in this video i want to cover both hemoconcentration and hemodilution hemoconcentration and hemodilution are two important concepts when you're looking at labs you always want to look to see is my patient dehydrated or hemoconcentrated or are they fluid overloaded are they hemodiluted if you don't look at this first and you just automatically treat high potassium or say a low sodium maybe the creatinine and bunny creatine are both really high and you treat those it may be that you're treating a pseudo lab so you're not treating a lab that's actually high or actually low what you're doing is you're treating something that's just either concentrated because of low volume or low water in the blood or maybe you're treating something because it's it looks like it's too low because it's actually diluted so in hemo concentration you have a loss of water not overall whole blood okay so you're not hemorrhaging you're not bleeding but you've lost water whether you're being maybe potentially diurese and other things are being hemoconcentrated so your maybe bunny creatinine rbc hemoglobin hematocrit various other things might be concentrated because you're dehydrated maybe you've also lost electrolytes because of diuresis but it's primarily that you've lost water and so you have falsely elevated results across the board so if you're just dehydrated if you've just lost water then everything should be high so in this situation you'd want to rehydrate your patient get that volume back to normal then reevaluate those labs for treatment because again you don't want to treat something that's falsely high so let's say again uh their potassium looks high you treat that you you bring that potassium down at the same time you're hydrating them because they're dehydrated and you could potentially drive them into hypokalemia and cause cardiac issues so you always want to make sure that you're really treating the true lab and not a hemoconcentrated or hemodiluted lab same thing with hema dilution it's because there's excess water in the blood not excess blood components but excess water in the blood and it's diluting it so it's going to make everything look falsely low across the board so in this situation the patient either needs to be diuresed or they need to just have fluid restriction then their labs need to be evaluated for treatment so going back to the concept review we did at the very beginning of this part of unit 1 with lab lab values looking at osmosis diffusion and filtration so when you're thinking about hemoconcentration hemodilution that's when these these concepts really become important so again let's say on this side this is hemoconcentrated there's more solutes and less water on this side let's say that it's hemodiluted so anytime you have that difference in concentrations across a semi-per semipermeable membrane you're going to have fluid shifts or you may even have solute shifts in diffusion depending upon what that cellular membrane is uh semipermeable to and what is actually going to be different or yeah diffusing across that semipermeable membrane so let's take a look at this guy right here let's say for example that this right here is my cells let's say that my cells are just overloaded i have cerebral edema let's say these are brain cells on this side here i have too much fluid in my brain cells so if i administer a hypertonic solution what's going to happen is that fluid is going to shift into my bloodstream and it's going to re reestablish that balance in my brain cells vice versa if this was a brain cell right here and it was really dehydrated and say this is the blood vessels because we've actually put in a hypotonic solution the fluid is going to shift into the brain cells and rehydrate them and that can be the same for cardiac muscle skin cells any kind of cell in the body because all cells are going to be affected by changes in fluid and solute concentration with hemo concentration and hemodilution i want to drive home again the importance that it's an overall increase in the labs so that means the blood is concentrated or there's been loss of water overall fluid or it's hemodiluted meaning that all the labs are going to be falsely low because everything's diluted there are some exceptions to this for example with hemo concentration if maybe a patient is diuresed and they have lost some electrolytes maybe with lasix along with the extra fluid and so now everything is concentrated with the exception of the electrolytes so as long as the increase in labs this false increase makes sense with the treatment the procedure the condition their history as long as it makes sense as to why maybe most of them are high and just a few are low that might mean that they're chemo concentrated but they had just one little element that was maybe causing the chemo concentration same thing with hemodilution but i want you to keep in mind with true hemoconcentration and true hemodilution it's just the loss of fluid and so again it's an overall increase or concentration of solutes in the blood or it's an overall decrease in concentration of solutes in the blood so it's really really important that you address that first before you start treating anything so for example i had a lady on medical telemetry a long time ago now and she was quite sick when we got her labs back the lab tech told me well everything's critical i said what do you mean everything's critical he said all the labs are critical turns out she was just severely dehydrated and once we got her rehydrated that's when all of her labs are truly out of whack started popping out so once we had her back to euvolemia or euvolemic status then we actually knew what solutes in her blood were high or low and actually had to be corrected i want you to take a few moments and also look at this graphic here now i know some of us if you're in the lpn paramedic track you should be pretty familiar with isotonic hypotonic oh i'm sorry and hypertonic solutions if you're in the basic track you're not yet may have heard of these terms before but you're going to be more heavily introduced to these concept into ns110 at a much deeper level but just to give you some basics let's first start over here hypotonic excuse me and hypertonic hypotonic means low concentration tonic just means concentration or dilute hypertonic means high and highly concentrated okay so you can kind of see this one's got some sparse solutes here there and everywhere and fluid is shifting into the cell here you've got a bunch of solutes everywhere super concentrated blood and it's actually pulling fluid outside of the red blood cells what's causing them to shrink hypo and hypertonic those are high and low compared to isotonic iso means the same so the same tonicity this is also known as normal saline so what are we saying it's the same as what exactly well it's the same tonicity as your blood so all iv fluids are going to be iso hypo or hypertonic compared to the tonicity of your own blood so isotonic literally means it's the same concentration of your blood so when we give someone normal saline we should not expect any fluid shifts we might be completely replacing them not completely but greatly replacing their volume if they're dehydrated but we're not going to be causing any fluid shifts within the body whereas if we give a hypotonic solution we'll be forcing fluid into the cells if we give a hypertonic solution we're actually pulling fluid out of the cells sometimes this is good because we need to promote cellular rehydration sometimes this is good because we need to promote cellular dehydration like in the case of edema so just get a general idea of what these concepts mean again if you're in the basic track you're going to get in much more detail with these when you get into iv therapy in 110. so let's move on to critical results and what that actually means so a critical result is a laboratory result that is acutely dangerous not just high not just a little bit low but it's reached a certain threshold and really almost every facility has a slightly different level that's considered a critical but just like lab values you know whether it's saint francis mo delta southeast health anywhere else where you any you know maybe a facility in popular bluff anywhere where you work there might be slight differences say like in a sodium range but they all kind of hover at about 135 to 145 or potassium is about 3.5 to 5 something like that whereas the critical results and i i can't remember right on top of my head but i want to say for potassium um i want to say it's like a seven or an eight i believe i'd honestly have to look at that just to validate and make sure but it's a really high result that means that this patient is really in danger of having some pretty serious symptomatology such as cardiac arrest so it's really important that lab calls and notifies that nurse that hey we've got a critical result so that lab can't just sit in the computer for an hour 30 minutes because you know maybe you're busy giving a bath or you're doing a dressing change or you're doing an assessment or whatever and you don't see that really dangerous lab result on that patient so lab has to call and make sure that they have contacted that primary nurse and verified that that nurse knows about that acute um that acute situation and so this requires immediate attention from a provider so what you have to do excuse me is work up the chain of command so of course you first want to try to reach your provider your aprn um your either the hospitalist that's who admitted maybe it's a surgeon if that's who admitted ideally it's the person who admitted for the you know the situation related to the situation that you're calling about um and you have to make sure that you get in touch with them within 60 minutes 60 minutes is that magical time frame you have to get in touch with them within that period of time now if you have a patient that is actively confused that is actively experiencing tetany that is actively experiencing um enough of a cardiac change that they're feeling a little bit woozy i wouldn't wait 60 min 60 minutes sorry i would jump on that right away and make sure that this provider knew but let's say you go and you check on your patient they're actually tolerating things pretty well i would still get in touch with them really quickly but it wouldn't be as critical as if my patient were actively experiencing some kind of symptoms i actually had a patient on cpc her potassium was 2.4 um and she was just sitting in her room i remember sitting at the nurse's station i got the critical and i just so happened she was sitting right across from the nurse's station i remember looking at her she was just talking with her husband and everything's hunky-dory her her telemetry her um i mean her rhythm looked perfectly fine everything was great she was tolerating it fine because she'd been on lasiks but had not been taking in enough potassium so it was a slow change her body had adapted to it so yes i called that provider right away but it wasn't as critical as if she were having symptoms and actively needing some kind of rapid intervention so again if you can't get in touch with the provider then you have to work up your chain of command so you may have to go to your charge nurse then you're going to go to your nurse manager house soup and all the way up to chief medical officer if you need to don't skip these levels don't just go straight to house super or cmo you need to work up your chain of command i've actually had to do this before it turns out it was just because um the the new i want to say it was a hospitalist his cell phone just was not picking up a signal for some reason so i had to go all the way up to the cmo and get an order from him to take care of the patient everything ended up being fine but i've had to actually do this work up the chain of command and go all the way up to the top because i could not get an order for this patient but the bottom line is make sure you're following your chain of command and you're not skipping any levels