Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. Um Welcome to our fourth online webinar session of uh the UK MLA series. My name is um Deborah and I'm one of the medical educators um part of Meath. Um Today's lecture will be based on fluid management and it will be taken by uh Doctor Latif. Um Before we start a reminder for all participants that feedback forms will be distributed following the conclusion of today's webinar. Um Your insights are obviously invaluable and helping us to um enhance the quality of our future events. Um If you have any questions, feel free to contact us via our email through or through our social media. Um And if you need any clarification on today's lecture, then please drop us a message in the chat. So I'll hand over the session to Doctor Li. Hello everyone. My name is Doctor Ban Laif Abdullah. I'm one of the general practitioners uh practicing in the region of Kurdistan, north of Iraq. I used to be a General clinical fellow in uh Royal Free London Hospital in General Internal Medicine and Geriatrics. So let's just dive right into the subject of therapy. You can ask questions in the chat if my voice is good, please. Someone type it in the chat that the voice quality is good so we can just go into it. Um So how is the voice? Which is good? Perfect. Um Thank you everyone. So let's get into it. So IV fluid therapy, first of all, before we prescribe IV fluids, you need to make an assessment of the fluid balance of the patient. So how do you make a fluid assessment by the following? First of all, by history and examination for fluid status, which we are gonna come to it later on in detail. And then you have daily weighing of the patient ideally twice weekly. And in some patients where fluid balance is more critical, you have to do it daily, for example, in patients with heart failure and then you have fluid balance charts which you have, if you have worked in the NHS, you can see in many places where you have fluid charts um on the electronic patient record system where you can just check and uh with the fluid balance charts, maybe in some other trust, it's paper based, but in some places it's electronic and then you have lab values. Of course, we're gonna come to that as well. Some lab values will uh give you a clue and an idea about different types of uh fluid balance problems. And then of course, there are medications to consider. So and the history um we have some point suggestive history for dehydration and fluid loss. Just by history, we have to have a clue that the patient might be dehydrated. So if the patient had vomiting or diarrhea or blood loss or fluid loss from a surgical output, like stoma or fistula or drain, or the patient had previously limited intake for whatever cause. For example, the patient was sick, had fever and was not able to drain low appetite. And if the patient has thirst and comorbidities, that's limiting fluid intake. For example, patients with Alzheimer's are very likely to be dehydrated. Even though if they feel thirsty, they just might not drink. So then you have history points with a suggestive of fluid overload. For example, if you have a patient with a past history of cardiac disease, like heart failure or renal failure or liver diseases, these might suggest that the patient can be in fluid overload, not necessarily but can be. Um then you have patients who have shortness of breath, especially on lying down. This goes more with cardiac diseases and then waking up in the middle of the night due to shortness of breath, which is known as paroxysmal nocturnal dysnea. So these are all points that suggest that the patient might be in fluid overload. So we care in prescribing fluids in these patients. So now we're gonna come to examination and uh what are the points that we're gonna look for in dehydration? You have a list of signs and I'm gonna go all through all of them quickly. So for example, you have cool periphery, but you have to make sure that the patient does not have peripheral arterial disease because sometimes cold peripheries can happen in a patient uh with peripheral arterial disease and does not necessarily mean dehydration. So you have a tachycardia anything more than 90 or more than 100 you have decreased capillary refill time, which is CRT less than two seconds. And then you have a postural drop, which is any BP drop in the systolic more than 20 and a diastolic more than 10. So a drop of 20 systolic and a drop of 10 diastolic after five, after one minute or three or five minutes of standing up is called a postural hypotension or a postural drop. It is a more sensitive sign than just hypotension, which is low BP of the systolic of less than 100. Um because that is a late sign of hypovolemia. So if you have an elderly patient, which has a postural drop, then that patient is likely dehydrated. So that is a more sensitive sign. And then you have sunken eyes, you have dry mucous membranes from the conjunctiva and the mouth. And then you have tachypnea, you have delayed skin tiger and then decreased in output and then you score more than five. Then there's something called passive leg raising maneuver. Before I talk about the passive leg raising maneuver, I wanna mention one of the studies done in geriatrics that even though we study all these signs and how to detect them and we rely on them and we make judgments on them, but sometimes they cannot be relied on still, it just has to be based on clinical judgment. So despite these signs being the signs that normally you would be asked or expected to know or expected to base your judgment on on a dehydrated patient, but they are not very reliable um in the elderly. So now I'm gonna ask you about passive leg raising maneuver. Has anyone heard of the passive leg raising maneuver? If anyone has heard of it, could you please give a quick, quick explanation in the chat? If not, then I'm gonna go ahead. So anyone. Ok. So I think there is no one talking about that. So I'm just gonna give you a explanation of what is a passive leg racing maneuver. Basically when a patient is hypertensive and you raise the leg of the patient by 45 degrees and you have after one minute and a half, when you have an improvement in cardio um in cardiac parameters, like for example, improvement in the BP or improvement in the pulse rate, then that patient is again likely dehydrated, that is a sensitive sign, more sensitive than the others mentioned in the list. So post drop and passive man are two very sensitive signs for detecting dehydration. So you can do it either by lifting the patient's leg up or putting a patient in a 45 degree position bed and then tilting the bed all the way up, whatever is easier or whatever is more convenient for you to do at the bedside. So then you have signs for fluid overload. So the following would be tachypnea, raise a VP and you have pitting edema of the sacrum or ankles or even legs and abdomen. You will have bi basal reputations, which is very reliable and then pulmonary edema on chest X ray. So these are the things that you can check to know if the patient is um and fluid overload. And then, as we mentioned before, the third thing would be to check would be to check the fluid chart. Please make sure that you always look at fluid chart before you prescribe fluids or you check the patient for dehydration because you cannot just rely on the signs or on the history. So you check the total in and out on the previous day, not on the same day because obviously the flu chart for today has not been completed. Um You are seeing the patient, let's say um at 12 pm or at um um 11 a.m. it has not been completed. So it has to be for the day before. And then as you know, the normal is you should have around 400 mL of positive output. So this is reflecting the losses, which is around 800 mL and um the insensible one, which is you lose it through perspiration and through uh respiration. And of course, the metabolic was generation of around 400. So basically, net you should have around 400 mL during output. This is in a normal patient. And of course, you would also check the fluid balance for the past 3 to 5 days in the NHS. You would have the nurses writing down all these things for you in the patient records and to check how is the patient progressing or are they deteriorating or not? And of course, you will always have to check losses from gastrointestinal tract and surgical drains. You would have patients admitted for whatever cause they might be admitted for cellulitis. But because of an antibiotic, they would develop diarrhea. So you have to check and estimate the losses that you would get in gastrointestinal tract. Um of course, insensible loss, which is what you lose in uh during fever. You'll have much more of insensible loss during fever. And so in some medical conditions where you have third specials, like for example, in pancreatitis, so you have to have an estimate on these as well. So before prescribing IV fluids, please take into consideration all sources of intake and that means whatever the patient takes orally, whatever the patient takes via um UBS and um other tubes, like for example, a um um peg tube which is directly into the stomach, any drugs that we give IV, or even oral, sometimes you have drugs, um dissolved in water in a cup of water or IV, nutrition, blood and blood products. Everything has to be calculated to know that how much we're giving the patient, it's all considered. So now we are gonna come to the lab values. So you might already know most of these, but I'm just gonna quickly run over them anyway, because it's relevant to our lecture. So you have to have um serum electrolytes with every patient who is dehydrated. Roughly the plasma sodium is a marker of how much water balance do you have. And plasma potassium is a rough guide to how much extracellular potassium balance do you have and bicarbonate. Of course, you know, it's a clue to acid base disorder and then you have the urea and creatinine to monitor renal function. Now, the following four things I want you to know because you are gonna face a lot of these in the worst daily, which is serum albumin white blood cells. The packed cell volume are known as the hematocrit and urea. The reason why is because all of these rise with dehydration. For example, I have seen white blood cells as as high as 17,000 in a patient who was just yeah in an elderly patient who was just dehydrated, no signs of infection, normal crp no granule site increase. Nothing. Literally, the patient just came in for dehydration. And again, the opposite is true. They all fall with overhydration. So that means including the hemoglobin where you would have an anemia called dilutional anemia. So maybe you are in the wards and you have a patient who has an hemoglobin drop. After admission, after three days, you would be scared like is the patient having a internal bleeding? So you before you go to do APR before you check um for other signs of bleeding, which you might as well do uh just make sure that if there is a drop in the urine as well, if there's a drop in the albumin as well, because all these drop with overhydration and they rise with dehydration. So chloride levels for you would need to have it in suspected hyperchloremia or acidemia. This can happen when too much normal saline is prescribed. I'm gonna come to that as well. And then of course, sometimes you would need urine sodium levels, sometimes you need lactate levels when relevant and sometimes you would need arterial ph and base says by doing an ABG again when relevant. So chest X rays, as we mentioned before, it can be before the complaint or it can be before prescribing fluids. So before we come to the um prescribing the fluids, we are gonna come to how much fluids required daily. So the requirement is roughly around 22.5 L of fluid we need and that's an estimate for a 70 kg man, over 24 hours. So, of course, you would need more. If you have fever, you would need more if you have diarrhea or if you have a drain. And of course, your loss is normally would be through urine, which is 1.5 L in urine and around 200 mL in stool roughly. And it look at this 800 mL, insensible loss. No wonder we call it insensible because you will lose much more in, in, in through your skin and through respiration than through stool. Um So, rightly, so it's called insensible losses. Um It would be of course, much more during fever and other conditions and uh provision. So where do you get our fluid from? So we get from drinks mostly around 1.5 L and of course, from food, around 1000 L, these are rough measures that are not accurate. So now I'm gonna give you a table and we're gonna go over it. So this is basically how much water and electrolyte you would need per day. And this is what we need to prescribe fluids. Those are really important. So for example, for the water, you would need around 35 to 45 mL per kg um of water. So that would be around 2.5 to 3 and three and a quarter liters per 24 hours for a 70 kg adult for sodium, you would have 1.5 to 2 millimoles. And for the potassium, you would have 1 to 1.5 millimoles per kg. So that roughly equals 100 to 100 40 or between 7 to 100 5 millimoles of potassium. So that is taken from a textbook called Davidson's uh practice and principle of uh internal medicine. According to nice guidelines, they, we use different measures and if you're gonna work in the UK, you would need to follow the nice guidelines. So in the nice guidelines, it's basically much more simpler and the values are less. So you are taking 25 to 30 mL per kg per day of water and one millim m of all the other electrolytes, which is potassium, sodium and chloride. So that's basically much easier to remember. One millimeter, one millim M per kg per day for all the other electrolytes. And of course, you would need around 50 to 100 g of per day of glucose. That's actually quite little. It's not to provide the daily need for calories, but it is just to prevent starvation, ketosis. That's how much glucose you need just to prevent ketosis. So my question would be if anyone can answer, I'm gonna move along, but I would like you to answer the question. What if a patient is overweight since we're gonna base our water um intake based on weight? So if a patient has a BMI of 40 or more, how are we gonna calculate the water or how much water should we give? So I'm gonna give you a couple of seconds, 10 to 15 seconds. If no one's gonna answer that, if not, then I'm gonna answer it and knock according to surface area. Ok. So somebody wrote according to the surface area. So somebody said the same, what do you mean by the same? So if you have a 70 kg person and you have 140 kg person should be increased. Yes, it should be increased. That is true. But is there a rough guide on what we should do the, what should we do in these patients? So um in response to Abdullah, uh f um I actually do not know if we have ever considered surface area in patients for the sake of IV fluids. I've never heard of this anywhere in and no guidelines. Um but in burns, we do, we calculate the surface area in burns uh but not in IV fluids. Um So I'm not aware if there is anything regarding this one regarding the water. Roughly speaking, you would never prescribe more than 2 L of fluids or 2.5 L of fluids for any patient, regardless of the indication. If any patient reaches the point where you would need to prescribe more than two. By that time, you would already have to have involved someone more specialist than yourself, whether it's someone more senior than you or the uh um intensive care unit team, which they are more specialized in managing these patients, which this is a scenario you might never face. But it is good to know that after 2 L, it's best to consult someone else. So basically that is the answer to the question. So what's your calculation for the following is different for anyone who is older or more frail and for those who are renal or cardiac impairment and those who are malnourished and at risk of repeating syndrome. So it would be 20 to 25 mL per kg per day instead of the 25 to 30. Ok. So now indications, so can someone list what are the indications for IV fluid prescription? Why do we prescribe IV fluids? So they are broadly categorized into a couple of indications nearby patients. That is true. But if someone is name by mouth might have that would be categorized under something. So what do we call that failure of oral intake? Good. The voice is good. Perfect. Anyone else for gestation? Perfect. Yeah, that is the type of categorization I was looking for. So for cessation is one of them to avoid renal failure. Definitely all these are correct answers. So I'm just gonna go through the uh main reason why we prescribe IV fluids. So the first one would be for resuscitation where IV fluids are the first line and then the other one is gonna be for maintenance. So that is what we prescribe fluids as well. And then the third one will be for replacement and that's where dehydration and the other things come into place. So if you ever decided to give IV fluid, you would need to do the following. For example, for maintenance, you would use the weight that you mentioned. So 25 to 30 mL per kg per day of the following fluid, sodium chloride of 0.18% and 4% glucose with around 27 miol per liter of potassium for day one. That is the ideal fluid for maintenance and mark my words, I'm just gonna say for maintenance. This is not for ation, this is just for maintenance in a patient who is not dehydrated, who is not in fluid overload. There is a patient who are gonna put for, let's say a surgery and it has to be nil by mouth. So that is the ideal food to prescribe for day one. OK. So that's roughly around 2 to 2.5 L in a patient who is 70 K GS which also totally gives them 70 mill more sodium and 70 mill more potassium in 24 hours. So prescribing more than this as you know, it can cause hyponatremia and other issues as well. And the ideal food for maintenance that is the takeaway from the slide is the following 4.18% sodium chloride, 4% glucose with 20 to 30 millimeter of potassium and of course, potassium needs to be um rounded to the nearest value. So if you have, because you don't have 30 miller potassium preparations, you have either 20 or you have 40. So you need to go pick the nearest one. And of course, ideally fluid should be given during the daytime and not during the night time for two reasons. First, the day team are available and they're responsible for the patient. The team is there. Um If any complications happen with fluid you, they can detect it and they are prepared to handle it instead of the night team because in the night team, the worst will be empty. Um No one's gonna be there unless some someone calls for an issue. And the second, we don't want to wake up the patients by just uh um putting tubes and making noises with equipments that we're gonna use just to give them fluid. So, ideally in the daytime. So, um Yep. So I have got more answers to about renal failure, rehydration, dehydration, intraoperative and burning cases. Yep. These are all correct. Um But they are all broad categorized into either resuscitation, maintenance or replacement. So, fluid mismanagement complications, even though our body is excellent at maintaining homeostasis. Even if you prescribe fluids wrong for a couple of days, the body might compensate. But um fluid mismanagement has complications and it is not uh uncommon to face them. You would have volume issues. For example, the patient if prescribed with the wrong type of fluid might become hypovolemic despite prescribing fluids um or might become hypervolemic. And of course, you would have electro disturbance, you would have hypokalemia, hyponatremias, or you have hyperkalemia and hypernatremias. Um of course, hyperchloremia as well. And there was one thing mentioned in the nice guidelines. I don't really remember to be exact but uh a lot of um the fluids as prescribed that was, I think it was two in five or three in five of all. The fluids prescribed has been prescribed by mistake, not by indication, but the choice of fluid was not appropriate for the indication. And that job most often folds, not on the senior staff, but on the junior doctors to prescribe. So when you're making a tool with the senior or with the someone more senior than yourself, all they will tell you is please prescribe IV fluids because the patient needs, they are not gonna tell you about the type of fluid about anything else. So that is why it's very important to that. You are very aware on how to prescribe uh based on guidelines and based on evidence. So before we prescribe any fluid, these are the rough things that we need to know about the body as well. So for example, for a 70 kg man, um you would have 60% of his body weight will be water. These are just gonna be some rough numbers. I'm gonna put a graph afterwards. To make it more easy to imagine. So that is, and two third of this is intracellular of that total water. And then only one third is extracellular, which is 14 L. And in that one third of the extracellular is further divided into two parts. One third is intravascular, which is the blood that we have, which is the what we use for ation. So only one third is intravascular, let's say in the blood, the other two third is interstitial. And we're gonna come to um talk about them all the reason why it is important to know because different IV fluid types fail different compartments depending on the osmotic content of the fluid. So that is why we need to know about the types of IV fluids and how the body is, how the fluid is distributed in the body. So as I mentioned, I'm gonna show you a graph. This is a very nicely done graph. I found it on the internet where you have a distribution of the solace 40% in adults, 40 45% and then 60 or 45% of fluids. And if you see on the orange um or orange rectangle next to the fluids, you have two third is intracellular. So most of her fluid is actually intracellular stored and then you have the one third which is the extracellular and that extracell is divided into 80% interstitial and then 20% in the plasma or let's say one third in the plasma. So now when we prescribe IV fluids, the following things have to be mentioned. So when you prescribe, maybe if you have practice in the UK, you would know that you have to pick on the system um type of IV fluids. But then if they ask you the following questions, the following things to fail. Um So I'm just gonna go through them quickly in case you don't have it, you have to type it in the notes that you wanted the fluid in this way. So for example, you need to type type a fluid, you need to specify I want fluid X or fluid Y and then you want the volume. How much of the fluid do you want to give and then the time to be infused because also that makes a huge difference on how much, how fast you want it to be infused alternatively to time you want to give the rate of flow. Um So whatever you type, the other one is co related. So for example, is this an example, I want um um 0.9% sodium chloride, I want 1 L of this um type of fluid to be given over 10 hours. Alternatively, that is instead of 10 hours, I would say 100 mL per hour. So there is these are some common IV fluids and I'm gonna talk about a couple of them in the next slide. But these are like the top three fluids that you're gonna be prescribing as a junior doctor. You are not gonna be prescribing anything extra outside these unless under supervision. So you have 5% extra, which is the on and you have normal saline or you have the so or they call sodium chloride, you have a Harman or ringer or lactated ringer. These are all the same solution very close to each other. Not that much difference. If you can see that only dextrose has 50 per 50 g of glucose, which is too little as you mentioned, that's 200 calories just to prevent starvation, ketosis. And then the o the only normal saline and Hartman have sodium content 154 and 154 of chloride as well. That's a normal cell line. And then you have the Hartman, which is somehow again close to 131 to 111. You have other electrolytes in Hartmann, which is your potassium, calcium and lactate as well. Potassium is actually a bit too little, which is just 5%. Some people consider Hartman to be a bit more physiologic and in many recent studies and guidelines, they all seem to favor Hartmann over normal line. Um previously in textbooks and everywhere you could see that they are just equivalent. So if you have normal sign or Hartmann, both can be used for um the same purposes. Um But nowadays, they prefer Harman and or lactate uh for the p for many other purposes. So first, let's talk about the crystalloids. For example, you have one of the crystalloids which is 5% glucose or 5% dextrose. So it is isotonic and that means um the content, it contains 50 g per liter of glucose. So that provides a very little energy that is 10% of the daily intake. So we are not giving it for the sake of energy. So the liver rapidly metabolizes all the glucose and leaving only the water. So my question is why is this inflammation significant? Why is it important for you to know that if you give a patient, this thing and the liver rapidly metabolizing glucose, what would happen to the fluid? Now, why it is important to know this theoretical information? Anyone can tell. So I'm just gonna explain it myself. Um So the reason why this is important because after you have the glucose leaving the intravascular space, then you have only water left. And then if you have only water left, you know the rules of osmosis, um that water escapes to an area of higher concentration. So the water rapidly equilibrious throughout all the fluid compartments. Remember the fluid compartments we mentioned. So that means it's not good for fluid resuscitation, as we mentioned, um you have only 1/9 remaining in the intravascular space. We don't for resuscitation purposes, we want something that's going to be remaining in the extravascular um extracellular space inside the blood vessels intravascularly. Um That's why glucose, 5% glucose is not an ideal flu. It's actually useless for fluid resuscitation because it's not gonna remain there. It's gonna just equilibrate and distribute throughout all the other compartments equally. But it is again a good one for maintaining hydration. So that is the indication for prescribing this one. For example, the patient is not dehydrated. It's just no oral intake. I'm afraid that he might be dehydrated or she might be dehydrated. So I'm just gonna need to prescribe and of course, you are all aware that maybe excess of 5% of glucose IV may lead to water overload and hyponatremia. So this has happened before where a patient has been prescribed. Um multiple uh let's say multiple uh uh doses of uh 5% glucose over many days. And we have had the patient eventually developing hyponatremia. So, again, on the crystalloids, we have something called uh again, please about the crystalloid. Someone said about the crystalloids. What was the thing mahmoud be rahal? I don't know. What was the question, what did you want about the crystalloids? So I'm just gonna move on with the slide. I'm gonna come back to the chat later. I'm gonna read you a question and then I'm gonna answer the question. OK. So then again, now we have another crystalloid which is a normal cell line or 0.9% cell line or sodium chloride. So it is again isotonic uh which has the same tonicity as the um uh plasma. So we mentioned it has about the same sodium content as plasma, you know the normal range. Oh it's 135 to 145 to 150. So that has the same amount of sodium in there. And this one equilibrate rapidly throughout the extracellular compartment only. So that means it stays more in the extracellular compartment and it takes longer to reach the intracellular compartment. So it takes a lot of time for it to go into the cells as compared to 5% glucose. That is why this information again is important to know because it would make it appropriate for fluid or cation as it will remain there mostly in the extracellular space. Ok. So it is also good for maintaining hydration and you know that you would have other preparations other than just 0.9% you would have hypertonic and hypotonic healing as well. But almost never, you would be tasked as a junior doctor to prescribe these without someone senior um advising you. So then you have crystalloids and then you have Hartmann, which we just mentioned earlier, one of the slides, it's again an alternative to 91, some considered more physiological uh and some considered superior actually. So it contains the following electrolytes, potassium, sodium and calcium and some bicarbonate and lactate per every liter of fluid. So crystal there is one more crystalloid to mention, which is glucose and sodium chloride, which is called 1/5 normal cell line. It's again isotonic. We mentioned this before. The following thing, if you remember we said this is the ideal fluid for maintenance, especially in day one. So it's roughly the same quantity of sodium required for normal fluid maintenance when given 10 hourly in adults. So for a patient who is undergoing surgery, this is the perfect fluid. So now this is commonly used in pediatric settings. I don't know how many of you have done pediatrics. But when you go um to pediatric practice, you would see most of the fluid is actually glucose align except for ation. So one last crystallic would be hypertonic glucose as you know, it has either 10% or 20 or 50 depending on preparations and its use in hypoglycemia. The only thing we need to know regarding the 50% is that it is irritant to the veins. So we need to care and you have to check infusion sites regularly and you have to flush it with normal after every use. So now I'm gonna show you a table which might look scary, but it's actually not. And it actually gives you a good idea regarding the types of fluid. It's actually a very simple thing on the second column. You have the plasma. So this is the content of the plasma. You have that much sodium and that much chloride and that much potassium. You know, this is the normal ranges that we have and then you have each fluid compared to the plasma. So as you can see, only sodium chloride has roughly the same amount of sodium and chloride as compared to the plasma with a bit more chloride than normal. Um but it has no enough of the electrolyte. Meanwhile, you would have heart and solution contain a little bit of potassium and the sodium content again, and the chloride being more physiologic than the uh the chloride contain, being more physiologic than the sodium chloride because your heta around only 100 10 um of chloride. So this is just an idea, you need to have about all the fluids. So you know what to prescribe at what time. So I'm gonna leave the slides for later. You're gonna take the slides, I'm gonna read them um to compare, I believe if I'm not mistaken, this is also found in nice guidelines IV fluid prescription. So you can find it there as well. So now we're gonna come to colloids, a type of fluid, for example, something like albumin, it has a high osmotic content, which is the same that of plasma. And this is important because if you have something with high osmotic content, it tends to draw water to itself instead of instead of the water equating to the extracellular department, to the extra uh intracellular department quickly. So that means again, it's one of the good fluids for um resus station because it stays in the intravascular space, but it is not good for general hydration because as we mentioned earlier regarding osmosis, so colloid are expensive and it might cause an like reaction. Again, as a junior doctor, you are almost never task of prescribing colloids without someone senior. So in reality, as we mentioned, fluid recess, you might already be aware, it uses a combination of both saline and colloids. Sometimes when cell lines are not effective, you would use colloid to maintain um reust. Now we're gonna come to a very important topic in fluids, which is potassium replacement. So just to ha to have an idea, gastrointestinal fluids are very rich in potassium. So whenever you have any history of diarrhea or vomiting or you have any surgical um surgical um gi tract, for example, um stoma or a fistula, you need to think about potassium replacement. Of course, you will do tests. But as a history you need to know about this and potassium iron can be given inside the following fluids. So it can be given with 5% glucose. It can be given with normal cell line or it can be given with albumin. Some sources say the most superior one would be albumin. It's the perfect vehicle for um giving potassium, especially in hypokalaemic patients. In practice. I have almost never used albumin. I have just used either glucose or saline depending on the patient's condition. But that's what some sources say. So usually you have either 20 millim more preparations or 40 millimoles per liter preparations. So I'm gonna ask you a question. Um, the maximum concentration of potassium that is safe to infuse via a peripheral line. So how much is the maximum concentration of the fluid? I'm gonna wait for the chat to answer. You don't have to be correct. You just have to make a guess based on what you think is the right thing. So someone said so is 0.18% considered as hypotonic. It would be considered hypotonic if there was no glucose in the solution. But overall the 0.18% with the glucose contain overall makes it an isotonic solution. So she mentioned 10, Hannah mentioned 40/60 hours, over six hours. So that's a 22 points mentioned by Hannah. Uh first is the concentration and the other one is the speed of infusion. So 10 another 10. So I'm just talking about the concentration of the back. So how much potassium should be there per liter? And then we're gonna talk about how much the infusion speed should be. So um the correct answer would be 40 miol per liter is the maximum allowed via a peripheral line because if you have higher concentrations, you might cause inflammation of the veins, of course, the smaller the vein, the higher the likelihood. So if you have anything more than 40 it needs to be given via a central venous catheter. And what is the maximum rate of infusion? So some people wrote 100 100 is a bit too much. Um 40 is the maximum you can give. So what is the maximum rate of infusion? How fast are we allowed to give? Very good. We have many people mentioning it's 40. So the maximum rate of infusion would be 20 millimoles per hour in a patient who is cardiac monitored. So that is the maximum you're allowed to give 20 Millo per hour. OK? And if you have any faster rate, it can risk cardiac arrhythmias and ayol. And that's why we always use, we ideally use ECG monitoring for any patient which receives potassium more than 10 mol per hour. So in flu with the restricted patients, you might need higher concentrations or higher rates. For example, in lifethreatening hypokalemia, that is something you have to put in mind. In these cases. Of course, you would need to involve the itu or the parking. So some notes and some scenarios and some concentration regarding each type of fluid that you are gonna give. So for example, in resuscitation and shock, you always rested with the following three. It's a colloid like normal cell line or Hartmann or ring lat via a large vol cannula. You already know this. And if you the patient is in shock, please identify the type of shock. Of course, the third fluid would be a colloid um a crystalloid like the following, for example, sodium with the following with the sodium content of 130 to 150. So what has this content? You would have either no or you have Harman which has this range with a bolus of 500 mL over less than 15 minutes. So that is what I want you to remember for today. Again, the takeaway from this slide would be the following. When you are a patient, it has to be within 15 minutes. That is a bolus of fluid and resuscitation. And if the patient is elderly or heart failure or fluid overload or renal failure, you would give it over the same duration of time, just less. So you would give 250 mL in the elderly and you would consider human albumin solution 4 to 5% for reation only when there is severe sepsis. So up to 2 L of fluid can be given in resuscitation. Anything beyond 2 L warrants that you need to involve someone more senior. And if you have acute blood loss, again, all the following three that we mentioned before are correct, but you would wait for blood to be available whenever blood is available, you would give blood until then you are just giving fluids. So, and if you have poor urine output, normally you would get cold in the middle of the night by the nursing staff um that a patient has low urine output. So you would need to know what is the scientific amount for urine output? What is the scientifically considered low urine output and what to do about it? So, um if anyone can answer, what is the, how much is the normal rate of urine production in a normal adult or in a normal patient? So how much I'm expecting per kg per hour? So somebody mentioned half a milliliter per kg, 25 mil to 30 mil. Is this per per kg or per what? So if you have the unit per kg per hour, that is the best way to know 25 miles. I need to ask again, what is this? 25 mils um 25 MS in how much time or in how much? So fo mentioned 1 mL 0 25 mill per hour. OK. But there is no kg involved. I see. So we're gonna move along. I'm gonna give you the right answer. So that would be what the normal weight would be. 1.5 mL per kg per hour. Sorry for the type Y forgot to type the R and we aim for more than 1 mL per kg per hour. That is the thing. And the minimum allowed is more than 0.5 mL per kg per hour. So these are the numbers 1.5. And so how do you treat if a patient has low urine output? And you suspect it is due to dehydration? So you give a fluid challenge, which is half a liter of normal saline over one hour. OK. Of course, as you mentioned, half of this volume and heart failure, elderly and you recheck the urine output afterwards. So if the patient was not catheterized, what do we do? Anyone tell us if the patient is not catheterized or if the patient was catheterized, what to do? So I'm gonna move over this quickly because I'm sure most of you know it already. So if the patient is not catheterized, you do not try to catheterize the patient just because of that, but you try to exclude retention. So you have the nurses team in the NHS, they are skilled at doing bedside ultrasound. It's a good skill if you can learn as well. Um You just bring the probe and you check the bladder, see if the patient is in retention. So if the patient is in retention, then you would definitely need to catheterize the patient um later on. Not necessarily right away because sometimes with some fluid, you might have urine tension as well improving. So if the patient is catheterized, you would need to first ensure the catheter is not blocked because this has happened before in my personal practice. Not in the NHS though outside, I have seen a patient which was a, which was a known patient with uh uh recurrent DKA um coming to the emergency and was admitted when he came, he had uh ketones, um poor diabetic control and abdominal pain. So he was, of course, he had a catheter, a long term catheter in there. So he was admitted and for the DKA regimen to get all the fluids and everything else. So, while I was trying to examine him as a junior doctor, I just tried to examine the abdomen and I felt when I palpated the suprapubic area, he was tender in there. So I just checked, were you tender in there or it was just like, um, let's say, um, equivocal finding. Um He said, uh no, it was tender. So I checked again, I tried to distract him and I examined him again. He was tender in the suprapubic area. So I felt like maybe the catheter is blocked. That's why he has urine tension and we don't have beds. We didn't have bedside ultrasound at that time. So I just looked at the catheter and the back, I could see a lot of slough of tissue because it was a long term catheter. So what I did, I brought a tummy syringe, which is a 15 mL syringe. I put it in the catheter and I pressed it once I pressed like um 20 mL of air into the uh bladder. The patient had a ah reaction. So he wa he became in a little bit more pain, but then he immediately got relief from the pain. So that means the catheter was blocked and uh uh the patient didn't have to go through the uh DKA pathway. I know this is not scientific way to manage DKA. You would have to have to strictly know how to uh follow the DK A PA. But in area with poor facilities, sometimes you would have to just clinically in some cases where the uh you don't have much facilities, especially in developing countries. Um you would need to do depend on clinical uh scenarios, clinical judgment. And that was the clinical judgment given at the time that because the patient has had 10 previous uh admissions for DKA, he's coming again with blood glucose control and ketonaemia. So likely he is in DKA again, but he didn't, he was just having ketosis and he was uh having a blocked catheter. So again, we're gonna continue with the notes. So as we mentioned before, if you have gi losses, anything you would need to consider giving potassium and the fluid and always think about transpiration losses, which is the insensible losses. We have a lot of these, we lose around 800 mL. It increases in fevers and burns. So a large amount of these can be lost without you or the patient even noticing. And of course, especially burns may require aggressive flu resuscitation. So in heart failure, you already know that as well because we mentioned that IV flus need to be used with care to over overload in liver failure. So there are some notes that patients have a raised total body sodium. So we need to use a su salt poor albumin, which has very little sodium and or blood forestation. So we try to avoid normal cell line for maintenance. And in acute pancreatitis, just like in third space loss, you have to consider lots of fluid being lost in the third space. So you need to aggressive fluid resus and acute pancreatitis as well. So in the elderly, you would need because they are more prone to fluid overload, both for being frail as well as likely they are gonna have multiple comorbidities. So we need to use IV fluids with care. So you give smaller fluid boluses and of course, postoperatively, it's always good to check the intraoperative nodes. Thankfully, in most of the trust that you work in and most of the places that you work in the surgical team already take to takes care of the losses that they have inside the operation and they stabilize the patient before discharge. But it is always good to know what the patient had lost during the operation because if the patient deteriorates again, likely might be deteriorating by losses from the same source that they lost during the operation. So, and in Children, um I don't know if you have done pediatrics or not, but the resuscitation in pediatrics is different. So you use glucose with sodium chloride for fluid maintenance. For resuscitation is sodium chloride or ring lactate. Um um sodium chloride mostly. And for maintenance, you use glucose with sodium chloride. So or let's say glucose saline and the way they calculate it is the 1st 10 kg of the child's weight, you would calculate by giving 100 mL for that 10 kg and then for the 2nd 10 kg, you would give 50 then for the remaining you would use 20 mL per kg and all of it is per 24 hours. That is how you calculate a maintenance fluid in pediatrics. So that is all for the fluids. Um Thank you for your time. If you have any questions, please ask it in the chat. These are my sources. I used Davison's principle on Practice of inter medicine. I used the nice guidelines which is made in 2019 and I highly recommend this link which is present in the guidelines. Look at the algorithm which I'm gonna click. I'm gonna show you um what it is. Um I highly recommend that you have a look because it summarizes whatever we discussed in some beautiful graphs. And then of course, I use the ox handbook series and when I was working in the uh role free, I used the local departmental guidelines and trust guidelines. So these lectures has been uh I have taken some notes from there as well. I don't know if you can see my tab. Yep. So now this is the nice guidelines um algorithm which you're gonna have text explaining as well. But this is the algorithm. It talks about assessment, how you assess a patient. This is the assessment, how you assess a patient. And if the patient needs cessation, this is how you resuscitate and what to do after assess how much to give and what to do. And then afterwards you cal you assess the patient again and see if you need to do stop protein maintenance or not. And then of course, you have the fourth part which is replacement and redistribution, which is over um um issues and um and electrolytes. Of course, hypos and hyper. And then of course, you have the other pages talking about each one of these above again, separately. So you can have a look. It's uh something I highly recommend and of course, I highly recommend that you read the nice guidelines as well. Um This is the end of the session. If anyone has any questions, please go ahead. I am done with today's session. I apologize if my voice was not very clear or if I was a bit fast. So wait a couple of minutes um to see if anyone has any questions to ask. Um if you do have any questions, just please ask in the group chat. OK. So it seems like nobody has any questions. Thank you doctor for such an informative and helpful lecture. Thank you and thank you for attending. It was really, really helpful. Um I'm sure everyone found it really um helpful and thank you for everyone for joining today's session. Um We encourage you to share your feedback by completing the feedback form and which will be sent shortly after today's session. I think we might have a question. All right, f say thank you. Um And lastly just to remind you that our next upcoming event hasn't been put out yet. But um please look on our socials when that will be. Um Thank you all for joining. Bye. Thanks. How everyone take care.