So you just got handed over this patient? What's the first thing on your mind? You can just, uh, okay, a A to be ops examines fluid status. Electrolytes, check the M. Okay. Got some good answers. Um, in real life, you pretty much do all of these. Um, but one really important thing is check the b. M. He is type two diabetic. One thing about the medication that he's taking. Empagliflozin. And it's SGLT two inhibitor. And one thing about this is that it must be stopped in in acute illness. So sometimes it's not really clearly communicate it to the patient. But, um, if you're taking an SGLT two inhibitor and you have an acute illness like gastroenteritis, in this case, you need to hold the SGLT 22 innovator because you have a higher risk of getting into DKA A. So I know in medical school they sort of teach you that Type one diabetics are more likely to get d k. And then type two will more likely are less likely to get the d. K but it's not really true and realize so. If anybody with diabetes has come in with, um after pain, diarrhea and vomiting, just keep the DKA in the back of your mind. So important thing is check the B. M. It might be really high. Check the ketones and you're in depth as well. Also very important. So in terms of managing D k. A. The main important thing is, um, IV fluids, Which is why I decided to mention it here. You also run a fixed rate Internet infusion alongside that, um, and you sort of monitor their potassium level. You monitor their PMS. And once those and ketones, obviously, and once they come down with it, once they start to come down, you sort of add on some treatment. So if their glucoses has, um has come down enough, then you start them on a glucose infusion. Okay, next case is 58 year old, another diabetic. He's on insulin. So he's had a recent coated 19 infection, and he's presented to the E. D with the pain headache with some visual changes and nausea, and they handed him over saying quarry, gastroenteritis, quarry, migraines. Now what's the first thing on your mind about this patient. Mhm. Okay. Looks like someone's learned a lesson from the previous case saying, um, you think about the K. Um so and someone said fingerprint finger stick glucose check. So we did a B M. It comes back. It just says high on the meter. Does that change things? Okay. Yep. So somebody got got it right. So when the PM comes back as high, I can't really remember the cutoff for the B M machines, but it's somewhere around 27 point something. So if the capillary glucose is more than 27 then it would just come up as high. So one thing you could do is take the patient's blood and send it off for a serum, Um, glucose, and you'll get the accurate reading. So another thing to keep in mind about diabetic patients is, um h s H h s, which is the emergency? Same with the K A. So they tend to come after, like an infection or a stroke. Or am I so, like a big, um, acute event? And they present somewhat similarly to DKA so very non distinct after pain, there might be some nausea. Headache is slightly different because the, uh, sorry from the d k. A. So the main thing is, um, really, really high B m. So I mean blood glucose. So, in the d k. A scenario you're probably looking at, um, blood glucose about 18 to 20 HHS Your it's easily, like 40 or 50. And what, Whereas DKA develops quite rapidly over hours, Um H s, um, there's usually, like a couple of days long history of patients slowly declining slowly. Getting this after pain is getting worse with these headaches. So again, the main the main stay of hatred has treatment is fluids. So you give them fluids, you don't right away. Start them on insulin. So the main state is slow IV, um, replenishment. And also, in the case of HS, it's really important not to forget about VT relaxes because because their hospitality is really high there. Blood is stickier, so there are a lot more likely to get GTE, so you need to put them on low molecular weight happen. Okay, so that's the sort of like the first part of the lecture done. So I think we'll take a short couple of minute break, and then we'll talk about some real life scenarios or tips and tricks into how to assess the patient's food. ST status in real life. All right, so I'll see you guys back in three minutes. All right? I hope everyone has had a chance to get up. Stretch your legs Get rehydrated. Really important. All right, So before you get into it, I thought, um, I'll just share a really funny episodes. So I was doing some research preparing for this talk. And, as always, with background research, I digress a little bit and, uh, ended up reading this article about the history of IV fluids and one of the first records of human IV fluid. Well, IV fluids in general, as as an experiment is made in in the UK by Sir Christopher Wren. And in 16 56 he writes, I have injected wine and they'll into a living dog to the massive blood by a vein in good quantities until I made him extremely drunk. But soon after, he pissed it out. And quite interesting. The dog then lived on quite healthy, and then until he was stolen from his owner. So just I felt it was quite interesting how they thought about IV fluids, and then they tested out quite successfully on the dog back in the 16 hundreds. All right, so let's talk about some realized signs and symptoms of dehydration. Now I say this is real life. It might be slightly relevant to your PS A because, especially in the multiple choice questions, they tend to give out these little buzz words, Um, to indicate the patient is dehydrated instead of just giving you say, BP or a raised to re account. So most obvious sign will be thirst. Um, the patient is dehydrated. They'll tell you, uh, feeling quite just thirsty. Uh, my mouth is always dry. So, um, maybe that's a good sign for you to review their fluid balance chart. So speaking of which, um, the next thing is urine output. So if the patient's not catheterized, it's not. Sometimes it's very difficult if the patient's not catheterized is incontinence, so she's the patient's sitting on an income pad. It's nearly impossible to get an accurate, um, estimate of urine output. So whenever possible, whenever and whenever it's relevant, ask them for urine output chart even better and output in the chart, which measures any fluids going in and any fluids going out, including, um, urine and vomiting, another scientist. Unsteadiness and dizziness, especially when they get out from both beds so they automatically become a false risk. Um, dry membranes. So if the patient, for some reason, is saying they're thirsty, one thing to check their euvolemic is to get them to open your mouth and examine their tongue. So that's dry and cracked. Then you know, um, the patient's getting dehydrated. Same with reduced skin trigger, really. But that tends to be a little bit more of a late sign than dry membranes and thirst. Now the opposite side of fluid overload. So one of them are easier signs that you can pick up is peripheral edema. So you can. It's really easy to examine, um, someone someone's legs and just find papilledema. Um, if you haven't seen one before, you really should have by now. But if you haven't just go to any cardio ward and walk into any heart failure patient, they will have a massive leg, and if you put your finger to it, it will sort of event and same thing with dehydration, you could always review their input output charts and weight changes. So very often say, for for patients where weight is critical, important, critically important. So it's notably like heart failure patients. They will be very often be put on daily weight. So every day we measure their weight and see how much they're losing. So this is especially true if the patient is on furosemide, so for giving them for furosemide, daily weight is a good way to estimate the progression that we're making with that medication. Um JVP um, it will get raised if your if your fluid fluid overload the patient, but chances are you won't see one. And, um, it's really hard to distinguish between that and, uh, character pulse. And sometimes especially older patients, they just have twitching chins. And there's just no way to tell if that's a real JVP or just a bit of a twitch and also really important, um, occupation. So often, One of the first signs that you get a fluid overload is fluid in the lungs, so just have a listen. If they're Practicals, then it's a pretty good sign that the patient might be fluid overloaded. Um, later on. If you leave them like that and keep fluid overloading them and you take a chest X ray, you might even see a meniscus, which means, like, a fluid line that you can see very clearly on the chest X ray. Um, but hopefully you shouldn't leave your patients to get to that stage in the first place and in terms of blood. So your area is, um, usually the better indicator of the dehydration. So you could use your area to creatinine creatinine ratio to determine the pre renal renal or post causes of AKI. So if you have a much higher rate of rise of your area compared to your creatinine, then you're thinking more likely prerenal. Um and obviously you want to look at your e g f r and then very later on when you're really, really, really dehydrated. Um, like, in the case of HHS, when the blood gets very thick, you get abnormally high FBC markers across the board. So when you have something like that and the patient is dehydrated, wanting to consider is dehydration causing this Okay, so one last interesting case to consider. So this was a This was a slightly tweaked version of a patient I saw. So it was a middle aged man he presented to E. D with a GP referral after a routine blood test showing a k I. And he didn't produce any urine for for six hours. So we got quite worried. And he was kept on an IV fluid. Quite an aggressive manner. But the HPI numbers kept worsening. So what did we miss in this case? Okay, any one point out in the chart? Very good. So he did have, um, urinary retention. So we only found out in a bad way. So? So patients with urinary retention or any sort of obstruction? Um, they sometimes get something called an overflow incontinence. So you think the patient is incontinent? They'll there? You think? Oh, that's the opposite of retention. So there's no way he's in retention. What's actually happening is that the, um, keeps gathering in the bladder more and more until it just cannot hold anymore and sort of gets through the obstruction little by little. And then you get a dribble of urine just like you're being incontinent. So we did a bladder scan. Turns out that was what was happening. We ended up putting a catheter in and everyone was happy. So And in, uh, in our defense for the team, the reason why we missed the obstruction in the first case was because this patient didn't actually come in with just an a k. I was a very complicated patient with a brain tumor, and there were a lot of things to consider at that time. Okay, um, so that brings me to the end of the talk. Um, I am happy to stay for any questions. I do have a slide with some dark humor. Um, mean, um, so if you're disturbed by that, feel free to leave the chat Now, Um, so, yeah, again, Like I'm happy to answer any questions. And I would really appreciate your feedback if you can just fill out the platform there. When do you use rule one over rule to Okay, So rule one and Rule two are not sort of contradicting each other. It is used to It's supposed to be used together. Okay, So, um, rule one just states that you need three bags of one liter of fluid over 24 hours. Okay? Rule to says of those three bags. You want one salty and to sweets. Okay. Any other questions? It doesn't necessarily have to be like about the lecture I can answer questions about. And then the F one, Um Sgts oil. What kind of jobs usually avoid What kind of yes, So one liter of the line. Two liter of dextrose. Yeah, over 24 hours. Um, yeah. I'm happy to send the slides out to the, uh, the academic officers. Um, what jobs should you avoid? Um, it depends on your goals. Really? Um, if you want. If you want to go into surgery, I say go after surgical jobs. But if you're not into surgery, um, I would say, try to stay away from surgical jobs because the satisfaction and the welfare and surgical F on jobs tend to be lower than medical jobs. But again, it's not really always the case. Um, And if you just want a chilled F one or chilled F to try to look for things like community psychiatry, even if you hate psychiatry, Um, once you start F one, you'll start to love it. Um, once you see your colleagues doing on calls and night And you're just doing 95 every day, Monday to Friday, Okay? With maintenance fluids. Do you do run the potassium? Only in one of the bags. Okay. So usually what happens on the ward is, um, uh, the potassium chloride comes in as like a plastic. Sort of like a Oh, yeah. Like like a like a ketchup bottle. Like a very flexible plastic kind of thing. It's tiny, and you just hang it up alongside the sodium chloride bottle, and then you just hook it up using an octopus. So you brought it together, but I've never seen it sort of mix it together. I don't know whether I think it's mostly because it's, like, quite inconvenient to mix it and then give it, um, patient who has initial infusion running any special care? Um, the real answer is yes. Um, so it really depends on why the patient is on insulin infusion. So it could be any reason, like they're on a routine elective surgery, or it could be there on on D. K. So, first of all, figure out why they're on Internet infusion. And whenever you started the insulin fusion, um, each trust would have uh, Internet infusion protocol or guideline? Telling you exactly what to do in each of the so telling you which parameters to monitor and then what to do when each of the parameters goes deranged. So just really following the protocol. All right, if they're okay. Oh, the insulin fusion patient, um, so again depends on the situation. Um, sometimes you let the insulin fusion run until, um, your BMS get to get below a certain point, and then you just want to maintain them at that level. Yeah. We sometimes run some dextrose alongside the, uh, insulin infusion. So because obviously, we don't want the patient to go into a hyper. All right? So if there are normal questions, thank you for coming to the talk. I'll leave you guys to enjoy the Saturday afternoon. Um, quite nice and sunny outside here. So to enjoy your afternoon, I'll leave my email address here in the chat. So if you guys have any further questions, feel free to contact me there. All right?