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AimsRecognising common blood abnormalities
including;Deranged potassium, sodium, phosphate,
magnesium and haemoglobin
Learn how to manage these in an acute setting
Understand importance of the clinical picture, not just the numbers
Hopefully feel a little less scared about Wednesday!
Case 1Mrs A is an 83 yr old lady on the surgical ward
admitted today with an incarcerated inguinal hernia
You check the bloods for Mrs A at 4.30pm, just as you are about to leave
Unfortunately her blood results are as follows;Hb110, WBC 12, CRP 25, Na 138, K+6.5, Ur 6,
Creat 102
How are you going to manage this lady?
High potassium (hyperkalaemia)
Normal range 3.5 – 5.5
>5.5mmol considered raised
Threshold for treatment is 6.0 or ECG changes/symptoms
Can be caused by AKI (or ESRF)
ECG changes in hyperkalaemia:Low, flat p wavesBroad, bizarre QRSSlurring into the ST segmentTall tented T waves
Management Acute treatment:
ECG Stop any antagonistic drugs 10mls 10% Calcium Gluconate (cardiac monitoring) 10 units actrapid insulin in 50mls of 50% dextrose(can do
20%) dextrose over 30 mins Salbutamol 5mg nebs Repeat K+ 4 hours post infusion
Longer-term treatmentFind causeCalcium resonium 15g TDS
Case 275 yr old lady, Mrs B, has been on the medical
ward with a LRTI for a few days
You check her blood results at 6pm, just as you are about to leave and they are as follows (sorry!);Hb 120, WBC 6, CRP16, Na 136, K+2.0, Urea 4.3,
Creat 99
How would you manage this lady?
Low potassium (hypokalaemia)
• Lethargy• Cardiac arrhythmias
• Management;• Depends on level• Find the cause• <3 IV replacement – max
80mmol KCl per day via peripheral line• 40mmol in 5%
Dextrose or 0.9% N Saline over 4-12 hours
• >3 oral – 2 tablets Sando-K TDS for 3 days only (monitor K+)
You are an excellent F1 doctor and have been diligently replacing Mrs B’s potassium inravenously for the past two days
You check her blood results today at 7pm, ad are certain that they will have improved;Hb 120, WBC 5, CRP10, Na 135, K+1.9, Urea 4.0, Creat
97
Uh oh!
Why hasn’t Mrs B’s potassium improved? What else do you need to check?
Low magnesium (hypomagnesaemia)
Can be due to poor diet, diuretics (loop), refeeding syndrome
Can lead to arrhythmias!
Replace as per trust guidelines
Either:Magnesium Glycerophosphate 2 tabs (8mmol) TDS
for 3 daysOr 20mmols MgSO4 in 500/1000ml N.Saline/5%
dextrose over 4-8 hours
Low phosphate (hypophosphataemia)
Can be due to poor diet, GI losses (diarrhoea)
Beware REFEEDING SYNDROME If patient not eaten for 5/7 at risk When fed, serum levels of Ca, Mg, PO4, K all plummet Low PO4 can lead to seizures
See Intranet guidelines for replacement regimes: Phosphate Sandoz 2 tabs TDS for 3 days Or if <0.5 – Phosphate polyfusor as per guidelines
Rate of 9mmol over 12 hours500ml bag contains 100mmol phosphateSo give 100ml over 24 hours – will deliver 20mmol phosphate
(must discard rest of bag)
Indications for haemofiltration
Persistent hyperkalaemia, resistant to treatment
Acidosis, resistant to treatment
Pulmonary oedema, resistant to treatment
Low sodium (hyponatraemia)
<135mmol
Very common – causes are many, commonest are drugs! PPIs, Diuretics, SSRIs
In reality unlikely to cause problems unless < 120-125
Can cause seizures
If <135 & >125 and stable can usually just observe
Trust guideline on hyponatraemia is good
Treatment depends on cause (hypovolaemic, euvolaemic, hypervolaemic)
Management;Find the cause;Send urine osmolality and serum osmolality, urine
sodium and serum sodiumCheck drug kardex for culprit drugsCan fluid restrict to 1.5L per day (not if
hypovolaemic!)
High sodium (hypernatraemia)
>145mmol
Usually due to dehydration, or too much 0.9% Saline!
Treat with IVI (Dextrose, not Hartmann’s or 0.9% Saline!!)
If the patient is well, ask them to drink more!
Recheck U&E’s
Low haemoglobin (anaemia)
With low MCV
With normal MCV
With high MCV
Consider the cause Is the patient acutely
bleeding? Occult haemorrhage? Post-op? Chronic
disease/malignancy? Renal failure?
Management;If Hb <80 or patient is
symptomatic then usually a role for transfusion – discuss with senior as some clinicians may wish for higher levels in specific situations
Transfusion written as RBC to be given over 2-3 hours (in stable patients)
If acutely bleeding and massive haemorrhage suspected then activate MHP by calling 2222
High WBC (leucocytosis)Usually a sign of infection
Elderly or immunosuppressed (eg. steroids or transplant patients) – dampened immune response so may not mount a leucocytosis in response to sepsis
Remember SIRS – WBC <4 or >12
N.B. Patients on steroids may have a neutrophilia
Low WBC (neutropenia) Can be caused by sepsis (e.g. atypical infections or elderly)
Or by bone marrow suppression e.g. post chemo, or bone marrow failure e.g. MDS
Neutropenia <1.0 x109
If <1.0 and signs of SIRS/Sepsis – follow trust neutropenic sepsis guidelines Side room Cultures and CXR IV Abx ( as per guidelines) IVI
Discuss with haematology
Raised CRPAcute phase inflammatory
marker
24 hour lag
Can be raised in inflammation, infection, malignancy
Will be raised post-operatively
Management; Search for cause/source Are there obvious signs of
infection eg. urine, chest? If signs of SIRS/sepsis
then do a septic screen – CXR, urine dip, ABG, blood cultures, bloods, if indicated: wound, line, drain cultures
If suspected source of infection then treat accordingly – sepsis six
Do not treat purely on basis of the numbers
SIRS and Sepsis SIRS criteria;
Temperature <36 or >38 HR >90 bpm RR >20 or PaCO2 >4.3kPa WBC <4 or >11
Sepsis = SIRS + source of infection/suspected source
Septic shock = Sepsis + organ hypoperfusion leading to organ dysfunction
Low platelets (thrombocytopaenia)
Sepsis
Post-chemotherapy
Coagulopathy
Drugs
LMWH-induced thrombocytopaenia
HITT syndrome
If <80 can’t have procedures e.g. liver biopsy or surgery
If <50 hold LMWH
Management;May need discussion
with haematologyMay require platelets
prior to procedure
Raised platelets (thrombocytosis)
Usually a reactive finding
Can be raised due to infection, inflammation, surgery, hyposplenism, splenectomy
If persistently raised platelets with no explanation – discuss with haematology re: further investigations ? myelodysplastic syndrome eg. polycythaemia rubra vera, CML
Deranged clotting factorsDIC – low fibrinogen, raised PT, INR, low platelets
Raised INR;Stop warfarin (if on warfarin)Look for cause (if not on warfarin)Trust guidelines for management If INR raised but no acute bleeding – Vitamin K 5mg
PO, or Vitamin K 5mg IV – depends on level, and whether operation is likely to take place
If acutely bleeding and INR >8 then prothrombin complex (octaplex) needs discussion with haematology first
LFT’s made easy… Standard LFTs: Albumin, Bilirubin, ALT/AST, ALP/GGT
Raised bilirubin = Jaundiced (>50)
Pre-hepatic (unconjugated) e.g. haemolysis, Gilbert’s syndrome
Hepatic (mixed) e.g. viral hepatitis, drugs, ischaemia
Post hepatic/ obstructive (conjugated) – dark urine, pale stools
ALP/GGT are markers of obstructive jaundice i.e. gallstone in CBD
ALT/AST are makers of hepatic damage i.e. viral hepatitis
If ALP/GGT rise is > than ALT/AST it’s a post hepatic problem
If ALT/AST rise is >ALP/GGT it’s a hepatic problem
Hepatitis screenSerology – Hep B, Hep C, (Hep A and E), HIV
Autoantibodies – AMA, SMA, ANCA, LKM
Iron studies – Ferritin, Serum Iron, TIBC, Transferrin sats
Others – A1AT genotype, Caeruloplasmin & Copper levels
Don’t forget to USS the liver
P.S. You don’t need to get a gastro review before doing these!
Low albumin (hypoalbuminaemia)
Negative phase inflammatory marker In sepsis it will drop – this doesn’t mean they’re
malnourished
Can be low as a marker of malnutrition if chronic (but Anorexics often have normal levels)
When <20-24 can develop oedema
No role for IV albumin replacement!!
Low calcium (hypocalcaemia)
Can occur due to drugs (diuretics), poor diet, refeeding syndrome
<2.2 (adjusted calcium)
Symptoms includes cramps and tetany
Management;ECGAdCal1-2 tabs ODor IV replacement
10mls 10% Calcium gluconate
Raised calcium (hypercalcaemia)
Can occur in renal failure, dehydration and malignancy (particularly breast)
Stones, bones, moans, psychological groansRenal tract calculiBone pain / fracturesConstipationDepression
Management;ECG IV fluid replacementBisphosphonates eg.
Pamidronate – only if calcium >3
Discuss with renal team if associated renal failure
Case 3 78 yr old man, Mr C
PC – ‘Off legs’
HPC – Care staff state he has been unwell for past few days in the care home. No appetite. Unable to mobilise today. Seems more confused
PMH – IHD, MI x 3 previously, previous TIA’s, prostate cancer and chronic back pain
Allergies – Nil
Medications – Ramipril, spironolactone, omeprazole, MST (recently started by pain team)
Social – Lives in a care home, usually lucid and able to undertake personal care for himself
O/E:Unkempt and strong smell of urineTemp 38.6, BP 130/80, HR 68bpm, regular, RR 16,
02 sats 98% on air Appears very confused – believes he is at his
marital home, and that the year is 1972Not oriented in time/place/personHS 1+11+0Chest - Reduced air entry at left baseAbdomen soft, non-tender
InvestigationsBedside
Urine dip – positive for leucocytes, nitrites and protein
ECG- no acute ischaemic changes
BloodsHb 120, WBC 16, Ur 8.9, Creat 109, K+4, Na 125,
CRP 40, INR 1
ImagingCXR- cardiomegaly, shadowing at left base
suggestive of consolidation
Confusion screenAcute confusion, acute delirium or undiagnosed
dementia?
Septic screen inc FBC, U&Es, LFTs, CRP, BCMs, urine dip, CXR
Check TSH, B12, Folate
Consider CT head
Check the drug chart!!
Case 4 A 92 yr old gentleman, Mr D, is admitted having sustained a
right NOF fracture. He was given diclofenac in A&E as he was in a lot of pain.
He is operated on, on the same day of admission (which is a Saturday, Jeremy), and is taken back to the orthopaedic ward.
Unfortunately they are extremely understaffed, and Mr D, who usually requires assistance to eat and drink, gets slightly overlooked as there is a very sick patient overnight who is peri-arrest
His initial blood results were; Hb 140 WBC 6 CRP 6 Na 140 K+4.5 Ur 5 Creat 90
You are the F1 on call on Sunday and are asked to recheck his blood results…
His blood results today are; Hb 135 WBC 10 CRP 15 Na 144 K+4.4 Ur 10 Creat 190
O/E: Appears very dehydrated, with dry mucous membranes Observations stable No oozing from wound site HS1+11+0 Chest clear Abdomen soft, non-tender Urine output for past 3 hours ~ 15ml
How will you manage Mr D?
Acute kidney injury In adults, a diagnosis of
AKI can be made if:
Blood creatinine level has risen from the baseline value for that person (by 26 micromoles per litre or more within 48 hours)
Blood creatinine level has risen over time (by 50% or more within the past 7 days)
Oliguria (less than 0.5ml per kg per hour for more than 6 hours)
Management; Try to identify a cause eg.
recent contrast? Dehydration?
Stop any culprit drugs (especially NSAID’s in elderly)
IV fluid replacement Discuss with renal team
DehydrationA proportional rise in both
urea and creatinine
However, urea may be slightly more raised than creatinine
Note: If urea is dramatically raised out of proportion to creatinine – suspect GI bleed (as the blood acts as a protein meal)
Clinically – dry mucous membranes, patient feels thirsty, oliguria or anuria
Management; Search for the cause IV fluid replacement Catheterise patient Meet fluid demand eg. if
high output fistula/stoma Discuss with renal team
SummaryRemember to repeat the sample if you suspect a
spurious result
Common things are common – low/high potassium and sodium and anaemia
Trust guidelines can be very useful
Don’t panic!
If in doubt, ask!