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Ok. Hi, everyone. Thank you for coming. Uh Everyone can see us, hear us any issues. I'll just wait for an answer for a second. Yeah, perfect. Uh Thanks if um so I'll make a little bit of introduction while uh we wait for the other people as well. Um As some of, you know, um we are four doctors that moved to UK uh about a year ago and we started uh this UK newcomer doctors, not network to uh help other I MG doctors um to understand the NHS system better to get adjusted to uh the system better. So uh hope it is helpful for the uh for everyone. Uh in today's session, we're gonna have um a medical case and we're gonna discuss uh how we manage these situations uh in NHS. Um I try to include more um like NHS abbreviations uh and some uh like special teams that would do this and that um that I have only seen in the NIS to before. Um I feel like that was one of the struggles I had when I first joined. Like you're trying to adjust to the new system, you're trying to understand what's going on and on top of everything you see this million uh abbreviations trying to understand what that means this means. So I tried to include some of those uh relevant in this um uh slides. Um I will explain as we go, but if I miss any of those uh obviously ask about it uh right away and we'll try to explain further. Um it will be um um interactive session, hopefully, um we'll try to make it as inactive as possible. So uh don't keep yourself uh from answering like uh we want this like discussion uh environment. Um Sabrina is with us today. She's one of the great stars. Kindly excited to uh help with this uh presentation to give us some more insight from the registrar point of view. Um Do you want to introduce yourself as well? Yeah. Um So I'm one of the doctors that work alongside and I um at a hospital. Um I primarily work in elderly care but also do the general medical on call. So uh these sort of medical emergencies are quite typical when we um do the acute take. So they're probably the good ones to review today. Uh So I will start, I'll share my screen. Uh I won't be able to see your comments probably. So uh Sabrina and the other moderators will help me with that. OK. Can you see the full screen slides? Yeah. Yes, we can. Perfect. Um So here we have a 25 year old gentleman with no significant past medical history. Uh, he has been having diarrhea vomiting for four days. This is one of the ways they use an NHS to determine time. Like if it is four days, they would write it like this and if it is like two weeks they would write like, uh, two slash 52. Uh, that II find it a bit weird. So I wanted to include it here as well. You know, that's fair enough. We do use that quite a bit. Um To be honest, I think there are a lot of abbreviations but um as when I go through the slides, you probably start picking them a little bit. Yeah, so he's not able to eat and drink very well and uh he started to be drowsy for the last day. Um What else would you like to know about this guy? Uh What would you do? Any other information you would like to know? Uh Someone said whether they have abdominal pain? Uh The uh yeah, they have abdominal pain but they didn't have any fever. Ok. Someone's asking if they've had any blood in the vomit or stool. Uh No, she, he hasn't noticed anything um any recent travel history. No, no travel history. Um and the opposite. Yeah. So observations go like this. Um BP a bit on the lower side, heart rate and respiratory rate a bit on the higher side. But looks like generally stable. Um as part of the observations, they also taken uh blood glucose uh because he was drowsy and blood glucose came quite high. It was 24. Um As part of the protocol in NHS. If someone's blood glucose is more than 20 we also do ketones. Uh And his ketone was 4.5. Um As you know, like this guy didn't have any past medical history, but because he has high blood glucose, high ketones, um we now try to start to uh suspect a bit of uh diabetic ketoacidosis. So, uh we sent a blood gas and some other routine bloods, blood gas came back like this. So uh he, it, it looks like in general he had metabolic acidosis with lactate of 3.5. Uh So to diagnose diabetic ketoacidosis, I've gotten this uh from the ABCD guidelines. That's um association of British Clinical di diabetologists. So, it's the national guideline. Um D stands for diabetes. Either you need to have high blood glucose A or uh known to have diabetes. Mellitus K stands for ketones. Um Here in the UK, they check capillary blood ketones very frequently. Um They didn't check at all in my previous country. So I had no information regarding this, but it is like a very small machine like the one you would check capillary glucose. Um It's just done by, by the bad side, very quick test. So they always monitor with the uh blood ketones. The normal level would be less than 1.6. And if it is more than three, that's one of the criteria of the K A and the A stands for acidosis um for acidosis, they said either bicarbonate less than 15 or ph less than 7.3 obviously, they can be present uh simultaneously, but just one of them um takes for the uh like uh amongst the EK criteria. Um So, while we are here, uh obviously like all of you know about um have a understanding of DK A but uh I would like to send this poll um to see how you guys preserve it. Um What would be the main issue in DK A? Do we have? Po Yeah, I can see, I can see that people are starting cancer. Give a moment for everyone to answer what's the main uh So uh 50% of people have put dehydration and then 25% have had high ketones or lack of insulin. Yeah. So um those are all like problems in the care. Obviously. Um I have put like a diagram here to understand it better. Um So the main problem, actually, there is no insulin without the insulin. Um the glucose we have cannot go through the intracellular i inter inter uh intracellular area and we cannot use the glucose when we cannot use the glucose. Body thinks we are hungry, liver tries to make more, more glucose which increases the level of glucose but doesn't really help us because um we cannot use the glucose. The issue is not uh not that we don't have any but more we cannot use it. Uh When body notices this, it goes to an alternative route and it breaks down fat. And uh maybe some of you remember from your biochemistry lessons. Uh when you break down fat ketones come up as a produce of this. Now, we have a lot of ketones and glucose in the bloodstream. And kidney tries kidneys, tries to clear this with a lot of water which worsens the dehydration and uh goes to a vicious cycle. Um So the it it all starts with lack of insulin but everything else comes with it obviously um to treat this uh I the I found this funny uh picture also to get a better understanding. So uh if the like si signs of signs and symptoms, you would feel um thirsty nausea or vomiting, abnormal pains, diarrhea, everything comes with it. So um to treat this, this is also from the same guidelines, it looks a bit um crowded. So I kind of summarize it the important points. So action one says give fluids because people are dehydrated and we need to uh kind of compensate that action two is give insulin, we need to um fill that gap of insulin to be fair. This is fixed rate insulin. Um and it's 1.1 units per kilogram per hour. In dosage. Um that um I find it like this part is very easy. Everyone prescribes the fixed rate insulin correctly. II haven't seen anyone that's uh couldn't manage this. Um But another important point is we also need to give longacting insulin because without um uh like a base insulin, um it's uh this the, the moment we stop the fixed rate, it, it will just keep getting into DK A. So that's one of the important points that most of the people miss feel, um, action three says, thoroughly assess the patient action. Four, talks about other, uh, investigations we do to try and understand the reason for DK A. Um, for this guy, we kinda had the reason he probably had a, a gastroenteritis which triggered all of this afterwards. Action five is very important as well because now this guy is, um, on insulin IV insulin infusion, we need to monitor the blood sugars hourly, blood ketones hourly and VBG S two hourly. Um, in VBG, we check for bicarbonate potassium and ph um, this is more to guide the therapy. Um, like, uh, we can change the, uh IV fluids accordingly or, uh, like we need to understand when he's, uh, the, the decay is resolving as well. Um So this is like a basic decay and nothing goes wrong. But there are times, um, we will, we might need to escalate things. Um, would you like to talk more about escalation plan? Serena Yeah. So um essentially there's a few things that we start to worry about if um patients aren't responding to the uh Costco DK protocol in terms of starting the fixed rate insulin infusion and fluids. Um and a lot of the time, it's because they are still um dehydrated or losing more fluids or they have other comorbidities that make it a bit more difficult um to treat DKA. Um for example, if they have congestive cardiac failure or kidney failure, predisposing them to being overloaded. Um And obviously the issue in DKA is that we need to give fluids. Um And we also find that the younger patients um whether they're newly diagnosed I've seen in pediatrics, um or teenagers, um or those in the early twenties also do uh quite badly with it. Um And then of course, in pregnancy, we have to be more careful because you have to be careful with in terms of how strictly we correct uh glucose levels um given the impact that will have on the fetus. Um So those sorts of patients you do need to be a bit more wary of and then make sure your monitoring is a bit more tightly managed um as well as making sure that you escalate if things aren't heading in the right direction. Um Now if I was working on call and you had a patient that you were seeing that came in DK, they usually end up in recess first. Uh or at least, um, the more monitored areas of A&E, um, once you start the protocol, yes, we need to hydrate them. Yes, we need to start the insulin. If on the monitoring of the glucose ketones and the gasses, they, they remain acidotic. Um, despite starting treatment, that's one key sign that you need to escalate it further. Um, other things to think about are whether when, once we've started fluids, if they, their potassium isn't picking up or their potassium is dropping further because we know insulin itself will drop the potassium further. Despite us supplementing with IV fluids. If the potassium remains less than 3.5 particularly if it's less than three, then you need to let us know because that's probably when we need to get HD to um to have central potassium replacement. And the only way to get central potassium replacement will be with the central line and uh close cardiac monitoring. Other things to think about are, are they so fluid deplete that they are not maintaining their BP, they're responding uh becoming very, very tachycardic um And have the, has their GCS dropped? Those are all worrying features where we need to have them in an environment that's more closely monitored. Um So those are all the sort of things that I um sorry mentioned on this little area anyway. Um And it's just to have more of an idea of these are the ones that we need to be more aware of. Um someone's asking how long does it usually take for patients ph to normalize. Usually prac, in practice, when I've seen them often within the first hour or two, you'd expect their ph to start correcting because the first hour you give the fastest rate of fluid and then the second hour is usually over two hours. So you would expect them as their BMS. What we call BMS uh is cap blood glucose. You'll see this in the N HSA lot BMS is what we call capillary blood glucose because BM is actually the machine. Uh the name of the machine that they monitor it with. Um So once the capillary blood glucose and ketone levels start to normalize their ph will correct and you'll notice that bicarbonate will improve too. Um If it's not improving, then again, that's a sign for escalation. Um or if the rate of the improvement of the glucose and ketones isn't as quick as you'd want it to be. Then it's probably worth having a discussion either with the medical registrar on call or the endocrinologist on call to decide whether we need to adjust the rate of the fixed rate insulin infusion. It may be just we need to increase how much insulin uh per hour that we are giving. Mhm. Does that sound ok, Jane II, don't miss anything. I don't think. Uh no, it's all good. Um I feel acidosis kind of resolves uh quicker and then uh ketones stay elevated for a longer period of time, maybe like uh 68 hours, ketones might stay elevated. And that's actually one of the things we see um to see, like uh to say, decay has resolved um to add to like summarize the things. Also Sabrina mentioned um about the DK management, there were like few little points. Um We need to be careful with the potassium like Sabrina said. Um uh if it's less than 3.5 we need to escalate that. Uh and then if it's normalized, we need to keep giving potassium because as you know, uh insulin while taking the glucose inside, it also takes the potassium. So um it will go lower and lower with the insulin infusion. Um Another thing to be mindful is hypoglycemia. Um as you, as you know, like these people come here with very, very high glucose and we put them in a insulin infusion IV insulin infusion. So um if they end up having hypoglycemia at, at a point, um that is a purely iatrogenic hypoglycemia, which is a never event, it needs to never hurt, ever happen. So, to prevent against that, um once the glucose drops below 14, uh we need to half the uh fixed rate infusion rate and add another IV fluid with, with glucose in it. So kind of trying to balance this. Um and in the end for resolution, once ketones go back to normal, so that is less than 1.6. And acidosis resolves, we say the K has resolved. Um once it has resolved, um we can switch the patient to variable rate insulin. Um So for those who don't know, so fixed rate is an insulin going on the fixed rate that I as a doctor decide in variable rate, there is a whole chart and nurses arrange the dose of insulin according to the patient's blood sugar. If they have lower blood sugar, they reduce the dose of insulin and if they have higher blood sugar, they increase the dose. So trying to balance it out. Um I got this part, just this part from uh our trust guidelines. National guidelines doesn't specify you have to switch to variable rate. Uh So terrifically if patient is eating and drinking, you can directly switch them to their normal subcutaneous insulin. Um but our trust kind of uh recommends to switch to variable rates. So it's like a tampon in between. Yeah, I think it's um mainly because there have been instances where um people aren't eating adequately enough or drinking adequately enough for them to remain out of DKA. Um So even if you need the variable rate, which um sometimes you'll notice people call it sliding scale. Um So it's the same thing. So variable rate on sliding scale um need to be on there for maybe 12 to 24 to 36 hours depending on how the patient is. Um And then once they're eating and drinking adequately enough, uh, you remain on the variable rate for at least, uh, 30 minutes after the, the first proper regular meal. Um, and then you can switch it off once they've established the long acting insulin and any other insulin that they take. Um, yeah. So I think that's usually what we do, um, are actually main things to probably mention in, in, in terms of what I've seen, uh, when we're on call, there are slight caveats to DK and there's a few cases where people might call it DK, but it may potentially not present in a classical way. Um, so without giving the name away there. So, one of the things, um, that you'd have to notice is someone might have, have high ketones but a normal glucose, um, is there anyone who's, um, watching that would potentially want to guess that why that might be or what it might be called when you have a normal glucose, but high ketones, you would still manage it in the same way. It's just, um, something to always bear in mind. You might notice it from their drug history. So essentially there's a group of medications that end in Gliflozin. So, Dapagliflozin or Glipin, um, and patients that are on those now, they can be on them for diabetes, but they can also be on them, um, for heart failure. Um, and you can get something called euglycemic. Exactly. Yeah. Euglycemic ketoacidosis or normoglycemic ketoacidosis, someone has mentioned Jordan. Um Essentially what happens is your glucose levels will be normal, but you will be ketotic. Um So you still have to manage it in the same way. Now, there are sick day rules with this medication. Um So anyone that is admitted into hospital who's on these gliflozin, you do need to pause them um whilst they're unwell just because they have a high risk of ending up in euglycemic DKA. Um Another instance when you may have normal glucose, potentially no history of diabetes but still be ketotic in someone who's vomiting um is starvation ketosis. So essentially, in this sort of instance, you don't really manage, manage it with fixed rate insulin infusion, you initially manage with fluid hydration. So the classical picture of this would be someone who hasn't been eating and drinking for the past few uh days or weeks. Um And their ketones are building up and up and that's just part of the starvation response because your uh fatty acids obviously are breaking down because you're not taking enough glucose uh leading to higher rates of ketones. Um In this instance, yes, you do manage um by monitoring their glucose levels. Um But primarily the ketones and the acidosis are the things that need to be corrected with fluid hydration. Um So those are, those are the two cases that often come alongside or confuse with DKA that you just need to be aware of. Um any questions, we are gonna conclude the care here. Uh Any questions about DKK? Nothing in the comments at the moment? OK. Um So while we're managing the UK, uh we received the U NE results for the same patient. So someone's written, what was the main problem? Um For this case, the main problem was diabetic uto acidosis. And what was the reason for you glycemic ketoacidosis? Um If someone has you glycemic uto acidosis, it not in this case but it, but it, it will be because they're on something like dag frozen or frozen, which will skew your um body's response to D KS and it will keep the glucose levels normal, but it still means that your ketones will go up in e if there's um evidence of illness, stress or dehydration. Yeah, sorry, carry on Jan. Um So while doing the DK bit, we received the biochemistry results, the U NE results. Um and as you can notice, uh these patients, a 25 year old that didn't have any past significant me past medical history has high urea creatinine levels, but um low VEGFR levels like this patient having some uh acute kidney injury. Um So how do you diagnose an acute kidney injury? Like um it is easy. We're gonna do a poll about this as well. Um And there are more than one correct answers but try to choose the most correct one. So most of us can say, ok, like uh from the general picture we can say uh yes, there is a acute kidney injury. But what is the uh actual, like textbook uh definition? That's what I'm asking any answers. Um, six people have said when the creatinine is more than 1.5 times the baseline. Yeah, that is about right. That's, um, I got this table from uh Oxford's Accurate Medicine handbook. I really recommend. Like if someone's coming to UK, you can just browse through the handbook. It's quite good with the basic stuff. Um, it is that like if creatinine is more than 1.5 times, we, that is how we diagnosed that AK uh AK I, um, or reduced urine output, obviously. Um, and once we notice someone that has AK I obviously we need to find out the reason. Um, since all of, you know, this categorization, it would, it could be prerenal, which would be the like, uh, hypovolemia would be the most common reason for prorenal. Uh, or it could be postrenal and postrenal, I guess blood, blood obstruction and kidney stones would be pretty common ones or it could be due to a direct injury to the kidneys, uh, which is a lot of other things, but I find that way less frequent than the other two. but do you think Sabrina is? Yeah, the, yeah, not as frequent. I think it's just because when we see the sequence, it's usually prerenal, isn't it? Yeah, most of them. Yeah. Uh also with our patient, he has been uh having a lot of fluid loss, both because of diarrhea, vomiting and because of decay. Um, so he had a quite significant hypovolemia. Uh, but I want to ask, uh, so say this patient's blood results were ok. He didn't have AK but um, a day or two later he starts to have AK I and DK has resolved. He is well hydrated. Then what would you think? Um What, what could be the reason in that case? And someone said acute tubular injury, mm could be uh pyelonephritis. He didn't have UTI or like like obviously, like I didn't give you much information. Um He didn't have UTI or something like that, that we noticed. Um but it could be su like we would review the drugs. Obviously, it could be one of the drugs we're giving. Um It could be like a vasculitis because he had an um gastroenteritis. Maybe they, that triggered the uh cross reaction and caused vasculitis. Um It could also be not for this young chap, but especially with old people. Uh when we put a urinary catheter to monitor your output, um also the urinary catheter obstruction maybe could be the reason it needs to be a very major incident to someone not notice it uh long enough to cause a kidney injury. But uh I think like needs to be in our mind. Um So yeah, what do we do when someone has ak uh first of all, we need to assess their volume. It are they dehydrated or um fluid overloaded? Uh We check like we assess them uh properly examine if there is uh like dry tongue, dry mucosis, uh increased capillary, refill time increased uh through BP. Uh Then we can say they are dehydrated and we need to give uh fluids, fluids, fluids, um if they, if they are overloaded, so if they're having peripheral edema, uh bi basal crackles increased. Uh Juvenis pressure, then we can say they are fluid overloaded. Then I wouldn't recommend uh the food challenge. Uh I feel sometimes quite often what happens. Someone comes with an AK I and hyperal. Uh then we give them fluid fluids, especially if they have heart failure, we might overload them in the process and uh the management will have to change. So we need to keep a, keep an eye on the patients after starting the treatment as well. Um Second thing we need to do, we need to review the drugs, we need to stop nephrotoxic, which would be NSAIDS ace inhibitors A BS. Um We need to, if we're giving any antibiotics, we need to uh we might need to change the dose. We need to review the dose to arrange it according to their uh kidney functions. Also, enoxaparin. Um This could be um a bit strange for MG doctors because um in my country, we didn't give regular oxopurine to patients. But in the UK, every patient that is admitted uh needs to have prophylactic and oxopurine unless they have a contraindication. So the usual dose is 40 mg if everything's normal and if egfr less than 30 you need to half the dose. So it would be 20. So that needs to be uh in our mind while reviewing the patients uh reviewing the drugs. Um we also need to be careful about, OK, because the excretion will be less. So they will build up on the system. So uh we might need to arrange the dose of that as well. Any other um drugs you would like to add Sabrina. Um No, I think that's pretty much it. Obviously the antibiotic dosing you're already talking about. Yes, with prophylactic enoxaparin, it's either 20 mg or 40 mg. If someone's on therapeutic enoxaparin, then um if the kidney function is impaired, then the dose changes to 1 mg per kilogram once a day. Um Yes, and be careful with opiates. So if there's any element of uh kidney impairment, then rather than using morphine, if they definitely need morphine, then you change it to oxyCODONE. Um Just because that's slightly better in renal impairment in terms of um as opposed, it's just in terms of um morphine is more accumulating in renal impairment because that's how it's excreted um out of the system. Um Anything else that we need to change? I can't think of anything at the moment from the top of my head. Yes. Those are the main ones. Nsaids. Cancer is another also like stuff, the medications, uh, in the sick day rules. Like the ones. Yeah. And then other ones in sick day rules that you need to double of steroids. Um, so those sort of things just be aware of. Um, then we send a urine dip. Um, this urine dip usually looks for like to try and figure out what is the, what would be the reason for AK I um obviously treat the underlying cause uh monitor fluid input output. You may uh want to put in a catheter, we need to maintain a fluid chart um and then urgent ultrasound. So Oxford handbook um specifies we need an ultrasound within six hours if we are suspecting an infected or obstructed kidneys because this will, these will need uh urgent surgical input. Um If we don't suspect these, they still need an ultrasound within 24 hours. Um This is just to like um exclude any other like uh renal or postrenal um cause less. Uh Someone's just asked what if the patient has AK that's not very mild but also overloaded. Should we give IV fluids? And how much and how do we decide the amount of fluids? And if we give diuretics, that's a good question because a lot of our patients will have these sort of um scenarios where they have overload. Um I usually find that it will really depend on how symptomatic they are from the overload point of view because some patients are fluid overloaded, overloaded, but they can be intravascularly deplete. Um, now, often you do have to get the renal and cardiology team involved and there's always differing opinions between the two of them. Um, what I usually find is, do we need to treat the AK or is it the heart that's causing the symptoms? First? Often I find that they're dehydrated enough that we will need to trial pausing the diuretic for at least the 48 hours if they're already on it and hydrate them uh with regular reviews. If they are so overloaded that we can't stop the diuretic, then we need to decide, hang on. Are they overloaded enough that they now warrant uh renal replacement therapy as in that we need to offload to filter them or if they're not for that, are they overloaded enough that we can actually just um start a diuretic infusion um over 24 hours and then just monitor their kidney function. So it really depends on the case um of the patient because uh some patients will be well enough for filtering. In which case, we'll treat the A we um treat the symptoms of fluid overload. And in terms of the kidney function, we'll just have to filter them in a lot of cases when they're not for filtering, then it is difficult to find the balance, but it's just something that you have to monitor daily. Um I in my country we used to do, we give fluids and frozen ice. Um but it's actually not recommended uh here because if they're overloaded, you need to offload them and if they're dehydrated, you need to give uh fluids. So giving both of them doesn't actually make much sense, but we can alternate in treatments. Uh like Sabrina said, like uh if patients more symptomatic on the overload, point of view, we give more fluids, but on, once they're relieved, we may, uh, we may give you some fursemide and once they're relieved, then we can, uh, continue maybe like a slow IV fluids. Mhm. It is difficult, honestly. Um, I think it's some of the cases that I find the most difficult to manage, particularly when you're covering the wards just trying to decide what's the main issue. Um, often I do just pause the diuretics and see how they do. Obviously, if the ejection fraction is, for example, 15 to 20% then it is really hard to decide what we should focus on. Um, which is why you get the cardiologist and nephrologist involved. So it's more of an MDT discussion. Um, but yeah, I usually, if they're not overloaded enough to be symptomatic, I would usually pause the diuretics. Um, and then see how they do. Sometimes we can pause the diuretics and not give IV fluids and just see if they improve with that Um But yeah, it's case by case basis. The problem is I I know you mostly work in elderly care, so it's always difficult to know exactly what to give. Um But yeah, it would depend on the patient. Um So these are the indications for dialysis, but obviously renal team will be uh reviewing the patient in that sense. Uh It's mostly like uh if patient, some complications happening and patients not getting better and you cannot manage everything, then they might have to go for dialysis. In that case. Um Anything specific you, you want to focus on here, Sabrina? Um I don't think so. Um I think what we have to realize and something that I've realized recently um with patients um going to critical care, for example, if they become very unwell is you need to, I have an understanding if they are well enough for filtration. Um I know it varies across countries, but particularly in the UK, we have um treatment escalation plans. Um If someone is for filtration or dialysis, the chances of them needing dialysis or filtration, long term increases significantly with comorbidities and age. Now me sending a 30 year old for dialysis just to correct how they're doing um is different for me compared to me sending an 80 or 90 year old. I don't think I'd be sending a 90 year old for dialysis or filtration unless they were very, very good for their age with no other health problems and, and even then physiologically, um, it would be difficult to manage. Um, so really, you need to decide, are they well enough for filtration? Is this something that we can reverse? And the chances are if the kidneys don't pick up and they need long term dialysis, will they be a candidate for long term dialysis? Those are the sort of things that you have to start thinking about. Um, but yes, most of the times if they fit this criteria and, and well enough, this is these are indications for dialysis that you'd get the renal registrar or consultant involved with. Yeah. Um So with a patient with AK, we also need to be careful about the uh complications of AK uh which mostly uh speak, spoken here. But um the most common ones, I'll focus on the uh fluid overload and the hyperkalemia. Um So for fluid level, we will discuss later on, let's first discuss hyperkalaemia. Uh obviously, because kidneys cannot get rid of the potassium, uh There is a higher chances to get hyperkalaemia with uh with these, with AK I. Um our patient didn't have any because uh it would have been a very uh difficult case to dis manage the DK A if you did. Uh So, um but we, that's one of the things we need to be careful about. Obviously, we need an ECG and if there are any ECG signs, we need to get calcium gluconate to uh help stabilize the membrane, the cardiac membrane. Um Then what are ecg signs? Does anyone know the ecg signs in hyperkalemia which you don't often always see by the way. And this is really bad. But what are the signs something to do with the T waves usually? Yes, exactly. Yeah, peak T waves are done. So they have PT waves, um short uh white cursor and it can turn into a VT or rehab afterwards. Um Yeah, so that's like it is just for the treatment. Um It says like all the guidelines say if there are ecg signs, then you need to give this. But what I've seen in the practice, they usually give it anyways just to be on the safer side. Um But it's usually because no harm in giving it most of the time. Um And if the hyperkalemia is significant enough that we need to stabilize them from a cardiac point of view, it's better to give. Yeah, exactly. Um Then we give a glucose insulin infusion uh which will bring the potassium back into the I intra area. Um We need to e even though this is terrifically uh supposed to the glucose and the insulin supposed to balance themselves, there is a high chance that patients might get hypoglycemia, especially if, if they had AK I they have more sensitivity to insulin. Uh So there is a high chance they might have hyperglycemia that needs to be monitored closely. Uh Also acc tunnel nebulizer helps also the lowering the potassium levels. Um So these are all the things, these three are, they help lower the potassium levels in the blood, but they do not get rid of the potassium from the body. And fursemide might be helpful in that if the patient is not dehydrated. Um again, we need to bear in mind like this is a patient with AK fursemide might worsen that. So it's uh case by case basis to be decided there is also this other drug. So, Zirconium uh cyclosilicate, it is not on the guidelines yet. I think it's a quite new drug, but we use it in the clinic uh in the practice very frequently. It does get rid of the potassium uh from the body and it, it's a tablet you give like uh most, mostly three times a day. Uh and even like one or two days helps uh to normalize the potassium levels quite often. Yes, exactly. So the um name of it that you probably notice is we call it Lacalma um quite a bit. So if we're giving la la essentially to um help with the excretion of potassium through the gi tract, which is why interestingly if you ever do an abdominal X ray in someone with who's taking Lakel, you'll actually see the all spect or particles in their bowels which look very odd. Um But that's, that's why. Yeah. So going to do fluid overload part. Um These are the I just put up some pictures to uh show the examination findings as well. Uh There would be some pitting edema JVP would be right raised. Um That's sugar, venous pressure and we might take an X ray which would show some uh fluid overload some um the blunting on the uh costophrenic angles and like these bits also showed a uh fluid overload bit. So if someone's having a fluid overload, we try to maintain oxygen levels. Obviously, um if this is not helping, I have never seen this actually done in the clinic, but CPAP could be an option to help with this um to, to help push the fluid back into the uh intravascular area. Uh So what we usually do in the UK, we give ibu fosamine infusion. Uh It's like an infusion for 24 hours. Uh It might go up to 500 mg a day. Um But again, this depends uh if de depends on their kidney functions, depends on their, how much they, they have symptoms. Um And even if they have stable kidney functions, we need to monitor kidney functions every day because it can cause uh ak just the drugs we give, we also use uh monitor their rates every day to try to figure out how much uh fluid was uh get rid of. Um we sometimes be mean and restrict their fluid in fluid intake because some of these people drink like 34 L a day. Which isn't nothing with their overload and obviously input, output, charting is um important, but that's all like monitoring the same thing, anything for you to add Sabrina. Um No, I don't think so. I think that's pretty much it. Um Yeah, Fursemide is usually the one that we'll go for. Um any questions about this guys. I think that's it. Anyway, I'll come back to the meeting so I can see people. Thank you for joining. Um I'll send that feedback form. Yeah, it doesn't look like any questions. Thanks everyone. Oh um close this.