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Someone let me know whether they can hear me. Ok. That would be very helpful I can hear you carry. Oh my volume is down. Did you just say that you can hear me? Ok. Yeah. Yeah. Ok, perfect. Um lovely. So we'll get started. Um my name is Carrie, I'm an F one in um Musgrove Park Hospital. Um and I'll be doing the first few bits of this talk um mainly on renal dosing um and palliative care stuff. I don't know if you want to introduce yourself to AMP as well. Yeah, I think I can hear. Mm there's a bit of a try again movie I think that that yeah, that's perfect. Ok. Um so I'm on one of the ones at hospital as well and I'm currently on endocrinology. Um and I'm just gonna today we're just gonna speak about um prescribing and I'm gonna do the second part um just pre and postop prescribing. Perfect. Um So we're gonna just start with the what we're gonna cover. Um so like I said, um we'll just recap some stuff at the beginning about safe prescribing um which we also covered in the previous one. So I'm gonna go really quickly through that. Um, and then we'll go through some stuff about renal dosing and A Ks and then I'll cover some, um, brief things just about palliative care prescribing and then will go on to do some pre and POSTOP, um, medications and blood products and we'll hopefully make it quite interactive. So, if you want to message on the chat, that would be really helpful just to get it a bit more exciting. And so the principles of say prescribing, um I'm sure you guys get lots of, I know that our med school gave us loads of teaching about kind of um the safe things to check before prescribing. And I'm sure you've all either done your PSA or doing your PSA. Um But obviously, it's really important to check the right patient. Um You're writing the right drug chart, um always check allergies for everything before you prescribe um and consider kind of contraindications um for anything you're prescribing. So they be actually helpful for that. Um And then some of the things obviously you have to prescribe are listed there. Um So some of the things that you have to write when you're prescribing, sorry, um Loads of places now have electronic prescribing, which is super helpful. So it'll give you like alerts if something's contraindicated or if they've got an allergy recorded for something. Um And even there's some that have like older sets we know in Musgrove, they have, um, kind of premade prescriptions that you can just knock across for things like paracetamol. Um, and yeah, always check it after you're done. Try not to get people to distract you. So if there's asking you questions and things try to very politely say I'm just prescribing something, please. Can you give me two minutes and then, um, you can concentrate on what you're doing cos it's really easy to make a mistake, especially when you're really tired. Um, this is just some other things. So if you're writing it out because it's, um, uh, a bit old fashioned, I think Bristol Hospital is like this. Um, always make sure you write down the actual, er, approved name, not the like generic company name, like Ventolin, Ventolin, um, writing caps, make it legible. Um, if you're writing insulin, always write units, not you. Um, because it can be mistaken as a zero. and yeah, that's correct. So we'll start on some of the renal impairment stuff. Um, so we'll start with a case. Um, so this is Missus Lee, she's an 89 year old who's admitted to ed with a fall and a long lie. Um, so you obviously want some more information. So we go ahead and we take a history, um, some of the history, er, so the history of the presenting company is that she had a mechanical fall. Um, I know that Jerry's hit the word mechanical fall because this is all fours of mechanicals. So we'll change that to accidental fall. I should have written at 8 p.m. found by carers at 7 a.m. the next day. Um called for an ambulance which arrived at 3 p.m. So arrives in easy at 10 p.m. So she's not passed urine in any of this time. So it's been Anuric for over 24 hours. Um So I just let you guys think about that for a second. We can get some more history up. So this is some of her past medical history. She's got hypertension, she's got heart failure. She's got terrible kidneys. She's got type two diabetes. She's got malignant otitis externa and she's got chronic back pain. These are her drugs. So a bit of a cocktail. She's on Ramipril furosemide, bendroflumethiazide, Metformin, SITagliptin Gent and Naproxen. Um her social history. So she lives alone. She's an exsmoker and she doesn't drink any alcohol. You go on to examine her. So this is her new score. She's actually using of zero. She is however confused. Um Her heart rate is 100 and seven a bit high. Her BP is a little bit low. Um At 96/37 I'm not sure that is a new zero. So maybe it's quite sorry about that. I think that's a mistake. I probably wouldn't use a zero. but her blood pressure's a little bit low. Her heart rate is a little bit high. She's confused but she's Afebrile and she looks quite stable in herself. Um Any other examination stuff that people would want, anyone have any suggestions of other things. I can't see anything on the chart. I don't know if you want to comment what they think. Um Hopefully I'm looking at the right bit. Um So what I'm kind of trying to get at is just doing an A to E so starting from, from the top and working her way down. So, um her airway was patent. Um she um on an examination of her chest has equal expansion. She has good bilateral air entry, her cap feels a bit prolonged, three seconds, she's got normal heart sounds. Um her chest X ray shows kind of mild pulmonary edema. Um So she has some bilateral infiltrates. Um She's confused. Um, she's got ABM of 6.2. So that's fine. Um And then the rest of the stuff is her abdomen soft, she's got dry mucous membranes, she's got a bit of pitting edema bilaterally. And um she's got ongoing reduced hearing, which is she's known to have. Um, so, um based on this history and exam, um, what kind of things are you thinking about? Um, at the moment, what would you like to do next? Any investigations? Um Yeah, what do you guys think? I'll give you guys kind of two minutes. We'll try and make it as interactive as possible. If you're able to send some suggestions, there's no wrong answers. Um, any thoughts by anyone? Mhm. Ok. I'll just continue. Um, maybe we're just warming up but, um, if we could be as interactive as possible, that would really, um, make things more interesting for you guys. Um, so the things that I was getting at first off is just to get some blood. Um, she's been Anuric for a very long time. Um, she's got loads of risk factors there, um, for kind of an AK I um she's obviously on a big cocktail of drugs which are all not that great for your kidneys. Um She also on examination, it's a bit of a tricky fluid balance. So obviously there's kind of things like she's got a bit of a pulmonary edema, she's got pitting edema, but, but she does sound kind of overall in that examination a little bit dry. So she's got that low BP, a bit of a tacky. Um She's got dry mucous membranes, her cap refills a bit prolonged. Um So yeah, just things to think about. Um So we did some bloods on her and we've also got some bloods from previously. Um So I'll let you guys have a little look at those um for a little minute. Um And if anybody wants to tell me anything that I noticed that's significantly wrong. So the main thing that's obviously very striking in these bloods is the EGFR of nine. it's gone from 50 to 9, which is awful. Um, her urea is really high at 20.6. Um, and her creatinine also jumped up to 250. Um, the other thing that's really important to look at is the potassium and the potassium is 6.2 so high as well. Um, so that's all in keeping with quite a severe AK I, um, and also adds to a bit of a dry picture with a high urea, um which is helpful. Um So some of the other things that we might want to add on to those bloods in somebody that's had uh sorry, a long lie. Um Anyone want to send a suggestion about kind of, I might have just given you a clue. Um But in any patient with a long lie, um especially if you notice they have a severe AKI. Um Is there another blood test that you would like? So the blood test I am going for is CK. Um So and also a VBG. Um So this is the yay. Thank you Connor. Yeah. Um So her K is 10,000. So that is abnormal. I can't actually remember the correct range, but that is definitely abnormal. Um That's really, really high and her ph is actually ok, it's 7.36 and her bicap is 21. Um So now you're thinking about sort of management of this patient. Um There's various different things that could be going on here contributing to her AK I, um, does anyone have any thoughts about potential causes of her bloods being like this in the clinical setting? Yeah, there's ABG as well, Monica. That's a, yeah, a VBG or an ABG is really helpful. Um, an ABG if you can get one is really, really good. Um, often in practice, I think when I've dealt with people with AK I, it tends to just be a VBG. But, um, yeah, um, so in terms of why this person's got a severe AKI, um there's a few things in the history that could be contributing to this. So one thing is obviously this really high CK long LA and Uric. Um when someone's got a really high, um you're obviously worried about things like rhabdo. Um and that can really cause your kidneys to go off. Um Some of the myoglobin casts um can accumulate in the kidney and that can cause a really severe AKI. Um So that is definitely kind of one of the top of differentials about why this has happened. Um The other thing that you could think about is um it's a bit of a chicken and egg with AK I and fluid overload. So, if they were fluid overloaded before they fell, and that might have, you know, contributed to things um that can lead to poor perfusion of your kidneys and secondary to heart failure, you can get a really bad AKI. Um And the management of that will obviously be very different to your prerenal A Ks. Um But also you can have fluid over a secondary to an AKI. So if she's been Anuric, because her kidneys are, are not working um for 24 hours, then that fluid that um she's got can go elsewhere and start third spacing. So that's the other thing to consider. Um So in terms of what I do as an f one, if I was presented with someone like this, um there's a couple of different elements that need a dressing. Um So her fluid status is obviously needs looking at um the other thing that you need to look at is um her ph um so always do AE BG if someone's in the sphere, AK you need to address the potassium. So her potassium is 6.2 that's quite high and you also wanna look at her medications. Um So she's obviously on a big cocktail there and all of them are not very good for the kidneys. So you need to be thinking about that as well. So what to treat? So I've kind of mentioned a few of those. So in terms of volume, this on purpose is quite a tricky case, in terms of um assessing fluid balance and II sort of think that's useful just because of practice as an F one, I think often on the walls, you go and see people and it's actually not straightforward whether they're fluid overloaded, whether they're really dry and it's sort of really difficult to know. Um if somebody is known to have really petting edema in their legs and they've always got swollen legs. Um They could actually just be really dry but still present with some features of overload. So, um I thought it was kind of realistic to keep that in as a tricky fluid balance. Um But I think in this case, some of the things that I've already mentioned suggest that she's maybe more on the dry side. Um So I think why we do in this setting um is probably do a really small fluid challenge. Um So you can then kind of assess whether someone's fluid responsive their BP and their tachy, you can monitor that and see how they do. So just starting with a teeny bolus um of 250 if someone's known to have cardiac failure is really helpful. Um The caveat to that, is it at the moment this person's saturating really well, it's looking like more of a chronic picture in terms of heart failure. Um But if there's any doubt about kind of pushing someone into overload, their, that's gonna start going down, they start being more short of breath. Obviously, you need to be reassessing and um calling on my dredge. But um some tips that I've received this year about people with fluid um tricky fluid bouncers. Is that one way to look at it is if somebody's quite is third spacing a lot and you can't tell is to look in their auxiliary. So that armpits will, will be really dry and they won't be sweating in their armpits if they're really dry intervascularly. So that can be a, a weird but helpful thing to look at. Um, the other thing is you can lift someone's legs up and that kind of simulates the thing, same thing as giving a fluid challenge would do. And if their BP c comes up um with lifting their legs, then that suggests that they'd respond to fluids. Um So the second thing we mentioned was um the ph, so that was something I ha I haven't really properly appreciated before starting f one that if someone's got a severe, I always do A PPG, um you need to know about their ph um as well as it gives you a really quick way to look at someone's potassium. Um One of the reasons it's really helpful is because if somebody is very acidotic, um because of their AK then that might mean that they qualify for renal replacement therapy. Um We'll cover it in a second. But one of the, the things that mean that they need renal replacement therapy would be refractory acidosis so that it's not responding to your treatment. Um And if further down the line, you need to talk to itu about this, then they love for you to have gas, they love gasses and they always want to monitor um which way the gas is going. So it's always helpful to have one early on um the hyperkalemia. So this obviously will differ between each hospital and to always look at your local guideline. Um cos it was definitely very different in the med uh the the hospital I was at as a as a med student compared to this one, the guidelines are very different. So I always check. Um but generally it's sort of the same that if it's above six or 6.5 then they're gonna need treatment. So if in our local um hospital, if they have any ECG changes, um so that's your to 10 T waves um or there's, there's others as well. Um Then they're gonna need calcium gluconate. And does anyone know what calcium gluconate does and why we need to give that if there's E CG changes? So the reason you give it is to stabilize the myocardium. So it doesn't do anything to your potassium. It actually just stabilizes your heart so that you don't go into uh ventricular arrhythmia, which is the main risk you're worried about with hyperkalemia. So it just buys you time essentially so that you can get the insulin dextrose into them to get the potassium down. Um And yeah, you give the insulin dextrose to actually um move the potassium um intracellular to get it down. Um The other thing you can do is to give salbutamol. Um And I've been in situations where we've been really, it's been really difficult to get a cannula into someone. So there's been delay in giving someone insulin dextros. Um, so we've just given them a salbutamol while we're trying to get a cannula in and that also helps to bring things down. Um, and then the last bit was to check the drug chart. Um, so this patient is on a lot of stuff. So she's on Naproxen. An NSAID terrible for your kidneys, Ramipril. You stopped that in ak also terrible for your kidneys and an AK um She's on lots of diuretics. That's a bit more tricky. And I would probably speak to my senior before making any decisions about that, especially in tricky fluid balances, but in a kind of standard AKI with mm no, like in a prerenal ak you would consider holding fosamine and bend. Um She's on Metformin and you hold Metformin and AK I can anyone tell me why whilst someone's hopefully sending in a suggestion also, Gentamicin is not good for kidneys. Um And so you want to avoid that. Um And normally have to speak to micro about an alternative. Um So yeah, um the reason that you hold Metformin is because of the risk of lactic acidosis. Um So yeah, so I've just made a little sheet. I don't, it was mainly just in case people want to take a picture of it. Um as a useful aid as an F one about the things to do before you phone the med reg with a severe AKI I um obviously if you feel out of your depth for the ASAP, um but these are just some of the things that it's useful to tick off when you're looking after people with an AK I. Um, the other thing I've put at the bottom is the renal replacement um criteria. Um So if these things are present and they're not resolving, um, in response to your, your basic um, treatment, then they might need renal replacement therapy and that requires it discussion. Um And then there's just a quick, um, quick slide covering when to restart meds. It's basically just to remind you that you do need to restart them once the AK I is resolved cos often, um, patients will just have things on hold and you won't realize until you're writing their discharge letter and they've still not had their Metformin and there's been lots of drama about their bms and then you realize that more form and it's still held because of an AK I, so, um, just remember to restart them once things have resolved so quickly just to cover, um, them prescribing in end of life care. Um, so this is just a quick scenario. Um It's quite lengthy. So I apologize, I apologize about how long it is. Um, but it's about a nine Mister Jones who's 96 years old. He has dementia, um end stage prostatic cancer, end stage COPD. Um, and he has recently been admitted for a cap, he's had five days of the antibiotics with no improvement and he's actually just gone downhill and he's become quite drowsy most of the time. Um, he is confused, he doesn't want to eat and drink anymore and the decision is made to kind of palliate him. Um, and the discussion has been had with family and things like that and the tap has been updated. Um And your consultant has asked you to do the paperwork which normally means to do symptom mos um and stop things like that but depends on the patient. But um one of the things he also asks you to do is to start him on anticipatory medication. Is anyone able to send a list of some of the A CPS that you would need to prescribe or just the standard set that we always kind of refer back to? So I've made. Oh, yeah, perfect opioid and Chloe. What why would you give someone an opioid for what in an end of life? Statin? Mhm Yeah, pain relief. Um The other thing I was thinking of was breathlessness. So opioids in end of life care, it's really helpful for people struggling with some breathlessness. Um which in this case, this man has endstage COPD and cap so that might be helpful. Um So I'll just skip on to the next slide. Um So this is just a summary of the A CPS that you prescribe. Um and for what symptoms. Um So the main things that people address um in end of life and often things that the symptom of the chart cover are pain and breathlessness, agitation, um, nausea and vomiting and respiratory tract secretions. Um And I've put a list of the drugs there um that we use. Usually there's a, if you've got online prescribing, there'll be an order set and you can just skip some all across, which is really helpful. Um But otherwise there's normally really helpful palliative care guidelines in hospitals um about the doses to start on. Um So I won't have on this for too long. Um One thing to know is that Ondansetron is really constipating. So people hate using it in end of life. Um And the other thing is that if you're prescribing um cyclizine and Buscopan, they are not compatible in the same syringe driver, which that's an interesting side note. So you can't give those together. Um This is quite a heavy slide. So I apologize about that, but it's hopefully just a crib sheet about opioids. Um So when you're starting an opioid in someone who's end of life, um you want to start with immediate release so that you can get a proper understanding of how much they're using. If you go straight in with those long acting, you're not gonna really know how much they need and what dose to start on. So start with your immediate release. Um Normally if they're opioid nave, so they've not had opioids before you want to start on something like 2 mg. Um And then if they, and that would be kind of four hourly, um if they've had opioids before you might want to start a bit higher, something like five. Usually morphine will, will work in 20 minutes and it'll last around four hours. Um People might need more or less. Um And you're kind of guided by the, by the patient, but as a rough guide, um the you might want to do that regularly. So 2 mg four hourly and then you want to prescribe um apr N dose as well that they need as breakthrough. And normally after a period of time of monitoring how much they're using, you can then start figuring out the P RN dose by um figuring out 1/6 of the, the total day um in renal impairment important to know um that morphine is not very good. So use oxyCODONE instead. Um it's better than C KD and in terms of adjusting the dosing, um so palliative care will be super helpful here. They're really useful with things like um anticipatory meds. Um But normally you would increase and decrease by 30%. Um More than 50% is likely to be too much. Um and less than 30% is not gonna do very much. So, normally adjust it by 30%. Um Once you've got a bit more of a time frame, so you've been able to monitor how much they're using over 24 hours, then you can start thinking about switching to a modified release that's gonna last longer for them. Um And the way you do that and often there's kind of exam questions about this is you add up how much they've had in 24 hours, you divide it by two and that's the MST dose that you're gonna be giving them BD. Um um that divided by two and then the P RN dose, like I said before would be 1/6 of that. Um In terms of switching opioids, I would just recommend looking at the nice guideline. There's like a good um crib sheet on how to do it. Um But important to know that things like oxyCODONE are um a lot stronger than morphine. Um So you'd want to divide it by two if you're prescribing that um or to subcut as well, you need to divide that by two if you're doing that switch. Um and codeine is a lot weaker than morphine. So you want to, if you're prescribing um 50 mg of codeine to someone that would be equivalent of of 5 mg of morphine. Um a quick page just on antiemetics. Um because I always found this quite confusing in terms of which one to prescribe. Um you can in the palliative care setting, you can sort of think of the cause of causes of nausea under three settings. So I always thought of it as like neck up, neck down and then chemical causes. Um So neck up would be things like ventricular ICP, um psychiatric causes sensory pain. Um and that's kind of your higher neuro causes. And then there's the gi causes which the neck down causes and that's things like gastric stasis. Um It can be metabolic problems and constipation, things like that. And then the chemoreceptor ones are your drugs. So, opioids can really make you nauseous, um and other meds as well. Um, metabolic causes like hypercalcemia can make you nauseous and then renal liver disease and sepsis or even just widespread kind of mets and things like that would cause you chemoreceptor type nausea. Um And using that information that can really help with knowing which um antiemetic to start. So neck up, go with psycho um neck down, go with metoclopramide unless they're obstructed, don't use it if they're obstructed. Um And then chemoreceptor causes, try something like a dopamine blocker. So that's haloperidol um or metoclopramide. Um Just my last slide on syringe drivers. Um So my main advice for syringe drivers would be to phone palliative care for advice because I always get really confused about how to do it, how many, how many times I try. Um But essentially you're gonna need to have a 24 hour period of how much you can either start on the basic low dose, um, of the medications that, that patient specifically requires. Um, so if they're struggling with pain and breathlessness, um, and nausea, then you would want to put, for example, cyclizine and morphine in your syringe driver. You don't need to put all four of the anticipatory drugs in. Um, you would want to know how much of that drug they, they've been requiring over 24 hours. Um, so that you can know how much to put into the syringe, which will need to be infused over 24 hours if that makes sense. Um In terms of Pr Ns on top of that, it's important not to forget about the P RN. So the syringes like a background dose, um they still need PRN S on top of that. So make sure you still prescribe that. Um And basically just get on palliative care if you've got any trouble with it because it's can be confusing at the beginning about how to prescribe it. Um And that's it from me. If anyone has any questions about anything that I've covered, please send some questions in the chat and I will get to them as basant does have it. Yeah, thanks. So just moving on um something very different. So prescribing perioperatively. So we've got a scenario where I can have next time, please. Thank you. So your, the surgical f one, you're working nights, you've got Missus Browning, a 58 year old woman she's got severe abdominal pain, vomiting. She hasn't opened her bowels for two days. She's not, she's not passing and she's vomiting quite a bit. Ok. Ok. On left side, please. So you take a bit more of history. You find out that she's, she had appendicectomy. She had hysterectomy. She had a recent DVT. She's got hypertension high cholesterol and currently she's got raised BMI S, um, raised BMI I and the type two diabetes and you take a quick drug history, you know that she's on Braxan and all of that, she's got no allergies, but she told you that she recently stopped her pill and that's the estradiol pill. She's warming up. Do you guys know why would she have stopped that recently? Any thoughts as in her past medical history? Something happened to her recently? Mhm. So I was just trying to him that she has got a DVT. Um, so with DVTs, you stop the pill or any estradiol because that increases your risk of having more pills elsewhere. So it could be DVT or P so that's why we stopped it. So just hold on. Yes, the nurse take her up and that's what you get. So she's currently using a four, slightly high respirate, slightly tacky. Um, she's a febrile BP depends on her BMI but it seems like it's on the lower side and she's not on any oxygen, which is good for now, next slide, please. So the exam findings you find that she's very dry, very cold. She generally looks quite unwell. They examined her tummy. So you find that she generally extended tender, especially periumbilically and you've got, you find out there is some guarding as well. You listen to bowel sounds, it's minimal and absent in left, lower quadrant and left, upper quadrant. Right. So, right now, what are you guys thinking with that history? What are you guys thinking? And what would you like to get in terms of investigations? No wrong answers here. So shout out what you were thinking. Yeah, small process. Well done. So what investigation would you want for that? Yeah, a CTI see that. Yeah. So yeah, so just before I see you, we can start with something simple. Yeah, after x-ray, that's what I'm thinking. So yeah, so you wanna get some blood, so you wanna get a x-ray. So we've got the Abdo x-ray in in the next slide, please. Next slide, please. Thank you. So we've got that and has that confirmed your diagnosis? I think Connor said it. So you know that small bowel because small bowel is gonna be in the middle and you guys, I'm pretty sure you know the 369 row so three centimeter, um, if the bowel, small bowels are more than three centimeter, that means that there is likely obstruction, it is dilated and six centimeter for um large brown and then nine for cecum. And also the other thing is the valve line in the middle. So the line is going across the bowel. If it's a straight line continuous, that's likely small bowel and in large bowel, that's how stress. So it's not gonna cross the midline. So that's how you can differentiate between the small bowel and the large bowel. But obviously, if you're ever unsure, just um, ask your seniors, right? So now we've got diagnosis, what would you like to do for this patient? So as an F one, what would you like to do? So what are you thinking just before that call the surgeon? Yes. So just before that you can do simple things. So what's the gold standard that we always say in small bowel obstruction? I'm pretty sure you guys know it. So if you go to the next slide, yeah, so that's it. So you wanna start very simple a you wanna make sure that they've got enough fluids cause they, these patients usually really have been vomiting for hours and hours. They're very dehydrated. You wanna give them some painkillers? So, but having bowel stress. Yeah, I'm pretty sure I've never had it, but I'm pretty sure it's pretty painful. So you wanna give them adequate analgesia, they're vomiting. So obviously you're gonna give them antiemetics and as Alan said, you wanna put an NG tube to decompress this um the bowels, so drip out, that's what we call drip out. You give them fluids and you wanna put an energy tube, usually arrows tube and you wanna keep it on free. So, so, um, you don't put a plug on it or anything. Um And you monitor them cause usually, and you need to have a strict fluid balance cause usually they can get quite dehydrated without you knowing next time, please. So, with fluids, if it's, you've just met them in A&E, you wanna give them a bolus because usually they're very dehydrated. And in that lady, um so Missus brownie, she had a low BP. So you wanna give her a both, see if she responds and most of the time they do respond and then after that, you wanna give them maintenance of your fluids. So usually we give eight hourly bags um of sodium chloride and depending on their potassium. Um So you're gonna take that if it slow you in a first of all um treat that. So give them more potassium and then you wanna give them the maintenance potassium. So usually we say one millim more of potassium per kg over 24 hours. And usually we give around 20 to 40 mill of potassium chloride. Uh and surgeons love Hartman. So if you're ever in a surgical irritation, you're gonna find surgeons just prescribe Hartman all the time. Um It's fine um because Harman is quite good and it's got all the things you need. But if you move on to medical, be aware that they hate Hartman, so just be aware of that. Um Next thing. So, analgesia, you wanna start with the pain ladder. So basic IV paracetamol or start with that, give it regularly to um make sure it, it works to its full effectiveness. Then you can prescribe things like nsaids. Um You saw things like n um you can prescribe IV morphine and just make sure that whatever you're prescribing is IV cause anything you're gonna get through the mouth is not gonna um get absorbed. And in a lot of these patients, they do not feel like eating and drinking anyway. Um So you're gonna find it quite difficult to convince them to take a pill or, or more or something like that. Um Be aware with IV morphine, just prescribes, prescribe it in um small amounts or low doses and then build up if they need more. And then one really helpful thing is Pr diclofenac. It works wonder especially obviously in renal colic. But also in a situation like that when you haven't got uh the oral access, it's really helpful for patients, but be aware that you can't give three consecutive doses. So if they're requiring three consecutive Pr and um PR DFAC, then make sure to um raise awareness to your senior as it in case that they need more support and in our trust, we've got something called the pain team. They're quite good because they can um put in like they can provide advice on what else you can add to this patient, especially if their renal function is not that great. So know what help you've gotten in your trust. And um always use that, especially if you're in and out in our, out of ours, you're quite limited with your senior support, only your team and that the antiemetics I think carry spoke slightly about it. So in other situations, my favorite is Ondansetron is because um it hasn't got a lot of side effects except the constipation and you can always give lax sips with it. But in this case, I'd always go with something like cyclizine just because it's a bit safer. Um, in this case, so it doesn't cause a lot of constipation and it's quite effective as well. You can give things like chlor um per perazine. But to be honest, I would use that as second line just because it does cross the brain barrier and you need to be quite wary about that because so patients with epilepsy, neuromuscular disorders, Parkinson's me Gras that's gonna worsen it. So you don't wanna um cause that. And I think as Carrie mentioned previously, metoclopramide and bowel obstruction, you do not wanna give that cause uh metoclopramide is a prokinetic. So if you're gonna get it in a bowel obstruction that increases risk of bowel ischemia and you don't want that. You don't want that to happen. I think we spoke about it. R tube. So you wanna insert the R tube as soon as possible. Uh You keep it on free drainage and you wanna start a fluid balance, strict fluid balance, right? What else? Hm. So that's all right. Um So I was just gonna say in these patients, they're quite dehydrated. They're very nauseous. They don't wanna get up because they feel quite sick. So, what else are you thinking? There's something that we need to prescribe for every patient that comes into the hospital. I think we gave you a hint there. That's all right. What do you guys think? I think we already gave you a hint. That's OK. Um So I was just trying to get out that we need to always prescribe BT. So it depends on your trust, but ours is you wanna start with test talking if they're not vascular patients. So if you haven't got peripheral vascular disease, so you need, you need to make sure that they haven't got that. Um The other thing is you wanna give them zacate heparin and less contraindicated. So, in our chart, we usually give enoxaparin and that's a perfect dose. Depends if they're high risk, low risk. We've got a really nice um VTE for me to fill in, but it's usually around 20 to 40 mg. Um And so some contradiction indications to an ox, obviously, if, if they got any active bleeding. So make sure that they haven't got like uh an upper gi bleed or um bleeding from elsewhere. Try to prescribe that. And if they're already on anticoagulation, what do you guys think you do? So for example, they're already on uh pro Apixaban. So would you keep it, would you change it to something else? Any thoughts? So, I was a bit confused about that to begin with also. But I think it depends on the trust. So in our trust, if they're on prophylactic dose, for example, the IAN or other anticoagulation, we keep it as it is. We don't prescribe low micro heparin. But in some trust in my old trust, we used to also to pause it and prescribe treatment dose, low micro heparin. So it all depends on that. Um And the other thing I forgot to tell you is if we can't have tests, for example, for PVD or um they've got viruses veins, you wanna um cause there's something flutron called flutron. I don't know if you ever seen them on the wards, but they're quite big machines which do not provide um any pressure on the legs, but still um it moves the muscle to make sure that the blood is flowing through it. Next side, please. Next one, please. So with patients know by mouth. So it all depends why they are no by mouth, but you still wanna prescribe the regular medication. So if they're know by mouth because they're going to surgery, then they can still have small tablets um two hours prior to their surgery. If they know by mouth because for example, they're having an obstruction, you wanna think because so you, they can't have any of their tablets, um, mainly because they're not gonna get absorbed cause nothing's getting absorbed from that bowel. So you wanna try and change their tablets or if they're not necessary, you can always hold them right? So this is Missus Browning, um, list of medications. So what do you think we're gonna do with that? So Oxone, that's an anticoagulant. What do you think we can change it to, to speak any thoughts? So if I was saying Missus Brown, I've changed it to low. He cause you can give that as injections and she doesn't need the tablet. Really statin. I don't think she'd need that acutely and the benefits from that is not short term, it's more long term. So we can hold that for the minute, Lisinopril. So if you guys remember that her BP was low at the beginning and most of these patients have low BP because they're quite dehydrated. So we wanna hold the acu eye on their BP. If their BP is quite raised, then you can always give IV labetalol. But I do that. But like after consulting with the meds cause um it's not something we do very often and it can bring the BP quite rapidly, especially I VV, labetalol and Metformin. I think we've already discussed that, but there is high risk of lactic acidosis in these patients as well. Um So we need to hold it, monitor CBG S. And if it's a diabetic patient, we always need to monitor the CBG S quite closely. But also if there are type one diabetes, we have got a low threshold to start a variable rate infusion because they're not eating, they're not gonna be eating and drinking in some of these patients four days. So you need to be just needs to be at the back of your head. Next slide, please. That's everything I was just telling you about. So we've done a CT now finally, um and we've confirmed that it's small bowel obstruction and slightly adhesional because she's had um several surgeries before. So with these out patients, you wanna start conservative first monitor how they're heading, how they're doing. Is it getting worse? Is it getting better? So, in that case, Missus Browning is not getting better and the pain is getting worse and she's still vomiting. So they decided to take care for it. The and then um so with the, they asked you to make sure that she's ready for theater. So what do you guys think that means? So there's several things to think about got, I think we touched on some of them. Any ideas group and save always, what else? What's the one thing you really need to tell the nurses? We might not be applicable to our case, but always to other cases. Mm any thoughts, if not. Um Do you move on to the left side, please just be a good time. So first thing always, always tell the nurses um that sh this patient is gonna be no by mouth. And if there's more behind them, please, please please write it on it cause there's so many cases I've seen so many cases get canceled because they had breakfast or they ate whatever. Uh and you don't wanna be that person who breaks news to the surgical rush that this patient should say. Um So you guys know that the six to rule. So no food, six hours prior to surgery and they can have fluids, fluids up to two hours prior to surgery. And in that case, if they've got oral medication, they can take it. Um, as long as they are two hours prior to um, surgery, you wanna give them some fluids because they're gonna be no by mouth for quite a while, especially if the patients the first on the list. So when I prescribe them overnights, most to likely they're not gonna, um, be drinking overnight and they're not gonna have any, um, breakfast in the morning or any fluids. You wanna correct, correct, any electrolyte imbalances as always. And with anticoagulation, if you are on ap span and therox span, make sure to change to low heparin just because it's got a shorter halflife. So it's, by the time you've got, they've got the surgery, it probably would have worn off. Um And you'll make sure cause that's always missed as well. You wanna omit the doors the night prior to the surgery and I think we already spoken that if the patient is insulin dependent. So you wanna make sure that you're putting them on a variable rate insulin next time, please. So I've got this list. Um I had this stable as a, a student. Um, and it just, you can look at it in your own time, but it gives you guidance on what to do with oral antidiabetics because it get, it gets quite confusing. But some of them, you can stop, some of them, you can reduce the dose. You all, to be honest, as an F one, I think in my experience, I found out most CBG S are usually normal. So I just um emit the dose prior to the surgery or the two doses prior to the surgery. But if it's high, then you wanna obviously look at your um local guidelines and speak to your senior because sometimes it gets quite tricky. Um and some seniors would like them to start on B ri straight away. Some of them um don't, especially if they got like Metformin with INSS and all of that. So it gets a bit tricky. So always speak to you soon, if unsure about that. Bye. So in these patients, some of them would have not eaten for quite a while. Why do we get worried in these patients. Any idea? Actually, just because I'm aware of time, I'm gonna um go through these quite quickly, but basically, we are concerned because of free feeding syndrome. So you find a lot of electrolyte imbalances. Um And you don't wanna feed them too quickly cause that's just gonna worsen all the electrolyte imbalances. So, with refeeding, you're looking at one thing that you look at, um or you see quite often early on is low phosphate and low potassium and then you see low magnesium, high calcium. Um and as you guys should know that in worse cases, it can lead to death and coma and we manage it by just making sure we're giving them small amounts of building cup and, and replace any electrolyte um disturbances daily, making sure that you're doing these daily bloods, including all the electrolytes. So magnesium, potassium, phosphate, calcium, all of them. And in some patient, if that's not resolving or if they're really haven't been eating for a couple of days. So 10 days, two weeks, you wanna start them on IV caverns to protect their brain as well and um reduce the neurological disturbances that they get next slide, please. So after his surgery, she um has got a she for pain control and then she still complains of painful distended abdomen on the wall joint and she says that she can't pass any wind. So things have, it seems like things haven't progressed, but we know that she's had the surgery. So in that case, what we're thinking is that it's probably an ileus rather than an obstruction in that case, just because she just had the surgery and her bowels hasn't been opening, hasn't been working for quite a while. So, what you wanna do in these cases is always first thing next time, please, Carrie, thank you. Um, you wanna read the operation note. So sometimes they have very specific instructions, for example, remove the tube, remove the drain, um, remove the after sheath is uh extra. So they're quite helpful. So you always wanna start on that. But also because these patients would still not eat for quite a long time, make sure that you've still got them on same thing. VT E analgesia and all of that. Um And in this case, if they are on OK, you can give them low doses of flox and see how they respond to it. And um so low doses of oral tablets or a laxative, sorry. Um And if that's not working or you find that, mm, you're not quite sure you can always go with suppository. To be honest, sometimes I skip the oral laxatives, especially if they're straight after surgery and go with the suppository first and once they've opened up little bit of their bowels, then I go in with the laxatives and as always, don't forget your antiemetics. So finally, Missus Browning is starting to feel better and she goes home so she had a lot of things happen um in hospital. So she had small bowel obstructions. She ha she had a laparotomy, um, and she had I postop and she also was a treat of UME syndrome. So that's a little summary for you guys. So the next case is your body as a show. You get a call from a GP saying that you've got the 70 year old female, she's got heavy periods, but also today she's passing large clots, she's feeling quite dizzy. Um out of breath. You do her observation, you find that she's slightly tachycardic for a 17 year old. Her BP is low, but other than that, she's quite fine in terms of other observation, um pregnancy test is negative, always do a pregnancy test. Um In young women, you ask her more questions, you find out she's been having heavy periods for quite a while. She's been also um passing lots of clots recently. Um So it's just on the next slide, please. And she's got a past medical history of hypothyroidism and syria disease. So bear that in mind going forward. She's on leave and she is prescribed an iron, which she does not take it because of constipation. So next thing you would wanna do an exam, you find that there is blood there but nothing abnormal other than there is some blood dripping, right? So what are we thinking? So, too many things we wanna do is stop the active bleeding. But also she's quite symptomatic. So you wanna replace what is the best. So how do you stop the bleeding? So, always, always ol acid 1 g. Usually we give her IV especially in actively bleeding patients three times a day. In that specific case, you can provide some hormonal treatment. So both of these are progesterone pills and they're um they're quite rapidly acting progesterone. So they stop bleeding usually within a day and you prescribe them orally three times a day. Um and just to try and get that bleeding stop quickly and then you wanna replace what's lost. So two things you can do that. So blood, so you replace what's lost like by life. So is she off blood? You wanna replace that blood, do not give fluids. Um Second thing you wanna do her blood and if you find in this case she likely has got iron deficiency anemia. If you find that she's got iron deficiency anemia, you wanna replace it orally, that's gonna be taking quite a while or you wanna give a once off IV, but just make sure with IV iron, you wanna make sure they are well within themselves. So if they got any, if they, for example, develop infection or um for example BK, you wanna hold off the IV iron just because it was um our immune system. So that will make the patients more susceptible to infections. So in terms of investigation. Obviously, you wanna get the bloods are including hes, you wanna check her, her thyroid because she was hypothyroid. She had hypothyroidism and as always do patients to sign up to get some blood. And in this case, you wanna do an ultrasound pelvis just to make sure that we're not missing any, um, pelvic abnormality that's causing that. Um, please. So I'm just, I'm not gonna go through the hemolytic but we, we covered on in our previous session. But these are her PLS. The one thing that um the one thing I want to look at in her bloods is the thyroid. So her TSH, so her, we just went through it briefly. She's got anemia STB. So that's my and the C is low. So that means it's ii fate is low. So you're gonna need to replace that B12 is low is fine. But if you look at that, you're gonna find that her TSH is high. So that means that she is, she's got low T four. So that's undertreated hepatitis. So that also could be a while she's having these heavy. So next, it's fine. We've discussed that already. Um last night. So iron tablets because several um format formulations of them, but you can use that be enough to prescribe that. But usually what we do is the best thing is given on alternative days for best absorption. But if you really wanna get that iron um up quite quickly, some people give once daily, you wanna give it on an empty stomach and make sure to avoid. So, just look at the interactions cause iron interacts with a lot of the medications. So that's why we usually give first thing in the morning on an empty stomach with some Vitamin C. And then if you keep about four hours between iron and other tablets, that usually is fine, um, in terms of absorption, uh, the iron, I think we touched on it, but it's usually mono in check and it depends on the weight and the target. Hb No, I'm pretty sure in every hospital there is a local guidelines how to prescribe that. Um So usually you give 1000 mg at one time, then a second dose a week after and if they're ill, quite feeling quite poorly, you can hold it off because it's gonna make them even worse. Um There is some occasional actions. It's very rare. I haven't touched with. I haven't seen any reaction until now, but um I do know about them. So you wanna keep a close eye on them as the nurses, I think they give a trial 100 mg of fast as the nurses to um repeat observation every 30 minutes. And I think after two hours, you can get the dose and then you wanna stop any iron for about 10 days after the IV infusion. Uh I think you guys would know that already, but there's in terms of blood transfusion, 12 group and say different timings at least 30 minutes apart and you only transfuse at HP less than 70 you give one unit see how they're responding. If they need that, you can get another one. It depends on, I didn't know that we can um, initiate to begin with, but usually trust to keep the group and safe for 72 hours. So after 72 hours period, you're gonna need to send more per and you wanna check the um the HP after transfusion about six hours to make sure that that's above the transfusion limit in the patient, especially in patients with like um I believe where they're constantly breathing. So I wanna make sure that posttransfusion there's still a blood transfusion. So in this case, we're just closing off. But in this case, she, she was um she was, she was one unit, she was given omic acid and she received Hartmann as well because she wasn't eating and drinking much. She was quite um dehydrated. We gave her that infusion and we told her to come back for um uh a future week later. And regarding her raise TSH, you contact the endocrinology or if you're not to do it yourself, you increase the dose at 25 increments and wait um four weeks to see the results before rechecking the TSH levels. And you can ask the GP to do that as well. And she had her ultrasound which is showed thickened endometrial. And so you, um, ask for a followup in the colon outpatient clinic which they cut a Mirena coil instead of the progesterone pill for long term um management of menorrhagia. Sorry, that was quite quick at the very end. But if you guys have got any questions, please let me know in the chat and I'm happy to go through them and don't um worry about the size. We're gonna put them up and we're gonna put the recording up as well. I just added a quick summary to my part on this bit as well. Just to say, I forgot to mention it during my thing. But some really useful resources are the Scottish palliative care guidelines, which is rogue, but that is just like a really great website. And I would really recommend that if you're struggling with palliative care prescribing, um It's got loads of really helpful resources on there and also using the Renal handbook. If you've got someone who's got D or AK I, and you're not quite sure what to do with their meds. That's a really great place to look. Um Yeah, if you guys have any questions, we will try to answer them and please, please, please, would you be able to fill in the feedback form? We'd be super grateful for any feedback. Um So we can improve this and um please come to our next one as well. We've got lots coming up every Tuesday. Um The next couple of ones will probably be more useful for things like on calls and definitely the things that I worried about um before starting F ones and stuff like um managing, um which is definitely stuff you get less exposure to as a med student. Um So yeah, please come along. Please tell all your friends and very much if you guys haven't got any questions. Thank you for watching and please fill in the feedback form. Thank you.