What’s included in chapter 9?
Different types of anaemia
Blood and Electrolytes
Vitamins
Different types of anaemia
Sickle Cell Anaemia G6PD deficiency Hypolastic Haemolytic Aplastic Iron deficiency anaemia Megaloblastic
Sickle cell anaemia
Might need folate supplements
Hydoxycarbamide
Reduce frequency of sickle cell crisis which would lead to hospitalisation
G6PD
More common in men
Mostly seen in Asian, African and south European Union
Some drugs cause risk of haemolysis in G6PD deficiency
Quinolones like ciprofloxacin
Nitrofurantoin
Sulfonamide such as co-trimoxazole
Drugs with higher risk in G6PD deficiency
Aspirin
Quinine
Sulfonylurea
Hypoblastic and haemolytic anaemia
Can be treated with anabolic steroids
Various corticosteroids and pyridoxine
Aplastic anaemia
Treated with anti-lymphocyte immunoglobulin
Given IV through central line - 12 to 18 hours each day for 5 days; can cause severe reaction first two days and immunosupression can occur
Rate response may increase if ciclosporin given as well
Anaemia associated with erythopoietic deficiency
Can be seen in patients with chronic kidney failure
Treatment option eproietin
Eproietin beta - neonates with low birth weight (non benzoyl alcohol version)
Darbopretin long half life don’t have to administer frequently
Iron deficiency anaemia
Quiet common
Important not underlying conditions like GI cancer or gastric erosion
Prophylaxis with Iron
Menorraghea
Pre-term neonates with low birth weight
Pregnancy
Iron
Oral version and m/r versions
Therapeutically m/r has no benefit except u can take once a day
Parenteral versions - iron dextrose, iron sucrose: when oral version ineffective or can’t rake; main side effect hypersensitivity anaphylaxis, eczema and asthma patients at higher risk
Iron side effects
Constipation
Diarrhoea in patients with IBD taking m/r preparation
Discolour stools (black stools)
Iron administration
On an empty stomach because absorbs better that way
But if can’t tolerate side effects it’s fine to take after food
Advise patient to take with orange juice rather than water because it absorbs better with vitamin c
Megaloblastic anaemia
Usually due to lack of vitamin b12 also known as cyanocobalamine or folate
Establish underlying cause - pernicious anaemia causes malabsorption of vitamin b 12
Total gastectomy or total iliolresection
B12 prophylactically
Cyanocobalamin for b12 deficiency
Needs to be endorsed SLS
Cyanocobalamin replaced by
Hydroxycobalomine because it can be retained longer in the body
Maintenance treatment usually up to 3 months by IM injections
Folate deficiency
Due to pregnancy
Poor nutrition
Or even some antiepileptic medication
Folic acid treatment usually 4 months
Folic acid use in
Methotrexate therapy as folate antagonist
Also folinic acid but to do with cytotoxic therapy
Iron overload
Repeated blood transfusions
Treatment repeated venesection but if that’s contraindicated then iron chelating compound e.g desferrioxamine mesilate with ascorbic acid given separate from food and should be avoided in patients with cardiac dysfunction
In what situations would we need to give someone fluid and electrolytes
Vomiting
Diarrhoea
Particularly sodium and water in these states
Hyperkalaemia treatment >6.5mmol/l
Calcium gluconate 10% Soluble insulin Glucose 50% Calcium polystyrene sulfonate Salbutamol injection/nebuliser
Oral potassium <3.5
Potassium bicarbonate
Potassium chloride
Digoxin therapy
Anti-arrhythmic
Chronic diarrhoea
Laxatives
Sodium bicarbonate
Chronic acidosis state Metabolic acidosis Renal tubular acidosis Dyspepsia Increasing pH of urine
Calcium supplementation
In children
Pregnancy
Osteoporosis
Hypocalcaemia
Calcium + vitamin D
In the form of:
Calcium carbonate or
Calcium chloride
Hypercalcaemia treatment
Bisphosphonates Corticosteroids Calcitonin Phosphate salts Pamidronate Cinacalcet
Dietary restrict calcium
Medicines - thiazides and vitamin D contribute
Hyperparythyroidism
Cinacalcet
Paricalcitol
Parathyroidectomy
What causes hypomagnesia
Diarrhoea or even alcoholism
Can cause secondary hypocalcaemia and hypokalamia
Treatment for hypomagnesia
Magnesium sulphate injection
Phosphate supplements
Severe diabetic ketoacidosis
Alcohol dependency
Ricketts
Hyperphosphataemia
Calcium containing preparation
- Sevelamer
- Lanthanum
Acute Porphyria
Hereditary condition
Certain medication unsafe - antihistamines, anabolic steroids, antidepressant, contraceptives, HRT, phenytoin, rifampicin, valproate plus many more
Trace element deficiency
Selenium
Zinc - zinc sulphate (trauma or burns)
Nutrition
IV infusion in addition to tube feeding
Reason for tube feeding - renal or liver dysfunction, severely ill, major surgery
Parenteral feeding
Amino acids, glucose, fat, vitamins
Parenteral nutrition complications
Gall bladder slodging and colistasis
Phenylketonuria
Body can’t metabolise phenylalanine
Restrict dietary intake but still give sufficient small amount
Special diets
Cealiac disease - gluten free
Bleeding of gums
Scurvy causes bleeding of gums - lack of vitamin c
DEAK
Fat soluble vitamins
Water soluble vitamins
B and C
Retinol
Vitamin A
Lack of vitamin leads to ocular defects
Helps with night vision
Vitamin A
Avoid in pregnancy
Vitamin A
Where can you find vitamin A
Eggs
Butter
Fish oils
Thiamine
Vitamin B1
Riboflavin
Vitamin B2
Pyridoxine
Vitamin B3
Cyanocobalamin
Vitamin B12
Thiamine given to
Alcoholics
Wernicks encephalopathy
Parenteral form pabrinex
Thiamine found
Cereal
Bread
Energy metabolism
Riboflavin
Energy metabolism:
Milk
Cereal
Pyridoxine
Used in protein metabolism
Fish
Meat
Cyanocobalamin
Red blood cell formation
Vegans lacks in - meat, milk and cheese
Ascorbic acid
Vitamin C
Orange juice
Citrus fruit
Antioxidant
Lacking vitamin c
Scurvy:
Gingival bleeding
Bleeding margins
Petechia of skin
Vitamin D
Calciferol
Ergocalciferol
Cholecalciferol
Alfacalcidol (Renally impaired)
Too much lead to hypercalcaemia, too little rickets and osteomalacia
Vitamin E
Antioxidant
Little evidence of benefit
Found in whole grain
Blood clotting factors
Vit K
Green leafy vegetables, nuts and fruits
Given to newborn
Can get water soluble version
Nicotinic acid
Inhibit synthesis of cholesterol and triglycerides
Protein and energy metabolism
Found in kidneys and liver
Biotin
Beta-carotene
Carrot and peaches
Antioxidants
Folate/folic acid
Kidney, liver and vegetables and helps with red blood cell formation
Low risk of neural tubule defects - till 12 weeks
Child at risk - family history, diabetes, cealiac disease, antiepileptic medicines
