U+E

• Symptoms of Hyponatraemia

  • Level of consciousness altered
  • Orthostatic hypotension
  • Weak muscles
  • Seizures
  • Osmolality low (serum)
  • Diarrhoea
  • Increased ICP
  • Urine osmolality high
  • More bowel sounds/stomach cramping
• Magnesium levels

  • Eliminated in the kidney. Reduced levels with: Diuretics, Liver disease, Diarrhoea. Raised levels: (information missing)
• Signs and symptoms of hypercalcaemia

  • Bone pain
  • Arrhythmias, abdominal pain
  • Cardiac arrest, constipation
  • Kidney stones
  • Muscle weakness
  • Excessive urination
• Types of clinical tests

  • Blood tests: U&E’s, FBC, LFTs, Coagulation, Thyroid function, Calcium, Magnesium, Phosphate, Glucose
  • Urine samples
• Calcium levels

  • Reduced levels associated with: Renal failure, Raised phosphate levels, Hypoparathyroidism, Low magnesium levels, Deficiency/malabsorption
  • Raised levels (>2.65mmol/l): Can be a medical emergency if >3.75, at risk of M.I. 90% of cases are due to malignancy or hyperparathyroidism, Hyperthyroidism, Dehydration. Manage with fluids initially, if no response IV bisphosphonates
• Factors that may impact the results obtained in clinical tests
• Factors affecting test results

  • How specimens are collected, transported, stored and processed
  • When the sample was taken
  • Patient age
  • Gender
  • Nutrition
  • Sitting/standing
• Management of hyperkalaemia with a patient having a potassium level of 5.6 mmol/L
• Most likely cause of electrolyte imbalance in a 78-year-old patient with tiredness, muscle weakness, leg cramps, and increased urination
• Steps in Hospital Management of Hyperkalaemia

  • Step 1: Protect the heart
  • Step 2: Shift potassium into cells
  • Step 3: Remove potassium from the body
  • Step 4: Monitoring
  • Step 5: Prevention
• Clinical tests

  • Urea and Electrolytes
  • Potassium
• Symptoms of Hypokalaemia

  • Lethargic
  • Low, shallow respirations...failure
  • Lethal cardiac dysrhythmias (weak pulse)
  • Lots of urine (frequent and large volume)
  • Leg cramps
  • Limp (weak) muscles
  • Low blood pressure (severe)
• Symptoms of electrolyte imbalances

  • Bone pain
  • Arrhythmias, abdominal pain
  • Cardiac arrest, constipation
  • Kidney stones
  • Muscle weakness
  • Excessive urination
• Reasons why clinical tests are useful

  • Screen for possible disease
  • Aid diagnosis - Confirm, Support
  • Assess disease severity - Monitor, Follow disease process
  • Aid choice of drug treatment - Doses
  • Monitor response to treatment - Successful, Adverse effects
• Factors affecting test results

  1. How specimens are collected, transported, stored, and processed

  2. When the sample was taken

  3. Patient age

  4. Gender

  5. Nutrition

  6. Sitting/standing
• Magnesium elimination

  1. Occurs in the kidney

  2. Reduced levels with diuretics, liver disease, diarrhoea

  3. Raised levels with renal impairment

  4. Magnesium helps transport calcium and potassium ions in and out of cells
• Information about Potassium Binders
• Most likely electrolyte imbalance in a 78-year-old patient with tiredness, muscle weakness, leg cramps, and increased urination
• Symptoms of Hyperkalaemia

  • Muscle weakness
  • Urine output little or none (renal failure)
  • Respiratory failure (due to muscle weakness)
  • Decreased cardiac contractility (weak pulse/low HR)
  • Early: muscle twitches/cramps
  • Rhythm changes: Tall peaked T waves, prolonged PR interval
• Criteria for using Potassium Binders

  • Had an acute episode of hyperkalaemia between 6.0-6.4 mmol/L
  • There is a clinical case to restart withheld RAASi therapy at a lower dose once resolved
  • Potassium on repeat testing is between 5.5-6.4 mmol/L
• Haematological Laboratory Tests

  • Full Blood Count (FBC)
  • Haemoglobin (Hb)
  • RBC
  • HCT
  • MCV
  • MCH
  • MCHC
• Monitoring potassium levels

  Following initiation/dose changes check potassium 1-2 weeks after: If <4mmol/L, reduce dose of binder; If 4-5.3mmol/L, continue; If >5.3mmol/L, increase dose of binder. Once stable, monitor at least monthly
• Hyperkalaemia Hospital Management

  1. Step 1: Protect the heart

  2. Step 2: Shift potassium into cells

  3. Step 3: Remove potassium from the body

  4. Step 4: Monitoring

  5. Step 5: Prevention
• RBC carries haemoglobin in the blood and is the most abundant cell in the blood. HCT indicates the proportion of RBC that make up the blood pool. MCV is the average size of the RBC. MCH is the average amount of Hb in a RBC. MCHC is the average concentration of Hb inside an average RBC
• SZC dose: Initially 10g TDS, up to 72 hours, maintenance 5g once daily adjusted according to potassium levels, may range from 5g on alternate days to 10g once daily
• Deprescribing criteria

  Stop if potassium <5mmol/L without ongoing agents acting on the RAS
• Patiromer calcium dose: Initially 8.4g once daily, titrate in doses of 8.4g at intervals of at least 1 week, maximum dose 25.2g per day (8.4g TDS), initiated in secondary care or by a specialist, can be used safely in primary care with prescribing transferred to the GP with clear instructions
• Adherence considerations

  If adherence is an issue, suitability of the treatment option needs to be reconsidered
• Haemoglobin (Hb) performs the main functions of the red blood cells: Carries oxygen to the tissues, returns CO2 from tissues. A low Hb level indicates that the patient is anaemic. To determine the cause of anaemia, we need to look at the MCV, HCT, RBC
• MCV

  Average size of the RBC
• Microcytic anaemia is characterized by low RBC, Haemoglobin (Hb), Haematocrit (HCT), and Mean Cell Volume (MCV)
• B12 deficiency

  Replenish stores with hydroxocobalamin (B12): 1mg IM alternate days for 2 weeks. Maintenance 1mg IM every 3 months FOR LIFE
• A raised MCV with a low haemoglobin suggests vitamin B12 or folate deficiency, these should therefore be tested
• Management of iron deficiency

  1. Oral: Iron supplement e.g., ferrous sulphate 200mg OD (65mg elemental iron). Continue until normal levels are reached and then for 3 months thereafter (NICE)

  2. Parenteral: in presence of malabsorption e.g., Ferinject®, Cosmofer®
• MCHC

  Average concentration of Hb inside an average sized cell
• Other types of anaemias

  • Aplastic anaemia (Due to aplasia of the bone marrow, Defined as pancytopenia)
  • Haemolytic anaemia (Accelerated destruction of red blood cells)
  • Anaemia due to acute haemorrhage (E.g., trauma, GI bleed, surgery)
  • Anaemia due to chronic disease
• Causes of iron-deficiency anaemia

  • Inadequate diet
  • Deficient absorption
  • Blood loss (Menorrhagia, GI bleeding e.g., from oesophagitis, peptic ulcer, carcinoma, colitis, diverticulitis or haemorrhoids)
• HCT

  Indicates the proportion of RBC that make up the blood pool
• Folate deficiency

  Oral folic acid 5mg daily
• In macrocytic anaemia, the mean cell volume is raised