Urology - Water and Electrolytes Flashcards
What are the 5 Rs for IV fluid prescription
Resuscitation
Routine Maintenance
Replacement
Redistribution
Reassessment
What is resuscitation
give IV fluid to patients who are in shock or have hypovolaemia
what is routine
for patients that are nil by mouth or in coma
what is replacement
excessive fluid loss - i.e. vominting, diarrhoes
what is redistribution
Internal fluid loss - pleural effusion, oedema etc, common in sepsis - fluid leak into interstitial compartment
what is reassessment
always reassess to see if its working or if more is needed
when is resuscitation needed
for hypovolaemic and are haemodynamically unstable
what is shock
inadequate perfussion of tissues
what are the signs of clinical shock
Low SBP (<100mmHg) - cool peripheries
Tachycardia (>90bpm) - high or deteriorating EWS
Tachypnoea (>20rpm) - Responce to PLR
Delayed CRT - confusion/decreased LOC
what is the optimal fluid and rate for resuscitation
need sodium to match patient
saline or hartmans (130-154mmol/L)
use bolus doeses - 500mL over 15mins
then further doses of 250-500mL up to 2000mL
what is the difference between hartmans and saline
Hartman’s has potassium 5mmol and bicarb 20mmol. plus others such as calcium and magnesium
what is the difference between crystaloids and colloids
colloids are starch based - more expensive and has shown to be not as good - NO colloids for recuss
what is needed to take in over 24hrs for routine management
Sodium ~1-2 mmol/kg/day
Potassium ~1-2 mmol/kg/day
Chloride ~1-2 mmol/kg/day
Glucose 50-100 g/day (= 200-400 kCal)
Water 25-30 ml/kg/day
fluid volume and rate depends of weight and rate. for Kg of 65-75 what is the volume and rate
2,100mL at 85mL/hr
what is mainly lost in upper GI
tends to be vomiting - very chloride and potassium rich
what is lower GI loss
loss of small K+ and Cl-. therefore hartmans is ok
when do you reasess
after 15mins
24hrs for routine
what si the normal concentration of HAS used in sepsis and resess
4.2%
what in 20% HAS used
paracentisis - large vloume of albumin rich is lost
how much fluid is in 1 packed red cell bag
1 unit is 280mL
what are some serous issues with transfusions
Febrile, Allergic and Hypotensive Reactions
Haemolytic Transfusion Reactions (Acute/Delayed)
Post-Transfusion Purpura (due to thrombocytopaenia)
Transfusion-Associated Circulatory Overload (TACO)
Transfusion-Associated Dyspnoea (TAD)
Transfusion-Related Acute Lung Injury (TRALI)
Transfusion Transmitted Infections
Graft vs. Host Disease
Uncategorised (e.g. necrotising enterocolitis)
what is platelt shelf life and composition
pooled or single donor
shelf life - 5-7 days
how much volume is in Fresh frozen plasma
300mL
what is in cryoprecipitate
Fibrinogen, Factors VIII and XIII, and von Willebrand Factor
what is the east of england major haemorrhage protocol
- Get senior help
- Guidance as to what should make you suspect massive haemorrhage
- Initial resuscitation is still with IV fluids: crystalloid or colloid, it doesn’t matter, bleeding out = death otherwise
- Major Haemorrhage Pack1 = Blood + FFP, Pack 2 = Blood + FFP + Platelets + Cryo
- Stop the bleeding! (= senior help)
what do you give for hyponatraemia
check is symptomatic - confusion etc
treated in ICU
give NaCl slowly
what do you give for diabetes
- Normal saline
- initial bolus of 500ml-1L, then the first hourly bag do not contain KCl
- If BP remains low despite initial boluses escalate immediately
- Every bag after this should have potassium added as long as serum K+ ≤ 5.5:
what do you give for AKI
Sepsis and hypovolaemia – ABCDE care
Toxicity – Drugs, poisons, and iodinated contrast media
Obstruction – Bladder outflow or ureteric, +/- associated infection
Primary Renal Disease – e.g. nephritic and nephrotic syndromes
what % of total body calcium is in bone
99%
what is the noraml serum calcium levels
2.2-2.6mmol/L
what is the corrected serum calcium equation
corrected calcium (mmol/L) = Ca measured (mmol/L) + 0.020 or 0.025 (40 - albumin (g/L)
protein bound calcium is not excreted by the kidneys
true or false
true
what is the normal dietary intake of calcium
700-1000mg
what regulates calcium reabsorbption
PTH
Vitamin D
Calcitonin
what is some of the functions of calcium
bone structure, nerves, woulnd healing, muscle contraction etc
how is calcium regulated by PTH
acts via G protein couped receptor:
stimulate osteoclast
inreases serum calcium
do PTH and calcitonin both have the same effect
PTH and calcitonin have opposite actions
does serum calcium increase or decrease serum calcium
calcitonin reduces serum calcium
what is the chemical name of vit D
25 hydroxylation - 1,25 DHCC
how does liver disease cause reduced vit D
liver makes vit D precurser
what are some causes of hypocalcaemia
hypoparathyroidism, Vit D deficiency, fat embolism, hyperphosphataemia, rhabdomyolysis, pancreatitis, transfusion leading to rapid infusion of albumin
**what are 2 signs of hypocalcaemia
chvostek sign
trousseau sign
what are some signs and symptoms of hypocalcaemia
muscle cramp, seizures, bronchospasms, long QT syndrome, heart failure, cataracts, altered mental status, personality disturbance
what is commonly in exam qusetins
chvostek sign
trousseau sign
what is chvosek sign
tap facial nerve and facial spasm will occur on same side
what is trousseaus sign
what are some causes of hypercalcaemia
maligancy, sarcoidosis, thiazides, renal failure
how does renal failure cause high calcium
increase PTH
how do thiazides cause increased calcium
increases ca reabsorbsion in proximal tubule
forusamide is used for what
loop diuretic - increases calcium secreted - hypercalcaemia
signs and symptoms of hypercalcaemia
muscle shock, fatigue, short QT, pancreatitis, polyuria (DI, ARF, CKD),
management of hypercalcaemia
hydration
lower serum calcium - furousamide
give bisphosphonate
what is normal plasma potassium levels
3.5-5mmol/L
what is potassium used for
cellular membrane potential, acid-base homeostasis, vascular tone, hormone secretion, glucose and insulin metabolism
how does the body regulate potassium
depends on age
90-95% excreted, transcellular potassium shift
how is potassium maintained in homeostasis
what is cellular potassium shift
insulin drives potassium into the cells
what is treatment for high potassium
high potassium in blood treatment is insulin and beta agonism (salbutamol)
where is the majority of potassisum reabsorbed
65-70% at proximal tubule by passive trasport
10-25% in thick ascending limb of Henle - NKCC2 chanel
fine adjustment in collecting tubule
how do new diuretcs act - furosamide
inhibits NKCC2 cjhnel so calcium cannot get into tubule cell
what 3 things cause K to enter cells
concentration gradient - K+ driven to blood
electrical gradient
K+ permeability (how many K+ channels are open)
what are the 4 factors which regulate potassium
aldosterone, plasma K, distal flow rate, distal Na delivery
easiest way to get low potassium
alot of urine
what is the max potassium flow rate
20mmol/hr
NEVER reach this
40mmol in 6-8hrs is normal
what is cardioplegia
stopping the heart intentially - e.g. heart transplant - give a lot of potassium
causes of high potassium
heparin, increased intake, ACE inhibitors, spironalactone, cyclosporin, trimethoprim
management of hyperkalaemia
1st calcium gluconate - to protect heart
insulin and glucose
albuterol
furosemide
sodium bicarbonate
ECG findings of hyperkalaemia
tall T wave
small/absent p wave
ST depression
prolonged QRS
56 years old Mr John is referred by his GP to the clinic after he has found potassium of 6.3 on his routine bloods. He was recently started on Ramipril 5mg by his GP for HTN.
Likely cause
What are the management steps?
ramipril
stop ramipril
treat calcium gluconate and
what is the first line radiological investigation
Ultrasound
safe, cheap and can tell acute, chronic or obstruction
what is the normal size of the kidney
fist - 10-12cm
