Health Forum

Hospital Pantai Ayer Keroh Melaka

Date: 6-3-2010 (Saturday)

Time: 1.30pm

Venue: Conference Room, 3rd Floor, Melaka Mall
(Opposite Jaya Jusco, Ayer Keroh)

Protect your Kidneys, Control Diabetes

by 

Dr Chow Yok Wai

Consultant Nephrologist & Physician

(3 CPD points for All Registered Nurses)

Admission FREE

Calcium vs Corrected Calcium (BM Translation)

Apa itu “Corrected Calcium”

Terjemahan olih En Soong Chong Seng

Kita biasa melihat Calcium dan Corrected Calcium didalam laporan makmal keputusan kajian darah. Calcium adalah sejenis garam galian yang terbanyak bilangannya didalam badan di mana 99% di dalam tulang dalam bentuk calcium phosphate (garam). 22.5mmol daripada Calcium terdapat di luar sel dan 9mmol daripadanya terdapat di dalam serum.

Sr Calcium yang sentiasa di kawal dan mempunyai kandungan normal dalam lingkungan sekitar 2.2-2.9 mmol. Tahap jumlah Calcium adalah berkait rapat dengan tahap kandungan albumin dalam badan.
Semasa mengalami kegagalan buah pinggang, tahap albumin biasanya rendah. Oleh yang demikian, bacaan sr Calcium tersebut tidak menggambarkan tahap kadar sr Calcium yang sebenarnya.

Oleh yang demikian, untuk mengukur tahap sr Calcium dengan lebih tepat, kita perlu mengukur free(ionized) Calcium di mana ia tidak jauh berbeza dengan tahap kandungan albumin. Kandungan normal ionized calcium ialah dalam lingkungan1.1-1.4mmol. Jadi, tahap “corrected Calcium” dapat dikira di dalam pesakit yang mengalami kerosakan buah pinggang dengan nilai yang mewakili kandungan tahap Calcium di dalam badan dengan lebih tepat.Tahap “corrected Calcium “ mengambil kira tahap abnormal kandungan albumin dalam badan dan membuat sedikit pengubahan tahap kandungan Calcium melalui andaian bahawa tahap kandungan albumin yang normal. Formula untuk mengira “corrected Calcium”:

Corrected Calcium(mmol/L) = measured total Ca(mmmol/L) + 0.02(40- serum albumin(g/L).
1) 40 mewakili purata tahap albumin dalam g/L
2) Setiap 1g/L pengurangan kandungan albumin akan meningkatkan 0.02 mmol/L dalam sr Ca.

Dalam kes hypoalbuminemia, tahap “corrected Calcium” adalah lebih tinggi daripada jumlah Calcium yang sebenarnya. Perlu ambil perhatian bahawa jika tahap albumin melebihi 40g/L, maka bacaan“corrected Calcium” adalah lebih rendah.

Garispanduan KDOQ menetapkan bahawa nilai "lower limit" adalah 1.13 mmol/L dan "upper limit" ialah 1.78 mmol/L

Arterial & Venous Pressure Monitoring..(Part 1)

Arterial and Venous Pressure monitoring….

When we look at a Haemodialysis (HD) machine, we can see 2 ports where the pressure monitoring lines of the bloodline sets via transducer protectors are attached to. One is for monitoring the arterial pressure and the other for monitoring venous pressure within the extra-corporeal blood circuit.

The purpose of having the device to monitor the pressure within the bloodlines is to ensure the smooth flow of the extra-corporeal blood by detecting any pressure built-up within the circuit. Preemptive measures can be taken long before a problem can arise by just monitoring the pressure trend.

Many Haemodialysis Centres (HDCs) has found it fit to do away either with the arterial or both the arterial and venous pressure monitoring. Some staff and patients’ themselves find the alarm triggered by the arterial and venous pressure monitoring very annoying. The slightest movement of the patient’s limb to which the AVF needles are placed can trigger the alarm.

However without them, we would not be forewarned of any impending problem arising from the pressure built-up. These safety measures are in place for a very specific purpose, patient’s safety therefore they should not be arbitrarily omitted.

Calcium vs Corrected Calcium

What is the difference between Calcium and Corrected Calcium?

In our patients’ laboratory analysis printout we normally will see Calcium and Corrected Calcium values stated. So what is Calcium and Corrected Calcium…...?

Calcium is a mineral found in the largest quantity in the body and 99% is in the bones as calcium phosphate (salt). A total of 22.5 mmol of Calcium is found extra-cellular and of this 9 mmol is found in the serum.

Serum Calcium is closely regulated with normal range of Calcium (extra-cellular) of 2.2 – 2.9 mmol. The level of Serum Calcium is associated with the level of Serum Albumin. Calcium has an affinity to Albumin.

As in Chronic Kidney Disease (CKD), the Serum Albumin level is usually lower and therefore affects the reading of the Serum Calcium and does not reflect the actual Serum Calcium level.

Therefore to accurately measure the level of Serum Calcium we need to measure the free (ionized) Calcium. Ionized Calcium does not vary with the Albumin level. The normal range of ionized Calcium level is 1.1 – 1.4 mmol.

A corrected Calcium level can be calculated in situations such as CKD to present an actual representation of Calcium level in the body.

Corrected Calcium takes into consideration the abnormal level of Albumin and makes adjustment to the Calcium level as though the Albumin level is normal.

Corrected Calcium (mmol/L) =

measured total Ca (mmol/L) + 0.02 (40 - Serum Albumin [g/L]),

where 40 represents the average Albumin level in g/L

each 1 g/L decrease of Albumin, will raise 0.02 mmol/L in serum Ca

In cases of hyperalbuminemia, the level of Corrected Calcium is lower than the total Calcium.

Wishing
All Malaysian

"A HAPPY AND PROSPEROUS 
CHINESE NEW YEAR"

Best Wishes & Warmest Regards...

MalaysianKidneySPA

Blunt AVF needle....the final part

How is it done.....?

1.   First assess the AVF and identify the directional flow of the AVF.
2.   Select the appropriate sites for the arterial (supply) and venous (return).
3.   It is pertinent to stress that cleanliness is of utmost importance in establishing a tract for and using blunt AVF needles.
4.   Clean the intended area with "Providone Iodine" or any other suitable disinfectant. Remove any scabs from previous cannulations if any. Please use aseptic technique and a pair of tweezers, NOT the tip of a      needle.
5.   Either using the 3 fingers or 2 fingers technique, secure the vessel for cannulation.
6.   Aim the tip of the sharp AVF needle for the center of the vessel at 25 - 35o and proceed with the cannulation.
7.   Once blood rushes into the syringe, level the AVF needle and glide it along the center of the vessel.
8.   Secure the AVF needle and flush it with the Normal Saline in the syringe to check for good blood flow.
9.   This procedure is repeated exactly the same, the next 8 - 10 cannulations. Same spot, same hole, same
      angle and same depth by the same cannulator.
10. During the next cannulation, soak the scab that has formed at the opening of the cannulation site with Normal Saline and slowly peel it away with a clean pair of tweezers and NOT the tip of a needle.
11. After a number of cannulation, a hole will apear underneath the scab.
12. Do not allow patient to remove the scab him/herself.
13. Thereafter cannulation through the hole will require less effort than before the site matures.
14. When the cannulator is satisfied the tract has been formed and is matured, can he/she starts to use the
blunt AVF needle for cannulation.
15. When he or she is confident that other treatment practitioner can cannulate successfully the buttonhole with a blunt AVF needle can then others cannulate the patient.


What's next.....?

1. Do not use a sharp AVF needle on a mature site as it can injure the tract.
2. Do not use too much force when cannulating with a blunt AVF needle.
3. If bleeding occurs around the blunt AVF needle, it means that the tract is stretched or scarring has occurred.
4. If you are unable to insert the blunt AVF needle into the vessel, push the vessel to the vessel and gently lift the tip of the needle.The flap of the vessel may be misaligned with the tract.
5. If this does not work, then use a sharp AVF needle for the next couple of cannulations. Ensure that you stay in the tract so as not to injure or scar the tract. This will help in refashion the flap of the vessel.
6. What if the tract does not take form, not to worry. Select a new site and create a new tract.

Obstructions to a successful creation of a tract.....

1. Badly scarred vessel due to cannulation problems.
2. Thick subcutaneous layer.
3. One too many cannulators on the same patient.
4. Stenosis present at the chosen site.

Benefits.....

1.   Patients enjoy less painful cannulations.
2.   Patients can self cannulate.
3.   Patients experience less stress during cannulations.
4.   Less cannulation complications.
5.   Less mistreatment or reschedule treatments.
6.   Fewer hospitalizations due to cannulations or AVF complications.
7.   Longer AVF survival.

8.   Faster cannulations.
9.   Less stress on treatment practioners due to problematic cannulations.
10. Increased safety with less stick injuries.

The cost of a blunt AVF needle....?

Presently the cost is higher than a sharp AVF needle but nevertheless it is worthwhile to consider it and prices will comedown when demand for it increases.......

Are you game for it......talk to your patients.......explore the posibilities.....

Blunt AVF Needling....(Part 5)

What is a "Blunt AVF Needle"?

It is what the term "blunt AVF needle" implied..... an AVF needle that is blunt...

Sample of a sharp AVF needle

Sample of a blunt AVF needle

Pictures from:  http://www.nipro-europe.com/Biohole.asp



So how does one cannulate without a cutting edge.......?  So continue reading.......


 The "Blunt AVF Needling"

Who can blunt AVF needling be carried out on....? Anyone with a native AVF and not one with an artificial graft can undergo blunt AVF needling. Patient should have a satisfactory level of personal hygiene.

What is a "tract"

The tract is a passage from the outer skin to the vessel.This tract is formed when repeated cannulations are carried out over and over again. After sometime, the injuries of the inner surface of the tract is minimised and the tract is formed. This tract is similar to the tract of a earring tract.

Who can create a tract.....

The "Cannulator"

A cannulator is an experienced trained treatment practitioner whom has the consistency and ability to cannulate successfully any AVF. Once the cannulaor has been identified, he/she is give that task to create the tract on a patient for blunt AVF needling.

The cannulator is THE person whom shall cannulate the selected patient each and every time while the tract is being developed. The cannulator needs to cannulate at the same spot, same angle and same depth every time when the patient comes for treatment for the next 8-10 treatment (more if patients are poor healers).

The "Site"

A clean site for each arterial and venous cannulation points are selected which is straight, level and with a vessel prominently visible with no scars or aneurysm is chosen.

Initially a sharp AVF needle of 17G is recommended to cannulate the patient when the tract is being created.

During this crucial period, no one other than the cannulator can cannulate the patient. Should he/she is not available or when an infiltration has occurred than cannulate away (preferable more than 1 inch) from the intended sites.

to be contd......