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Edit Comment Close Premium member Presentation Transcript A weekend on call : A weekend on call Ward X : Ward X It is your first weekend on call (it is Sunday) You are covering the wards for the surgical team Ward X is a surgical ward but also has medical outliers The Medical House Officer is stuck at a resus call on another ward You agreed earlier to check on her patients on Ward X When you arrive you are asked to prescribe fluids on a number of patients They have all had their urea and electrolytes checked this morning The team covering the ward have left you a crib sheet Mr. Christian Anderson : Mr. Christian Anderson History: 65 year old, anterior resection 2/7 ago Not yet eating, sipping small amounts fluid BP 95 mmHg systolic, pulse 110 bpm Urine output 75 ml over last 4 hours Bloods from earlier that morning: Hb 10.5 (13.5-18.0 male, 11.5 – 16.0 female) WCC 9.3 (4.0 -11.0) Na 145 (133-147) K 4.2 (3.5 – 5.0) Ur 12.1 (2.5 – 6.4) Cr 160 (62-115 male, 53-97 female) Prescribe Mr. Anderson’s fluids for the next 24 hours on a drug chart : Prescribe Mr. Anderson’s fluids for the next 24 hours on a drug chart Discuss with your neighbour A bit more background : A bit more background Mr Anderson’s cannula stopped working overnight and wasn’t replaced until this morning Why are his U+E’s deranged? What symptoms and signs might he display? Symptoms and signs of dehydration : Symptoms and signs of dehydration Coma/confusion Dry mouth Loss of skin turgor Sunken eyes Hypotension Tachycardia Low JVP Management of dehydration : Management of dehydration 1st option: 1 litre 0.9% NaCl over 1 hour 1 litre 0.9% NaCl over 3 hours 1 litre 0.9% NaCl over 6 hourly until stable 2nd option: “Stat” colloid (e.g. Gelofusin) 500 ml Up to 3 bags of 500 ml in 24 hours If not responding then seek senior help These are fluid challenges Physiology revision : Physiology revision Let’s assume we are 64% water …and that the average man weighs 70 kg How many litres of water makes up a man? How is it distributed? Fluid distribution : Fluid distribution COLLOID CRYSTALLOID 5% DEXTROSE What volume stays in theblood vessels? : What volume stays in theblood vessels? Of 1 litre of 5 % dextrose? 111 ml Of 1 litre of Hartmann’s or 0.9% NaCl? 333 ml Of 1 litre of Gelofusin? 1000 ml But that’s just fluid replacement… : But that’s just fluid replacement… What about “maintenance fluids”? Why can’t you give sodium chloride continuously? Basic daily requirements : Basic daily requirements Sodium – 2 mg/kg/day Potassium – 1 mg/kg/day Water: Depends on weight and fever No fever Fever < 60 kg 2L 2.5L 60-80kg 2.5L 3.0L > 80kg 3.0L 3.5L So for your 70 kgsurgical patient… : So for your 70 kgsurgical patient… Approx 140 mmol sodium Approx 70 mmol potassium 3 litres or so of water You could look at bags of fluid and come up with a combination… 1 litre of different intravenous fluids : 1 litre of different intravenous fluids 0.9% NaCl +/- 20-40 mmol KCl “normal saline” 154 mmol Na+ 154 mmol Cl- 5% glucose +/- 20-40 mmol KCl “dextrose” 50g of glucose Hartmann’s Solution “Dex/saline” 131 mmol Na+ 40g glucose 111 mmol Cl- 30.8 mmol Na+ 29 mmol lactate 30.8 mmol Cl- 5 mmol K+ 1 mmol Ca+ Common solution : Common solution 1 litre 0.9% NaCl 2 litres 5% glucose Potassium in every other bag (40 mmol & 20 mmol) Monitor U+E’s daily or every other day A few other hints : A few other hints Don’t give potassium containing fluids too quickly If potassium not known don’t give it until it’s known Don’t give normal saline continuously – to avoid hyperchloraemic acidosis Prescribe enough fluids to last overnight Be guided by clinical picture Careful of overloading older patients Knowing all that, would you change your prescription? : Knowing all that, would you change your prescription? Make the changes on your drug chart? Any questions at this point? : Any questions at this point? A few more electrolyte problems : A few more electrolyte problems Mr. Eugene Benedict : Mr. Eugene Benedict History: 35 year old male Total colectomy for ulcerative colitis 1 week ago Patient nauseous for last 2 days High output iliostomy Vital signs stable Slide 21: Mr. Benedict’s blood results: Hb 12.2 (13.5-18.0 male, 11.5 – 16.0 female) WCC 8.5 (4.0 -11.0) Na 134 (133-147) K 2.9 (3.5 – 5.0) Ur 7.0 (2.5 – 6.4) Cr 120 (62-115 male, 53-97 female) Prescribe the fluids Mr. Benedict needs for the next 24 hours on a drug chart : Prescribe the fluids Mr. Benedict needs for the next 24 hours on a drug chart Treatment of hypokalamia : Treatment of hypokalamia Oral potassium: E.g. Sando-K, 2 tablets TDS for 3 days Each tablet has 12 mmol K+ Tastes disgusting and causes nausea IV potassium: Crystalloid comes with 20 mmol and 40 mmol potassium Identify and treat underlying cause Difficult to estimate deficit so monitor levels regularly When to use which… : When to use which… K+ 3.0 to 3.5: Sando-K 2 tablets TDS until normalises K+ <3.0 and asymptomatic: Sando K 2 tablets QDS Daily K+ monitoring K+ <3.0 and symptomatic or <2.5 (asymptomatic): 20mmol KCl in 500 ml 0.9% NaCl over 2 hours Continuous ECG Senior help Any lower – contact critical care/ITU What are the causes of hypokalaemia? : What are the causes of hypokalaemia? Hypokalaemia : Hypokalaemia Spurious – blood from drip arm Renal: Diuretics Magnesium deficiency Mineralocorticoid excess GI fluid loss: Diarrhoea/stoma output Vomiting Intracellular shifts: Insulin Salbutamol Theophylline Signs and symptoms : Signs and symptoms Often asymptomatic Neuromuscular – weakness, ileus ECG changes : flattening of T waves ST depression Arrhythmias Metabolic acidosis (increased HCO3) What else should you do in hypokalaemia? : What else should you do in hypokalaemia? Investigations : Investigations Immediate: ECG Repeat sample – venous blood gas and lab sample – will also give bicarbonate FBC, Glucose Review medications - digoxin Also consider: Urine K+ if site of loss not obvious Mg++ levels Don’t forget to treat the underlying cause! : Don’t forget to treat the underlying cause! Any questions or comments? The nurses ask you to take a “quick look” at a medical outlier : The nurses ask you to take a “quick look” at a medical outlier They have just done some observations on her Mrs. Veronica Lavender : Mrs. Veronica Lavender History: 86 year old medical outlier Admitted over night with decreased oral intake over preceding 10 days Dementia - non-communicative Also has severe Parkinsonianism Nil by mouth as awaiting swallow assessment Has 0.9% saline started in A+E running BP 100/60, Pulse 120, apyrexial, RR 18 Slide 33: Bloods: Hb 12.1(13.5-18.0 male, 11.5 – 16.0 female) WCC 5.2 (4.0 -11.0) Na 155 (133-147) K 4.8 (3.5 – 5.0) Ur 12 (2.5 – 6.4) Cr 150 (62-115 male, 53-97 female) Prescribe her fluids for the next 24 hours on a drug chart : Prescribe her fluids for the next 24 hours on a drug chart Treatment of Hypernatraemia : Treatment of Hypernatraemia Depends on whether they are dehydrated or not Usually they are! Correct the hypovolaemia 1st Correct the hypernatraemia with 5% glucose or oral fluids if possible Monitor Na+ especially if symptomatic Don’t correct hypernatraemia too quickly: Don’t bring it down by more than 10 mmol/l in 24 hours Causes demyelination What are the causes of hypernatraemia? : What are the causes of hypernatraemia? Causes of hypernatraemia : Causes of hypernatraemia Loss of water in excess of salt: Osmotic diuresis Excessive water loss Decreased water intake Diabetes insipidus Excessive salt administration Signs and symptoms : Signs and symptoms Dehydration/hypovolaemia CNS symptoms: Lethargy Confusion Management of hypernatraemia : Management of hypernatraemia Assess for dehydration Review fluid balance and therapy Check glucose Consider checking urine U+E’s and osmolarity (diabetes insipidus) Any questions or comments about hypernatraemia? : Any questions or comments about hypernatraemia? Now time for small groups The next patient you are asked to see is a vascular patient : The next patient you are asked to see is a vascular patient His results have been phoned to the ward by the laboratory staff. The nurse is worried… Mr. Francis Arthurs : Mr. Francis Arthurs History: 63 year old male with 2 previous MIs Had varicose veins stripping on Friday Past medical history of heart failure Staying in over weekend, because of some oozing from wounds Written up for spironolactone, perindopril and co-amilofruse Has also been prescribed diclofenac for pain Slide 43: Bloods: Hb 14.2 (13.5-18.0 male, 11.5 – 16.0 female) WCC 10.3 (4.0 -11.0) Na 140 (133-147) K 6.1 (3.5 – 5.0) Ur 7.0 (2.5 – 6.4) Cr 112 (62-115 male, 53-97 female) Prescribe Mr. Arthurs’ treatment for the next 24 hours on a drug chart : Prescribe Mr. Arthurs’ treatment for the next 24 hours on a drug chart This could be fluids or changes to his medication 2 main issues : 2 main issues NSAID’s: Contraindicated in heart failure Cause fluid retention and precipitate cardiac events Can also cause renal failure Need to be stopped in this case Hyperkalaemia Immediate management of hyperkalaemia : Immediate management of hyperkalaemia Stop offending medication: K+ sparing diuretics ACE inhibitors NSAID’s NG feeds ECG - to look for effects Repeat bloods: Serum and blood gas FBC and glucose Monitor urine output What are the causes of a high potassium result? : What are the causes of a high potassium result? Causes of hyperkalaemia : Causes of hyperkalaemia Spurious: EDTA contamination Clotting Haemolysis Delayed processing Failure of excretion: Renal failure Mineralocorticoid deficiency (Addison’s) Drugs Massive cell damage (e.g. tumour lysis) What are the ECG changes seen in hyperkalaemia? : What are the ECG changes seen in hyperkalaemia? ECG in hyperkalaemia : ECG in hyperkalaemia Tenting of T-waves Small/absent p waves Widening of QRS complexes Other signs and symptoms… : Other signs and symptoms… May be none May feel unwell and lethargic Neuromuscular symptoms Sudden cardiac arrest How do you bring down the potassium level? : How do you bring down the potassium level? Depends on level & ECG changes : Depends on level & ECG changes Identify and correct cause Step1: Glucose-insulin infusion Prescribe this on your drug chart Step 2: Add in calcium gluconate (cardioprotective) Prescribe this on your drug chart Step 3: Haemodialysis Glucose-insulin infusion : Glucose-insulin infusion 10 units of Actrapid insulin Diluted in 50 ml 50% glucose Give into large vein/central line Give over 10 minutes Then 5% glucose 1000ml over 12 hours No more insulin unless glucose >10 Calcium gluconate : Calcium gluconate 10ml of 10% calcium gluconate Give over 5 minutes: Large vein ECG monitoring Further management : Further management Check U+E’s and glucose every 2 hours until K+ stable and below 6.0 Consider referral to renal team How will you stop Mr. Arthurs from going into heart failure? : How will you stop Mr. Arthurs from going into heart failure? Furosemide Monitor with daily weights Any questions about hyperkalaemia? : Any questions about hyperkalaemia? Please return to the main group The nurses have just found another medical patient for you : The nurses have just found another medical patient for you They are worried about his respiratory rate Mr. Fergus Small : Mr. Fergus Small History: 80 year old, lives in warden controlled flat Admitted with collapse Has not yet had a chest X-ray On diuretics (furosemide), aspirin and not much else BP 88/50, pulse 115, RR 24 Slide 61: Bloods on admission (done in A+E): Hb awaited (13.5-18.0 male, 11.5 – 16.0 female) WCC awaited (4.0 -11.0) Na 120 (133-147) K 3.7 (3.5 – 5.0) Ur 9.0 (2.5 – 6.4) Cr 140 (62-115 male, 53-97 female) What are the main differentials? : What are the main differentials? Mr. Small – key points : Mr. Small – key points Collapse Low blood pressure On diuretics Low sodium Dehydration Renal failure ?acute WCC and CXR awaited Differential : Differential Collapse secondary to hyponatraemia secondary to diuretics Pneumonia causing SIADH, exacerbated by diuretics Dehydration would be caused by both situations You need to examine him and also CXR, FBC (and CRP).. Further details : Further details Chest sounds clear to you He’s in a bit of pain where he fell on his side (but nothing appears broken) He has a chest X-ray It’s clear His FBC comes back: FBC 12.5 WCC 7.5 Prescribe Mr. Small’s fluids for the next 24 hours on a drug chart : Prescribe Mr. Small’s fluids for the next 24 hours on a drug chart Hyponatraemia : Hyponatraemia In this case: Treat dehydration (underlying cause) Use 0.9% normal saline and review regularly But be careful in heart failure!!! Stop diuretic and monitor daily weights What are the features of fluid overload? : What are the features of fluid overload? Fluid overload : Fluid overload Raised JVP Shortness of breath Orthopnea Peripheral oedema Check sacrum if in bed PND Reduced exercise tolerance Ascities CXR signs: Upper lobe diversion Blunted CP angles Pleural effusions Kerly B lines Cardiomegaly What are the causes of hyponatraemia? : What are the causes of hyponatraemia? Hyponatraemia and dehydration : Hyponatraemia and dehydration Diuretics Osmotic diuretics Addison’s disease Renal tubular acidosis GI loss 3rd space loss Hyponatraemia and normovolaemia : Hyponatraemia and normovolaemia Blood from drip arm Excess water intake/administration Polydispsia SIADH: Drugs (diuretics) Tumours Pseudohyponatraemia (rare) Hyponatraemia and oedema : Hyponatraemia and oedema Cardiac failure Hepatic failure Nephrotic syndrome Renal failure See guidelines for treatment of different types of hyponatraemia : See guidelines for treatment of different types of hyponatraemia But in summary… If Oedematous… : If Oedematous… restrict sodium and fluid intake furosemide in cardiac failure correct hypokalaemia avoid diuretics in hepatic failure If Normovolaemic… : If Normovolaemic… If UOsm<SOsm likely acute onset due to excess IVI or polydipsia stop IVI or fluid intake If UOsm>SOsm likely to be SIADH Fluid restriction Senior Advice Don’t increase serum Na+ too quickly Causes of SIADH : Causes of SIADH Respiratory Problems eg. Pneumonia CNS disorders Cancers Drugs Commonly diuretics & carbamazepine If Dehydrated… : If Dehydrated… Measure urinary Na+ If >20 renal loss eg. Diuretics, osmotic diuresis, renal tubular disease, Addisons If <20 GI loss, 3rd space losses, excessive sweating, poor intake rehydrate Signs and symptoms of hyponatraemia : Signs and symptoms of hyponatraemia Nausea Cramps Confusion Seizures May be asymptomatic Further investigations : Further investigations Recheck U+E’s Check glucose Urine sodium Plasma proteins Watch for fluid overload!!! Any questions about hyponatraemia? : Any questions about hyponatraemia? Key Points for Hyponatraemia : Key Points for Hyponatraemia Is it a real result? If in doubt recheck with venous blood gas Assess fluid status Look at drugs esp. diuretics Check for oedema If cause not obvious check urinary sodium Don’t correct sodium too quickly, get senior advice! You think that you have done all the jobs on the ward… : You think that you have done all the jobs on the ward… But then, the staff nurse calls … “Just before you go doctor, can you write up a sliding scale and fluids” Mr. Robert Evans : Mr. Robert Evans History: Type I Diabetic Preadmission for elective surgery tomorrow Bloods: normal Prescribe Mr. Evans fluids and insulin for the next 24 hours on a drug chart : Prescribe Mr. Evans fluids and insulin for the next 24 hours on a drug chart Insulin sliding scale : Insulin sliding scale Varies from hospital to hospital Required when diabetic patients are not eating or glucose levels are unstable Separate sheet from drug chart, or a sticker Subcutaneous (in some hospitals) and IV scales BM range and dose Don’t forget to prescribe fluids: If BM >12 – 0.9% saline If BM <12 – 5% dextrose Sliding scale example – i/v for Type I : Sliding scale example – i/v for Type I Standard Insulin sliding scale regimen (Always use soluble Insulin 50 iu in 50 mls of 0.9% normal saline in a pump). Blood Glucose Range Insulin Dose (units per hour) < 4 mmols/L 0.5 unit (0 for Type II) 4.1 – 7 mmols/L 1.0 unit 7.1 – 11 mmols/L 2 units 11.1 – 15 mmols/L 3 units 15.1 – 20 mmols/L 4 units > 20 mmol/L 6 units “Unfortunately, doctor, none of the nurses are signed off for cannula insertion…” : “Unfortunately, doctor, none of the nurses are signed off for cannula insertion…” Time for more small group work, to keep you on your toes… Before you insert cannulae – stop and think… : Before you insert cannulae – stop and think… If asked to put in a cannula, what questions should you ask yourself? To cannulate or not : To cannulate or not Is it really needed? Is it for fluids or drugs? Can the patient drink? Do they need to be nil by mouth? Can antibiotics be converted to oral? Is the patient pulling cannulae out repeatedly? If so, would subcutaneous fluids be better? What size cannula is needed? Subcutaneous fluids : Subcutaneous fluids What are the benefits of these? Not as painful Can be sited by nurses Can be sited on shoulder Can give about 2 litres fluid/day Drawbacks? Can’t replace electrolytes Can only be used as maintenance Variable absorption Explain to Mr. Evans about having a cannula : Explain to Mr. Evans about having a cannula Volunteer please!!! Explanation : A cannula is a plastic tube that sits in your vein It is put in with a needle, but the needle doesn’t stay in It should feel a bit like having a blood test It saves us having to give you injections over and over Be sure to tell the nursing staff if it gets painful or inflamed Be careful when getting (un)dressed Don’t forget why it is needed… Explanation Cannula checklist : Cannula checklist Preparation of the skin Appropriate site Gloves worn Sterile technique Cannula inserted correctly so that it functions Cannula flushed with saline Cannula fixed and dated correctly Documentation completed correctly Any questions or comments? : Any questions or comments? You should be able to answer these questions now … : You should be able to answer these questions now … What quantities of water and electrolytes are needed for short-term daily fluid balance? What are the causes and nature of perioperative fluid losses? What fluids should be given after surgery? What are the fluid requirements in relation to body weight? What is the composition of fluids that should be used? How should one assess the adequacy of therapy? You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.