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roached hyponatremia and just go over again quickly. Some of the management of hyponatremia. I mean, think about some of the problems you might encounter in a d g h HDL kind of setting, as opposed to within a pick your or bigger hospital HD setting. So ow is an 11 year old girl who came to coordinate E at 11 o'clock on a Friday, As it always is on, she presented with the first ever focal seizure. So in the evening at 9 30 was sitting on the sofa watching TV and her dad's haven't looked over and noticed that she was having a fit. Her arms were shaking and his eyes were deviated. He couldn't quite remember which way they were looking on. Better telling you have no incontinence. The whole thing lasted around two minutes, and it is self resolved. But since that time, she's been extremely drowsy on it, quite agitated she hadn't talked to told since the seizures. This is an hour and a half on words shape from crying out and putting her legs up to her stomach, and her eyes were completely closed the whole time. She does have significant background, so she has an unusual genetic diagnosis of something called nephrogenic syndrome of inappropriate anti diarrhea cysts, which is a, uh, a nephrogenic SIADH picture, which was found in her is a baby because she wasn't feeding and she was found to have no sodium as a baby on subsequent to her having that diagnosis of the baby, her mom and the entire side of her mom's family were diagnosed with the same condition who were all self managing it with fluid management at home without noticing. She's not on a near any regular medication, and she's managed by a specialist team agree on the street on Be Just manages by self regulating her fluid intake. So she drinks about less than 500 miles a day. Not deliberately, that's all. She well, she wants to drink, and she only drinks. They concentrated fluids. She had been seen a couple of times in outpatient clinic at court, and just general piece input on her sodium had been 144 in 2018, 140 2019, so she normally runs normal to high sodium Story this time was should have three weeks of vomiting on diarrhea and some part of headaches on in the day should have a headache which had resolved in. Your friend should have a large vomit, but she wasn't unwell in herself. A month center to school anyway. But she had been drinking more than usual. Mom, Dad went. Sure if she was passing normal volumes of urine off. See, she's 11 year old girls don't necessary ask of those things on. She complained of a sore throat in the evening, but she had seen sort of Okay, she's not only break the medication in his work to date, So when the whip her in, we saw her. She was then, by this point, she was two hours post. Her seizure on her airway was patient. Her rest to 23 with SATs of 90 extent in there. She had no evidence of respiratory distress. Her heart rate was about 100 BP was 160 88 she was had a brisk capri filming century and peripherally and really well felt pulses. Normal heart sounds. She had a GCS of nine. She wasn't opening her eyes at all. Mumbling sounds on globalizing to pain. Um, people's were equal equal it size for a reaction, but she was pulling away from the light when we tried to open her eyes on G. Was moving her arms, legs resistance, but not following instructions. Has tone felt normal and equal on reflexes? I think President. But they weren't bit difficult to assess because she was quite agitated and moving. Amount throughout. Off know have blood. Sugar was normal at 6.4, and she's a perfect seal assessing her fluid balance, her skin totally normal, and she had moist membranes. She was quite sweaty on very flushed cheeks, obviously weren't able to tell whether she'd be passing the urine or not on the time was license often are nontender with no Organa medley. So as we do, the very first thing we did, uh, after seeing doing a process that was a blood gas which age normal. Ph. Normal respiratory gram. Attar's based off set of minus 1.6 and then the sodium of 116 on the potassium of 3.8 lactate 0.7 and could eucrisa 7.1. So I think we have We came cross our problem. We think a bit much mean secondary to low sodium 116. However, she had a persistent reduced level of consciousness. Now on, she was intuitively agitated, so I was worried that she was in carefully. Pathic. Um so I've been attending to you guys, If you don't mind stepping into that, Otherwise I feel like I'm talking to empty. Really? What would you guys do now? Any thoughts give us, Um no point. I said saline. Drink slowly. Think no 0.9. So really? Yeah. That's definitely thought yet. It's good. It's got a head. Yeah. Yeah. Do your in the late life. Absolutely. Yes. Absolutely. Same. Monitor her foods and restrict. Restrictive is Yeah. Absolutely. Yeah. So reality know she's got a low sodium, which is causing CNS symptoms, but we don't correct. It will correct it quickly enough to resolve the CNS. The acute emergent, um, CNS symptoms, but not so quickly that we don't cause problems and everything. Right? So my plan was to actually give her one the hypertonic saline bolus of 3 to 5 miles per kilo of 3% saline and then slowly to correct the sodium over 48 hours measuring her blood gases at least two hours that have regular neuropathy. 15 minutes, including GC s and BP on really straight input output with a capital wanted to cover her with cataracts. And it's like they're just because off her because you had the seizure and way Do you want to make any assumptions? I wanted to discuss whether we could do a CT head, but at this moment, time I didn't feel that she was necessarily okay to go for a CT had she was quite agitated. I didn't think she would tolerate it. I wanted to speak to the retrieval service because she had to persistent lower GCS to talk to specialist team a Gosh, I also see that consultant. No, because I suspected that this was going to eat up the night shift and I was going to leave the any department drowning. Um, so we have to work out her fluid replacement on the way you work out is you work out by working at the body water. So you know what it was about? 0.6 lead. Tuberculosis. Oh, put six times 27.1 moves her body Water is about 60 m, and we know we want to correct that sodium deficit at less than one minimal police two hours. So I want to be delivering 60 millimoles hour and Hypertonics Saline contains 513 minerals. Paletta. So I decided that she needs help on top of the bolus and 30 miles an hour of hypertonics, saying on the reason I wanted to get the hypertonic rubs and 0.9 is just cause I see it helps to restrict the fluids more, more fully if you get the saline ISS in smaller volume. So just have a quick talk about hyponatremia. I think about what's our approach like, What's your approach to hypertrophy? Patient? Obviously, we know this guy's diagnosis, but do you have a way of breaking it down? Do you much water to less of water? Yeah, absolutely, yes. So you assess the hydration so those same sodium can mean you got. You can absolutely sodium what you can have too much water on your total body. Sodium can actually be normal or increased or reduce depending on the underlying pathaphysiology. If they got extra cellular volume, contraction with weight loss or not get weight gain, it suggests that they've got primary sodium depletion. But if they've got that expanded, actually livadia him on that. That suggested the problem is with water excretion. Come on down. Let's get that on. So this is how you go on to assess the body with the differential diagnosis for each for your status. So if you're fluid overloaded, it could be an eye on Tradjenta. Um, fluid administration could be a nephrotic syndrome and cirrhosis or one of the renal. The heart failure is causing low abdomen or causing fluid retention on third spacing or obstructive uropathy you can occasionally cause, well, salt wasting in euvolemic patients, you can have it could be an excess central water. So psychogenic politics here or if they've got drinking, overdone you to more s, um SIADH picture, which is what we've got for her. But hypothyroidism, which I didn't know low cortisol, like a ch picture on some medications, including, and some appear anti epileptic. So valproate I think it's one of the, um is one of the culprits for that on then, hypovolemia losses could be loss is either through the gut through the skin or through the kidneys, really more than some of the underlying endocrine problems such as Hyperaldosteronism, Um, and some of the derangements in there really access. So you turn it off their history, looking at the common causes of hyponatremia history of fluid in taking losses on a clinical assessment of the current hydration status. And that's aiming to give you a rough idea off attentional cause of your hyponatremia on. Then you to look at the court the security of the hyponatremia. So you want to really carefully assess the neurological status on the red flags or things like nose been vomiting. It was 20 headaches. Decrease conscious. Stable seizures needs to be signs of keppra perfect picture. Um, you can investigate it using a pair of your any sodium. That's very helpful in getting your pathophysiology and blood sugar level on the blood gas. In the first instance, just to make sure they're not profoundly hypoglycemic or hyper, I have personally making you gotta. But underlying cortisol deficiency on the treatment, as we talked about earlier is actually depend. Depend, determined by the presence of seizures of the ultra conscious state, so you do want to correct the sodium slowly, but if they are in capital Pathic or having seizures you would give a 3 to 5 milk a killer Heartburn. Exciting. First a me to correct by to minimize please for our for 24 hours until they become more neurologically intact. I mean, really, really strict with your fluid balance with the least minimum daily weights, remember? Treat the underlying cause. I found this lovely little flow chart from from the Ocho Melvin. They have such nice guidelines. Didn't, um I found it quite helpful when I was dealing with her overnight, although well, it said actually was seizures. Oh, it's an emergency contact intensive care on, obviously of in the DHA. That wasn't really an option. So I had to do this and and try and speak to try and speak Teo STRS and Great Ormond Street. Um so, um, want to just talk a little about her diagnosis because it's quite interesting and quite rare. She's got this nephrogenic syndrome inappropriate after diuresis, which is a rare genetic sort of water balance, and it's quite similar in them. The way it looks to our best idea is that we see very commonly in our I/O kids up wrong keys and things. But it's characterized by a euvolemic state with hypotonic hyponatremia due to impaired water excretion. Come on. Uh, interestingly, her uncle was a taxi driver like a black cabdriver, and he had not even every had it, but he just never need to wait. So he was a really good black hard drive that never needed to stop for a week. Um, so I have her on me then we're obviously keeping her down. And 80 I'm doing ongoing reviews off her, um, on day two at eight. At one o'clock in the morning, she remained cardiovascular stable. She remains respect. Her respiratory system remains stable, but her urological status wasn't really improving. She still had a low GCS of nine. Her glucose remained stable, but she still wasn't talking since a seizure on, although potentially, she was a bit less agitated. It was hard to tell on. We've been trying to near a protect this child, but she's really agitated. Just kept on putting a heads downhill, issues during the opposite of what we're trying to do. Two in position over their head up. And then she would swim myself around and end up with that head down. So here we just laid her flat and hoped took you for a steak as possible in that way. And then she did pass urine to sweat the bed. But we weren't able to catheterize her because she was agitated. Became very much more shades do so. So we weren't getting really probably with balance. But we did a little blood gas that one talk in the morning and that showed that his ATM have come up 220. So it's gradually started to get better on it being 116 when she came in at 11. So by complete chance, fluky child's, we've actually gone up by the advice to millimoles per kilo power by Could be luck. Um, the whole time we've been speaking Teo Teo ST arrest, Um, that was trying to get them to come and take this young lady off our hands because about comfortable having heard the department. And, um, they just advised trying to Paris urine sodium in your in laws morality, which we haven't managed to do. Teo have a gradual increase in her. So, um, it it was 125 inch in your A protector, A Z I said way we're managing that at all. She was just up and down the bed. She was a BP was measurable by the time because she was It's a very labile and say very agitated on. But, um on, uh, she was just completely cooperative on, but we were checking her regular blood. Bit difficult to protection was tolerating process. Say the problems in reality are a bit different. Other two. The problems that we meet that we might think you might have problems with this child off the sodium and vegetation. But actually the problems in reality. Oh, that we can't enact a plan that we're making with with the retrieval surface because she's not being You're protected. We can catheterize her. My plan is for 15 minute year olds, but it's Friday evening in any it's heaving. Their Children everywhere would always a nurse down. There's just no potential for getting that kind of close monitoring. Um, sus didn't feel that she wanted to take you just yet. On discussing with being on the streets by getting her bed on Eagle Ward on my lovely S h o. It was fantastic, but she was fairly new GP training and so she couldn't do things like CANNULATE or take Bloods and so on every child that she saw also into the review. Um, And on top of that, um, I spoke Teo great over the street and unfortunately, was given the incorrect advice. Bye. The consultant that who I think maybe got a bit muddled in the middle of the night. And I thought she had diabetes insipidus and was advising liberalizing fluids. So I have this really awful period of time where I didn't know whether I should get with what she advised or there I should stick with my understanding of the physiology and keep on restriction, huh? I elected in the ends to do that after speaking to myself about it. Um, that said because it was I think she just got so she maybe she was mostly up in the patient. Um, So what would you guys do in this case in this in this situation? Any suggestions? Things. I could do it differently because it was It will be welcome because I didn't know. I don't know. Yeah, I don't know. What what would work. Did you Do you have any hasty capacity anywhere in south London. Um, so there's an age doing things. Um, Onda. There's nature to your mountain. It's every nerve. It's sort of a long term bed, one on them or the more of the d. J. Just not getting HD you beds. Um, do you have a next? Um, George is lucky. No, but is according getting out news, Frankie, it is. It is, but it's not there yet, but it certainly wasn't there then. So it's very difficult, isn't it? With these patients who are halfway where pick, you aren't really that interested. They travel services were obviously really stretched. They weren't being difficult. They were just trying to juggle lots of sick patients on. It does mean sometimes you are going to managing and HD patient in a non HDL setting on all week. It's just we could be capturing up the bed where we could see her on. We try to allocate, and that's and HCA to sit with her and do 15 minute your ARBs on. Um, try to bring us many other members of staff down. It's possible to try and help the trump, and so you know, the ent shor they surgical S H O and everybody roll coming down to try and help clot patients. Um, but it is really difficult. So I think the only points to me are that these patients, these chronic patients who can certainly go off I'm should have an emergency management plan on the notes in the DJ so that you know exactly how to manage them. You're not trying to make phone calls to try and manage them in middle of night sutures coming with the the patient front of you. And sometimes you need two sets them, especially if you're worried that the situation is unsafe, not just that child, that other Children and department as well on will say that that you don't need to blow and before low, especially surprised If it doesn't make sense, you can clarify and aspirin explanation. Um, and even if it means speaking to the specialties consultant. So I was having the conversation with especially consulting through the Registrar of Vytorin Street. Maybe I should have said, Can you ask for something to please call me on? Speak to me because I don't understand this, and I don't feel very uncomfortable in acting this plan, So those are some of the quints I took away and reflected Run. That's late state. So sodium continue to rise slowly. And when it was 100 24 she woke up and she started talking to us and she was orientated in type of person. You drain it, CP, this was by this point about four in the morning and in the end she did remain with me all night in the emergency department and she was transferred to either 1 11 o'clock the next morning. So after I will be gone, she's there for 48 hours and just on having her sodium corrected, having some observations. And then she went home on her consults and then subsequently said through an emergency plan, I'm complete with the whole shebang about physiology and some vaccinations to be attached her next week. And I'll see you in her notes on the parents also have it set at home that they bring out going to bring with them if it happens in future, gonna get drunk. The schools they child is like, Really, I don't really ask you something, but I guess what I thought was when you were saying at the end of that night. Um, I get to thinking in the sense of, Well, it's she you're like symptoms you're interpreting. Pressure is something that's not a problem that, you know, like you, you know, going to cut it. You can keep treating that what we hope to take them, But you're not gonna sort of fix it. Whereas with her, you could, as you improve her sodium, hopefully fix the's tree blood deem. And I guess DKA, isn't it, as you fix your kind of issues first, like you're kind of new patients maybe, maybe less in and like, I don't know whether you have, um, had any safe in your attraction. Um, even if you have to keep her there in a picky because I like, I guess sometimes that's not necessarily any easier. And it comes with its own risks and side effects. And I guess it's like it's like where those really tricky carries where you're kind of really on the fence and every sick. But actually, sometimes if you ride out that initial period of, um, off our disability with really close monitoring, you know, that you are heading towards hopefully like fixed. Think there primary issue, But yeah, it's tricky. And I did a I mean, I I would like, want a lot of support day, man. I think that's the difficulty in digitally overnight, really, isn't it? You're completely right. And this is obviously the things to consider as well that you know, she might become unstable in transferring things like that and you can't stabilize. And she wasn't a child who needed it. This point intubating and that kind of thing that would be completely unnecessary and also make a much harder to assess from a neurological perspective. So it would be completely inappropriate. But but so is just that balance, isn't it of where's the sake of his place and on what support can you get for yourself outside of her picky setting? Um, And outside of the HD setting, I one of the reason I think that doing something like this pen is a good idea because it does allow you to have more support in in the HD setting for for digits where we do get these kids, not infrequently, that come in, right? Yeah. Once it's only corrected Ironically, as they start to get better than an easier to manage. You can implement the plan, which they only really need when they're really sick. Um, of it, Yeah, that's what, um, country Gitic. It was really good out. You reflected on the theater vice from the consultant, cause I think I would definitely be a risk of being like, Oh, I'm a bit stressed out. It's probably me that's wrong. Let me just let me just do what they say. So I think that's a really good point that you don't expect that to you from a great on the street consultant. It's actually mix up the diagnosis, know, you know, and obviously the part is even harder if you're not only with a recommendation because you talked to on the Red speaks to them on on. They didn't know they didn't know her. A call on you can see from their side how it happened. But it was just when she said I was, I felt panicked. Have I been doing completely the wrong thing? Yeah, actually, my service be doing completely. A thing is, you're already dealing with something very unfamiliar, and then you get advice that doesn't make sense that you did really well to like see, I go back to them and say I can I speak to themselves of myself because I think I think in reflection I was so uncomfortable. No, I was so uncomfortable with it that I wish I I wish up in the next morning when I went home. I wish I just called her this out here myself. Um but you you did have the support. Your control is good. Did you consult? Consider coming in is coming. Yeah, she came in after a while. Yeah, um and she made me so other other people's trying care about the hypertonic saline. I think I've forgotten that I ap less minute for hyponatremia. Yeah, I've never had to do that. Yeah, I was going to say Where did you find the initial sort of go alone or management? Because I would have been from You know what? I can't remember. You know, I do know that it waas there's a There was a b m m b m a BMJ like rapid learning one of their rapid letting things online. Googled it on. The BMJ came to him. And that's where I got the thing about the working out the body water is 10.6 times comes. It's not the kind of thing to carry out. Well, you know, it's kind of like around my head, um, on, um and so I googled that I use that. Teo, get my numbers. I know. It's like a lot of worry about electrolyte corrections. Next time, don't give it to first. Actually, in that situation, you know it, didn't it, like, fairly fast. Like you. She's due season, and she's a couple of puppets. Like there's there's anxiety, isn't there about given King Street? Yes, were high concentration solutions. But the one time you do want to is yet when they're already neurologically compromised. Yeah, yeah. Yeah. Okay, so there was be I'll see if I can find it. If I could find it. All starts sticking on the, um on the what's happening. Thanks. Comes any, I guess. Next. Don't hear. So you don't have any expert consultant kids here hiding in the background? I would use the word expert. Okay. Do you have anything that you'd like to? That's, um I missed. I missed the case. Or as late as in an echo teaching session. Was it all about sodium? it. Waas. It was all about low sodium on a seizure in each of the low sodium. Yeah. I mean, I know in reference your case, I didn't see it, but my kind of bench marks in my head. A number one. If you're fitting, then you should bring up the sodium at least 1 to 5 on. If they're still fit, you may have to go a little bit higher. If they're not fitting, they're abnormal. Then I'll see you have to be a little bit more cautious. But I think conclusion is to do something rather than do nothing. Worry about it. So get a little bit of sodium in and start getting the child on the path to bring on the sodium back up and then, you know, work through all the clever things about why it's happened. But definitely, if someone's fitting, you need to bring it up. I did, until they stopped fitting that otherwise, about 1 to 5. You know, there are cases where kids have come in low sodium. It's kind of been left, and they've been put up on the ward and then neurologically abnormal, and they end up koning, contribute a demon, So I don't know again what your story Waas But they're the kind of numbers. I have my mind, but the most boring is actually to do something, isn't it? Wherever the child is giving, sodium is not difficult. But obviously, it's just, you know, work out. How much being a little bit cautious that work out the urgency the child does That kind of fit him with what you guys were talking about? Yes. Yeah, Just perfect. Thanks. Um, someone put something in the chapter, if you can see it. Oh, that's you. Yeah, I'll do you have. Is there a second case or have you done both already Know I've got second case. A bit short. One. It's slightly couple together. You happy for me to carry on? Yeah, thanks to you. What? Why don't we do that and see? See what questions? People have it in my internet. It's a little bit ropey, but you do carry him no props. Let me share it. Now. I'm afraid it's once again a sodium based one because that was what I had. Okay. Say this is sodium. That's gone the other way so we can have a look at a baby who I saw and 80 but kings on have a little quick chat about an approach too hyper Nutri Mia on some of the management of hyper to treat me a So you stop me if any questions or if you want to chip in with anything. So baby. LD was admitted to pediatric HDL kings on day nine of life through the pediatric emergency department at King's on the problems Are Sold to us by the by the E. D. Was it is that he was hyper no treatment with sodium of 187 with a concurrent weight loss of 20%. So I felt they were on their urge that place on HD you. So in terms of background, um, a little was born at 30. Leave on do nothing very exciting Mom Hard GM, which was diet controlled but Protective Soldier Normal scans. There was no no set up the sepsis, vaginal delivery. It waas Mom's fifth child, so she was pretty expert parent. But the next one up was 10 years old, so it's been a little while since she had a tiny dot in her house, Um, on the story was that she was seen on Day five of Life by that community. Midwifes on found have 13% weight loss. Breath for the breast fed baby on at that point was reassured. I don't we don't do it quite know what happened there. Mom reported it. The baby dizzy and the feeding all of the time on day was really passing much urine on. But she reported that bowels open the 1st 24 hours but really not open about significantly sense and stool was still this tiny amounts of marriage was getting with with meconium rather than changing stool on, Mom had mean, unfortunately, contacting the mid with three team over the throat four days prior to presentation with concerns about the lack of bowels opening and continue being reassured over the veins on. Then eventually, she presented to Emergency Department because she was worried about fact that maybe had open bowels. But that wouldn't think discovered the baby had this quite dramatic weight loss on a very high sodium. So she was not expecting. I don't think that the degree of concern that we had so on examination the money that was actually quite body so She was self insulating. An air respiratory wise was completely stable. Wasn't taking it rested. That were 36 SATs 98 with a good trace. She was hard. It was about 100 and 50. But pressure was okay and she was a bit cool Peripherally. Capri thoughts. 3 to 4 seconds, probably, but it was very brisk, centrally, to be honest with you, she has a bit sleepy, but she rows nicely and she handed really well when she was awake and her blood sugar was normal and she didn't have have any fevers. And there were no rashes in terms of doing a float assessment on her. She did have a some confronted now, and she looked like her skin was too big for her. She was very shriveled looking her hands and feet. The skin was ready, very dry, her mouth lips were dry and she had a lot of skin. Folds on very marked reduce skin. Turtle on her tummy was really calm. Cave, but with no organomegaly on her genitalia were normal on maintenance would patent. So I said, what investigations would you do? Like what? Your first concerns for a baby like this he's presented with with a marked hyponatremia. There's nothing particularly Yeah. Um, your sepsis ones. Yeah. Probate. Urinary. So, um, again yet? Yeah, I know what to do The renal function and see, maybe consider thrombosis. Um, these renal renal vein closest Such to risk of him being a Sinus thromboses. Yeah, absolutely. You get your right leg there gonna be really, um they could be very, very much. But good night on what often goes the office, along with the little babies who are high punching often they're quite Georgia's. Well, are they? So this baby had a gas and gas was normal. Basically based off set of minus 3.5 of that completely normal gas. The sodium was 187 on the potassium was 4.6. And you're really was up at 7.2 on. Crashed in. It was 20 but she basically have no muscles on her. So that's nothing with which to make craftsman her bili somehow was only 96 liver function was normal. A bone profile was normal on dramatic. It was her hemoglobin was 100 80 of a heart murmur that much after afraid on the CRP was less than one. We also sent off cultures. You're right about thinking about some basis. Catching was normal of not getting it down there. Um and, um, we did a head scan. Not that that's what works. A huge amount, but you had a cranial sound was normal when it was out of. It's either. Down the line, I'm so hyponatremia is broken down, usually into mild, moderate or severe on Moderate to severe have been dreaming we worry about because it can cause the brain to fruit can minute because vessels to rupture, hemorrhaging and yet demyelination and subsequent urological just injury on We know that little Children more vulnerable because they have more insensible loss, is on top of that. They can't tell you their need for your words or access your eyes independently. Um, however, we do know that corny hydremia, as with most things, is often well tolerated and can be asymptomatic. And this is really this baby was, was asymptomatic with them was tolerating very well on the causes could be broken down into a deficit of water or excessive sodium. So deficits water going to be losses in the garden losses and skin loss is through the kidneys, either drug induced or two something like diabetes or polyuria. If you got a picture, or if you can't obtain more time or concentrate influences in this baby, unless commonly you got your diabetes is this. And if you got your labs come out to you, which isn't herring your first month in, um so you have excess. Sometimes occasions see in babies to formula is being made up wrong or have been given the wrong rehydration solutions when they've seen her for getting diarrhea or if they're being having salt poisoning, being given too much sodium in terms of. Actually, it's a little searching bicarbonate by a doctor, but I'm floor. Um, some of the endocrine abnormalities hyperaldosteronism such a condom or second teacher in your forties and driven steroids. Um, so we thought in this picture than likely heard was that it was an inability to obtain water, but obviously wanted to do the work up just to make sure we weren't missing an underlying I'm underlying cause. So when you assess a baby with the well joy tried person, a young person with low sodium Eugene, a detailed history of their fluid intake and how that feedings been going on, then a detail history of their losses. Are they using it through the gut to being a lot of very sweaty? I'm just there any history of midline brain defects or green or underlying renal disease? Another only medication. So things that diuretic. So that's person. Or if they've been on any fluids for any reason. Um, you want again? As with the hope of Jeannie that we're talking about to assess their hydration status on, you could do that usually wait and save your weight. So it said on the thing I was reading weight with comparing to the last two weeks, which, I mean, how many Children come into the department have no way to the last two weeks? And it's that people maybe that away and then cereal weight measurements. If that's take up to every six hours, um on, then look for that CNS sign so there could be some non specifically irritable, restless a week lis a week. Start vomiting on. Did they say high pitch crying. Attack in here in infants, and then when they get very, um, march typing a treatment, they can become lethargic had about seizures hyper legs here. Then you're right back to your concerns about disease you're saying about the pinkie at From most even CNS would be accepted. This baby have nothing apart from being it's getting even shriveled. I'm getting skinny bit. Um, so the guy that I was looking at was once again the Greuel College modules nostril Melvin guideline. And they recommended investigating decisions over 100 50 to consider your other than that looking other electrolytes because they have it. But derangements correction at the same time. And it wasn't said boy remind us that if an albumin was less than that, you should check it on blood gas rather than in the lab just because it can give you a CD. I agree. Um, on, uh, initially, try and get your pad serum in your ears in the urine so you don't need their deny treatment. If you can't get away on diffuse, can't send it. If you don't have results that you can also get the way to look specifically at gravity because if their product is very high, is medical drink dehydration. Um, and you can do your things with the off morality and sodium. So if your urine the sodium is less than your serum sodium, you've got a concentrating defects such a D. I or renal disease. And if you're supposed teas you're in a stadium is higher than it is now. Zero. Then your urine is concentrating because I had lost it elsewhere. So treatment depends obviously on what the cause is. So if they got too much sodium, you know, really want to restrict any further. But if they've got water division, you do want to be careful to restrict their or fluid in. Take it first, because it can be really make a first the apparently, um, and you want to get really careful fluid Balance is urine outputs weight every six hours. Onda love the government I was looking at to say that. So give it a 170. You discussed with me. I see you on so you correct it slowly as we talked about. So with the hyperness tree so hyponatremia we were correcting by one minimal police for our. But with hypertension here bringing down by 10.5 minimal, our it's about 10 to 12, minimal tight in 24 hours on you. Correct? It prints the dehydration concurrently, but correct. But also, you have 72 hours. Well, just regular breaking that electrolyte correction. So occasional think Amy any was gonna pull in Case anything? One of those. You've got a present. Was it a little of this with hyper dream here who they couldn't get the sodium to come down on, ended up having to give really hypotonic fluids. And you can just give him water street because it was the anything that would bring the same came down. Oh, so you don't need to tailor the fluids depending on the rate of full, So you might feel that we don't want to give them isotonic solutions, but, um but, um, 0.9 sating it's still gonna be hypotonic for Children who are very hyper nutri neck on to think about carefully about your potassium, because if they're not passing urine, you want to make sure you withhold TASI. Um, but once they are possible, you could have potassium ensure fluids. So I think a lot of the guidelines now show you that a lot of the papers out there showing that it's best to correct your entry rather than we think IV fluids. And that could be with our s or with a rest of our mg. I guess on give if you do need to give IV fluids, you could give isotonic fluids and I only use hypertonics or hypertonic solution of the specialist. Guidance is just So this is the one came to meet each day. You on Daz, Think what she was saying. We screened, treated for sepsis. We didn't do an LP on hold. I think I'm set her urine for MTN s and electrolytes just because it could have been obstructive uropathy kind of picture on weight has six alleys initially on past mg and starts to one arrest. Initially, Zadie um came down. It's really very nicely. And once this idea, um, had come down, I think, to 175. So about about 24 hours later, I switched back on to milk. So even the formula and just more than just a bunch of every two hours, um, she did very well and you're into weight actually went home. But there were other things that we talked to consider, so we actually wanted to give months and breastfeeding support and did a big background say, to check to make sure that there wasn't something else going on that cause this may be to have such profound weight loss. Um, but back to the one with three team about once a practice on day five life reassuring them with the teams, the weight loss on not Teo we didn't discharge until the baby was completely established on feeds. And when they just go home did really quite structured packaging place with the middle of routine to wait. Maybe check on feeds on that until quite straightforward case in you. Anyone have any thoughts? Questions? We had a baby that like this and the other day that the Roland whether it, like, really shocked. And that too, was to the bicarb with eight. They're like Ph 7.0 and sodium. It's of 1 70 they've been given 40 millimoles put 40 mils per kilo of normal saline by the time we got involved. Onda Yeah, I was just wondering, like a month of situation. I I needed to get further boulders and actually she had a She had six months peculiar total by go plasmalyte because a lot of the acidosis, I think was Tradjenta like a chloride was 135 something and so like, should be if we need to recess, take these babies from a shot of shock. Point of view. But they're hoping a treatment. Would it be better to be giving, at least plus plasmalyte too big? Um, I I mean, I'm from but I would say so. I think I would say the last night's the best experience with you need to You have the shock is the priority, isn't it? So you have to manage the shock in the first instance on. So I think you would give plasmalyte would be more sensible than 0.9 if you can let your hands on it. Um hum, that's a problem with it. Yeah, so yeah, yeah, I think it wasn't like the but a bad thing. I don't know. I guess when you get to the point that I've actually been resuscitated to be it, then you can start thinking what's the best? That's a fluid. And what was wrong with them. What was their underlying was adding a virus in the end. But she she'd had lots of presentations to a D g h ends of document. My eyes sunk, um, sent home on that. In the end, they drove to the Roland and try and get So listen to me. But she was, like, incredibly pale and yeah, really shocked Micheli apparently, But she she turned around loosely and then, Yeah, the diarrhea wasn't that didn't, like continue. Um, when we started feed something that was that was the worry about giving it also and truly, once we treat it, the shot was that we might then just kick off the diarrhea again. So she was on IV's for quite a while and then So I went on to our our s and fluids a bit more. They're more gently, but I think I think, has it been on the the The ward probably would have got in with feet a little bit earlier. I guess that the flu is a less dangerous once a sodium, more know Anyway, if you're not really, I guess that's the main problem with giving you know flu is it's less physiological way of replacing the also do over of reducing else idea. And so it's more likely to cause the neurological sick. Really, That can result there is. But if they're not going to tolerate the entry, the stadiums you usually use, like the next day in the chat on don't let don't let of things the guidelines say is discussed with pink. You stop. He's starting a treatment. If you could put the child in the past improvement, you're likely avoid a picket mission. Um, and he has said normal state your heartburn's may well be a reasonable choice. If you go 0.45, you could make the sodium plummet. Yeah, binds. That was really bad. So I thought I'd type that. Thank you for meeting them out. Yeah. Uh, yeah, it wasn't for me. This baby potentially could be managed in a They were actually well enough to potentially not go to an HDL in the end. But I think they reason they got no, actually better because they were in kings. Weather is HD used to It was a natural flow. So tell me, what if their seizing with hyponatremia look was the like emergency management? If I no one no, like, if he if he had a baby that was happening fit in their sodium was 1 80. Like, what would you do to start him on some slow fluid and treat the seizure? Oh, I can't think I've never seen that happen. I mean, high sodium doesn't. I know it was there on your list of things, but high sodium usually isn't such a problem. I mean, when it's 150 160 people really start to worry. But I've never really seen that be a problem. Obviously, 1 80 is super high, the iconic cuttin and fit. But still it it was May I think I'd give a bolus if there as your patient was probably 0.9% because you'll fill them up. It will definitely bring the sodium down a bit. Yeah, remembering that, you know, normal saline is got 155. Whatever is Polina. It's hardened. Has got 135. If you If you put it in half saline, you could really drop it very quickly. Yeah, Yeah. I've never seen someone fit in with high sodium. Oh, that's good. Tonight. Don't know what? Probably say someone tomorrow with it. You should have thought about it. I guess it was very good. Really Good taste. You'd be worried about that. They've already sort of started having, like, you know, they've already got a thrombus or something in place is acting is a I guess that would be a concern. So I guess it's already scanned. Be? Um, yeah, I think that's a really good sort of different diagnosis. Yeah, Um, I think a had a nice little to a ms until about some other, um, electrode man. She's rather than just the sodium, which has got really useful little, um, flow chatting. So she's going to get on the what's that great when we're done, and I'll see if I could find that being a good well, thanks. The other thing that can be really useful is electrolyte corrections. So if you ever work somewhere with good electrolyte correction sheets, I grab it and say that I remember when I was a kings pick you, they had a really good a four page just told you how to correct if anyone's got one of them at the place. They work on your menses, sharing that on once at those air kind of their gold mine for two morning electric corrections. You know, silly things like phosphate, and, uh, whatever it is they're surprisingly hard to find in the VNS. Yeah, I think I've got one from Evelina. Yeah, it's impossible. Is it? Very good. What else did What was that? Someone doing something else? Did you say before we finish or their You know, I'm afraid just me today, You know what? They were great cases. And again, just to emphasize that you guys do in these cases and kind of, you know, peer, peer lead learning. I, I perceive, think it's fantastic, Um, and say well done. And thank you. Thanks for the input. And thank you for organizing it. No problem. Thank you for volunteering to do this session. It's men. I had to do a lot less asking around. And then so this would make, um yeah. If people have a topic that they've got a really, really good case full and they've got a week that is easy for them than please do volunteer. We can move weeks around so that teaching amount tables. No set. So if you got really good case, we can always find a second case. Put it out there. So, um, do you have a think about it. But thank you so much, Charlie. Yeah, I think so. It's really good. Thanks, Everybody love the evening. Thank you. Did everyone get the feedback? Stupid last time. If they didn't like that, that's a tendency. Ones. If they didn't, we'll try and fix it. I haven't been since. It's the new system. So exciting to see. I think once you've done the feedback, then you get the stiff Get sent automatically. All right, bye.