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2023.05.28 17:44 pylori pylori's Physiology Bites - Kidney function, acute kidney injury, and acid-base disorders

This is a series I am going to be working on where I endeavour to cover various topics in physiology intermixed with clinical pearls to impart some knowledge that doctors of most specialties and grades will hopefully find useful when looking after acutely unwell patients. Join me as we dredge through the depths of anaesthetic exam revision to answer important questions like "why do CT ask for a pink cannula", "why frusemide is okay to give in AKI", "why is hypoxic drive a bunch of horse manure" and many more. Pick up some of this material and you'll be well on your way to becoming a pernickety anaesthetist, whether you like it or not!
Questions, comments, feedback, and suggestions are both encouraged and welcome.

Previous installments:

Kidney function, acute kidney injury, and acid-base disorders

Next stop along our systems review are the mighty kidneys. I won't talk to you about Lupus nephritis or renal tubular acidosis, however I will try my best to cover some more typical things you might encounter like acute kidney injury (AKI) and drug dosing in renal impairment while trying to avoid embarrassing myself as a non-renal doctor.

What do the kidneys do?

An obvious question, they allow us to get rid of waste substances in urine. They are so much more than that however, they:
  • Regulate electrolyte concentrations, water balance and plasma volume, plasma osmolality
  • Regulate red blood cell production
  • Regulate blood pressure via RAA system influencing vascular resistance
  • Maintain acid-base homeostasis
  • Control Vitamin D production
  • Produce glucose from proteins and triglycerides (gluconeogenesis)
We will focus on only a few of these in this post, but the kidney's multiple roles and complex biochemical signalling deserves as mention as it can make diagnosing and understanding disease states difficult. It can also make us forget what other consequences there might be for patients in these disease states.

How do we measure kidney function?

In some respects knowing the heart or the brain aren't working is easy. Low blood pressure and infection? Septic shock. Low blood pressure + STEMI? Cardiogenic shock. Unconsciounsess or coma? Well whatever it is, it ain't working. So what about the kidneys, well we have creatinine, right? WRONG.
Although the kidney has many functions as we noted before, the easiest methods to quantify function look at the obvious: waste production. Its function is the sum of filtration through all the glomeruli in the kidneys, the glomerular filtration rate (GFR). When a substance is freely filtered through the kidneys and is neither secreted nor reabsorbed (which occur in the tubules rather than the glomeruli), the rate at which that substance is removed or cleared from the plasma can be used to measure GFR (in mL/min).
This substance is inulin and not creatinine. Because inulin isn't naturally present in our bodies, it has to be infused and then its concentration and the rate of decay measured. This is impractical clinically, so creatinine was selected as a practical alternative. The correlation between serum creatinine and measured GFR was researched and various formulas like MDRD and CKD-EPI were developed to estimate GFR (eGFR). This is why labs report eGFR as opposed to GFR. (There are also other methods to determine GFR like radionuclide scintigraphy...)

What's the problem?

The estimation of the GFR relies on assumptions that are not without problems. This review covers the topic at length, however the main points are:
  • Creatinine is secreted, unlike inulin. As mentioned this occurs in the tubules, so changes in secretion will affect serum creatinine level despite a static filtration rate. As renal diseases progress, more and more creatinine is secreted, making serum concentrations less reflective of actual filtration.
  • To truly reflect instrinsic renal function creatinine has to be in a steady state with stable generation and serum concentration. Creatinine is produced as a waste product of protein breakdown mainly from muscles. Therefore anything affecting catabolism, muscle activity, dietary protein intake, can alter this steady state. Frail sarcopenic patients will have artificially low creatinines and may not get as significant of a rise as a young muscular person in AKI.
  • There has to be adequate delivery of creatinine to the glomeruli. The kidneys receive ~20% of the cardiac output, so the heart has to be pumping out effectively with healthy blood vessels, good volume and blood flow. A hypovolaemic patient with an MI may have a high creatinine despite working kidneys, they're just not being adequately perfused. Chronic diseases like hypertension, diabetes, heart failure, lead to upset of autoregulation of normal afferent (entering) arterioles, whereas ACE inhibitors and ARBs block AT-II from causing vasoconstriction of efferent (outgoing) arterioles, an imbalance can lead to renal impairment if perfusion isn't maintained, or improved blood flow and urine output if it is.
  • The studies from which eGFR formulas are derived were conducted in mostly European and North American populations with elderly, black and CKD patients being significantly underrepresented. They only measured GFR a few times a year. With increasingly older, frailer, sicker patients, leading more sedentary industrialized diets and lifestyles, will the accuracy of these formulas hold up with time?
  • eGFR correlates loosely with important indicators like proteinuria, fluid status, blood pressure, acidosis, anaemia, bone disease, iron deficiency, tubular function, etc. In the absence of those indicators, the elderly often have decreased GFR without increases in morbidity and mortality.
The takeaway is that creatinine and eGFR are tools developed from the assessment and monitoring of long term renal function. It is not designed for use in patients with acute fluctuations or those with zero kidney function (eg, anuric dialysis dependent).

What else we can monitor?

The example of the heart earlier was misleading. Blood pressure is influenced by many factors. Septic shock is actually a high cardiac output state with low systemic vascular resistance (SVR). Patients with heart failure can have normal blood pressures despite severe systolic dysfunction and poor exercise tolerance. Blood pressure is an easy surrogate marker because determining cardiac output and SVR is invasive and complex (of course we have focused echocardiography to help us these days).
A surrogate marker we can use for the kidneys is urine output (UO). After all the end product of glomerular filtration is the ultrafiltrate which will become the urine. If there is adequate urine output despite raised or increasing creatinine levels, we can be reasonably satisfied the kidneys are actually receiving enough blood flow to get rid of waste and perform its other functions.

Acute Kidney Injury

This leads us into one of the most commonly encountered entities in hospitalised patients: AKI. Let's look at the KDIGO criteria seen in the table below.
AKI Stage Serum creatinine criteria Urine output criteria
1 SeCr increase ≥26 umol/L <48hrs or SeCr increase ≥1.5 - 2x from baseline <0.5mL/kg/hr for ≥6hrs
2 SeCr increase ≥2-3x from baseline <0.5mL/kg/hr for ≥12hrs
3 SeCr increase ≥354 umol/L <48hrs or SeCr increase ≥3x from baseline or started on renal replacement therapy (any stage) <0.3mL/kg/hr for ≥24hrs or anuria for ≥12hrs
Note: UO <0.5mL/kg/hr is the definition of oliguria.
Definining by creatinine is a more practical screening test in most situations, allowing earlier diagnosis and intervention. UO can be monitored during the course of the day to identify patients who are borderline or not responding to treatment, may need re-evaluation of the cause, or escalation of care. This way a combination of the two can help offset the limitations of each method.
NICE guidance already exists on the diagnosis and management of AKI, most hospitals will have care bundles or even 'AKI nurses', so I'll run over a few important points.
  • Pre-renal - This only means the cause lies outside the kidneys, and in at least in the early stages there is no histological change in the kidneys. In many cases like sepsis, diarrhoea, haemorrhage, there can be a relative or absolute fluid deficit and IV fluids are generally indicated. However excessive fluids can result in interstitial oedema in the kidneys, reducing the glomerular pressure gradient and so also reducing filtration. Similarly in poor cardiac output states where there is venous congestion there is a problem with the outflow of blood from the kidneys, so this is not a cause to reflexively withhold diuretics.
  • Intrinsic - Here there are structural histological changes in the kidney, caused by many intrinsic renal diseases or nephrotoxic agents like aminoglycosides, vancomycin, NSAIDs, etc. If this is suspected, stopping the offending agent generally resolves AKI without needing a biopsy. Furosemide is not mentioned here as it is not inherently nephrotoxic. Acute tubular necrosis is often mentioned as a specific clinical entity, either due to nephrotoxic agents or sustained hypoperfusion from pre-renal causes. It is not a very helpful term since histological tubular damage has rarely been proven in studies, nor does it help with treatment.
  • Post-renal - Obstruction may be incomplete, acute on chronic, with a normal ultrasound, no oligo/anuria, and may be associated with other pathologies like a kidney stone with pyelonephritis or sepsis. Catheters can get blocked too so don't forget a bladder scan if anuric, and obstruction can rarely be external such as by tumours or abdominal compartment syndrome.

When do I refer to renal or ICU?

Local protocols aside, advice should be sought when the patient does not appear to be responding to medical management and there may be a need for renal replacement therapy (RRT). This is often in the form of intermittent haemodialysis (iHD) on renal wards, and continuous venovenous haemodiafiltration (CVVHDF) in ICU. There are small differences in mechanism, efficacy, and indications of the many forms of RRT, the details of which aren't important for most non specialists. Generally accepted indications for RRT include:
  • Symptomatic uraemia - Encephalopathy, neuropathy, pericarditis. Elevated urea on its own is not generally an indication.
  • Hyperkalaemia - Persistent hyperkalaemia (>6.5) despite insulin/dextrose. Severe hyperkalaemia (>8 ) with arrhythmias, requiring pacing or isoprenaline. This can occur even without anuria and should be escalated as it obviously can be life threatening.
  • Severe metabolic acidosis, pH <7.1 - This will depend upon the cause and patient's condition. Patients with DKA and pH <7 can almost always quickly be turned around with insulin and fluids. Severely septic patients may not be able to tolerate medical management long enough to improve without RRT.
  • Toxins or overdose - Some medications and toxins may be removed by RRT (eg, lithium, vancomycin), with specific type of RRT better for some drugs than others. This is uncommon and decisions will depend on the input from renal, clinical state of the patient, and advice from toxbase or national poisons service. A drug may not be removed by RRT but if it leads to another entity such as acidosis it may still warrant RRT.
  • Fluid overload or pulmonary oedema refractory to diuretics - If patient is anuric despite diuretics then it's more likely they'll end up requiring RRT. In contrast pulmonary oedema in decompensated heart failure with worsening renal function is not helped more by RRT than by adequate diuresis.
Absent from above include oligo/anuria or specific values of urea and creatinine. This doesn't exclude them as considerations, however the whole picture should be taken together to make decisions on an individualised basis. It might be that the patient improves despite a creatinine of 700, it might be they become acidotic and hyperkalaemic with a creatinine of 400. Even on the ICU we still don't know when the right time is to start RRT.
This is a reason why renal and ICU often advise the generic "monitor I/O" rather than taking over care. We do appreciate accurate monitoring is unrealistic on the wards, but we also don't have the ability to admit everyone when few will need a specific intervention like RRT. An adequate UO to aim for is above 0.5mL/kg/hr. As AKI resolves some patients enter a polyuric phase, this will resolve but watch that they don't become hypovolaemic in the process, it may require further fluids matching what is lost.

Renal vs ICU referral

This will depend on local arrangements and acuity. Refer to renal if:
  • Single organ kidney failure - Normotensive haemodynamically stable patients, not septic or comorbid with poor cardiac function. The principal reason haemodialysis is intermittent because fluid is more rapidly removed therefore borderline hypotensive patients may not tolerate large volumes of blood and fluid being rapidly withdrawn from their intravascular space. I have seen patients arrest from starting dialysis!
  • Unclear cause of AKI - ICU can offer RRT as a bridge, but the underlying cause has to be treated, if the cause is unclear or there is persistent renal dysfunction, this will require renal input. We refer for this from the ICU too.
  • Diagnosis requiring specialist treatment - Immunosuppressive therapy for vasculitis.
  • Renal transplant patients - Even with a clear cause and response to treatment, the precarious nature of immunosuppression, renal impairment and graft function mean these usually merit a call to transplant renal physicians.
Refer to ICU if:
  • Multiorgan failure - Borderline blood pressure, high oxygen requirements, fluctuating consciousness level, coagulopathy, these patients are unlikely to tolerate iHD, but more importantly it suggests they are critically ill and may need rapid escalation of care (if appropriate) beyond what renal can provide (intubation, vasopressors, etc).
  • No on-site dialysis service - In hours there may be arrangements to transfer to partnetertiary hospital particularly for complex patients. However hospitalised dialysis patients known to the renal team may require more urgent RRT than this allows. Some ICUs have the plumbing to offer dialysis (this will need a dialysis nurse however).
  • Patient in extremis - ICU may be able to offer more timely input in patients needing urgent intervention especially if prior to surgery. A patient with bowel perforation and severe AKI will usually be septic and in multiorgan failure anyway, but a 70 year old with obstructive pathology may benefit from being close to theatre to offer RRT while awaiting a nephrostomy (or exchange). If it's reversible and there is somebody willing to operate, I would even dialyse a patient with a DNACPR we wouldn't otherwise admit.

Specific considerations

  • AKI in heart failure
    • The heart-kidney interaction is complex and works both ways (see this review). Volume status and cardiac function needs to be carefully evaluated. Seeing CCF documented in the notes is meaningless. What does their most recent echo show? What did they present with? Stable HF with reasonable ventricular function and sepsis with no signs of overload can receive fluids. Acute cardiogenic pulmonary oedema with severe ventricular dysfunction probably has AKI rooted in the decompensation of heart failure (type 1 cardio-renal syndrome) and would benefit from diuresis.
    • Acute decompensated HF is usually a hypervolaemic state. Elevated right atrial pressures reduce the arteriovenous pressure gradient in the kidney leading to venous congestion, poor outflow. Inflow is also limited adding to the poor cardiac output so glomerular filtration is reduced, leading to a vicious cycle. Aggressive diuresis with furosemide reduces this congestion, improves glomerular pressure gradient and increasing filtration (as long as the patient does not become hypovolaemic). Furosemide's initial beneficial effects in venous congestion is preceded by its diuretic action and is thought to be due to it causing venodilation, reducing preload. The addition of acetazolamide may improve decongestion further.
    • Creatinine rising is not an indication to stop diuresis, it may in fact signify adequate decongestion with improved patient outcomes.
  • AKI in liver disease
    • Like in heart failure this is a complicated topic (see this recent review). AKI is very common, occuring in up to 50% of hospitalised patients with cirrhosis. While we hear things like hepatorenal syndrome thrown around, common things being common we have to look at all the usual causes we've discussed first (so don't just throw terlipressin at everyone!)
    • Pre-renal causes are most common: Discontinue nephrotoxic drugs. Look for and cover for infections and spontaneous bacterial peritonitis. Hypovolaemia from diuretics or GI bleeds, resuscitate with crystalloids and blood as needed until euvolaemic (careful to avoid overload). Albumin has been found to improve survival in patients with SBP and can be considered if worsening renal function despite resuscitation (or following paracetensis for large volume >5L ascites). Hypervolaemia from congestion (cirrhotic cardiomyopathy leading to right heart failure can benefit from diuretics, abdominal compartment syndrome from tense ascites should be drained).
    • Intrinsic leaves us with tubulointerstitial causes and hepatorenal syndrome (HRS). Low fractional excretion of sodium and urine microscopy can help confirm HRS which offers a grim prognosis. Terlipressin may improve renal function at the cost of significant pulmonary oedema so regular volume assessment and avoidance of overload is paramount. RRT would only expected to be offered if waiting, or under consideration, for liver transplantation. If not, palliation will be the most likely alternative course.
  • Drug dosing
    • I would avoid using the BNF in renal impairment. Many of its recommendations are different than common guidelines and frankly weird. Do talk to your pharmacist (also microbiologist where appropriate), they'll often refer to The Renal Drug Handbook which is a good resource and covers scenarios like RRT. Most drugs will be dosed based on creatinine clearance not eGFR so arm yourself with an app or calculator.
  • Sodium bicarbonate
    • Bicarbonate infusions offer temporary extra buffering capacity, mopping up excess hydrogen ions resulting in a higher pH. This is beneficial in hyperkalaemia as a higher pH favours potassium moving intracellularly (for this reason saline is more harmful and Hartmann's more beneficial in hyperkalaemia). It also has accepted roles in tricyclic antidepressant overdose with adverse ECG findings (QRS, QT prolongation), urinary alkalinization (in salicylate poisonining, poor evidence in rhabdomyolysis), and normal anion gap metabolic acidosis (there is high cloride to replace loss of bicarbonate, see later).
    • Its use outside these indications is contentious. There is no evidence of benefit in DKA over conventional fluids even if normal saline's tendancy for acidosis may slow resolution of the acidaemia in DKA. It may be actively harmful in lactic acidosis and respiratory failure as the increased pH shifts the O2Hb dissociation curve to the left, causing reduced oxygen offloading. It also results in net CO₂ production (HCO₃⁻ + H⁺ → H₂CO₃ → H₂O + CO₂) which will have to be blown off with excess minute ventilation.
    • So why do ICU and renal advise it or use it themselves even with a lack of solid indications? Well, essentially it's a temporising measure. Severe acidaemia contributes to myocardial dysfunction, arrhythmias, and catecholamine resistance. In the critically ill it can be useful as a delay while you insert lines or in the hope it will avoid the need for RRT. The BICAR-ICU trial did find it delays the need for RRT and may even possibly reduce the need. I'm not entirely sold on the latter, but it can be reasonable to try if there are positive indicators like good UO.
    • How? Usually available in concentrated (8.4% with 1000mmol/L of each ion) or dilute (1.26% with 150mmol/L) forms. Due to the high tonicity of the former, 1.26% is generally preferrable especially if you can or want to give larger volumes. 8.4% should be reserved for fluid restricted states and should be given slowly via a central line except in an emergency. Slow infusions help combat significant CO₂ rises and hypernatraemia (especially with 8.4%). Dosing is 1 mmol/kg which is 1mL/kg of 8.4% or 6-7mL/kg of 1.26%. For real simplicity most patients can take a 50mL vial of 8.4% or 500mL bag of 1.26%.
  • Iodinated contrast
    • The entity contrast induced nephropathy, better termed contrast associated acute kidney injury, is a contentious topic. There are many good reviews already on this topic.
    • The evidence is from old studies using high osmolality agents during PCI. Fluctuations in creatinine may not be indicative of actual renal function and may simply reflect the underlying illness requiring a scan rather than the contrast itself. Patients are not more likely to need long term RRT.
    • IV contrast with modern low osmolality agents isn't associated with AKI in patients who aren't and even those who are critically ill. There was no association in patients even with pre-existing AKI. Prophylaxis with intravenous saline nor sodium bicarbonate have been found to make a difference even in CKD patients with eGFR >30.
    • The tl;dr is unless you're in cath lab or IR suite bolusing large quantities of dye arterially it is probably irrelevant. The benefit of a quality contrast enhanced scan in diagnosing and treating the patient are likely to outweigh any miniscule risk. RCR guidelines mention appropriate consent and identification of patients at risk (eGFR <40) they do not exclude the use of contrast or require hydration, at any renal function. You are the doctor, it's up to you to discuss and determine need and benefit. (It's the radiographer's job to ask, don't @ them, but they shouldn't refuse either).

Acid-base disturbances

Now it would seem we are forced to consider the fundamental concept of what acid-base physiology even is. You might have heard about strong ion difference and become lost in confusion. You're not alone. Put simply, there are two competing theories that try to explain how pH changes occur in the body: the traditional model that uses the Henderson-Hasselbalch equation to mathematically explain pH with bicarbonate, and the Stewart model that uses the concept of strong ion difference to explain why changes in bicarbonate occur. The bottom line is that these are detailed explorations of physiology more useful for bed time reading than the bedside. For the interested details can be read elsewhere.
More practically, we can work through a blood gas in a systematic fashion to help decipher the type of acid-base disturbance. Start with pH → PO₂ (always check oxygenation) → PCO₂ (respiratory component) → HCO₃⁻ (metabolic component). I've reproduced this in a simple but limited table below for reference, but this is a more intuitive flowchart to work through.
pH PCO₂ HCO₃⁻ Disturbance
<7.35 >6 Acute respiratory acidosis
Chronic respiratory acidosis
↔ /↓ <22 Metabolic acidosis
>7.45 <4.5 Acute respiratory alkalosis
Chronic respiratory alkalosis
↔ /↑ >26 Metabolic alkalosis
Numbers indicate primary abnormalities, arrows indicate compensatory changes. Respiratory compensation by altering ventilation occurs quickly, while renal compensation by altering bicarbonate excretion is a much slower process.


With the topic being the kidney, I won't discuss respiratory acidosis here (see this earlier physiology bite). Acute respiratory alkalosis is due to hyperventilation blowing off CO₂. This can be due to obvious things like pain or anxiety, a compensation for hypoxaemia (eg, high altitude climbing), pregnancy (increased minute ventilation stimulated by progesterone), or salicylate poisoning (direct stimulation of respiratory centre).


Dipping back into some physiology, we can consider two concepts that can give us more information: base excess and anion gap. The purpose of these concepts is help narrow our differential diagnosis, rather than serve as pathophysiological explanations of illness.
  • Base excess (BE) - This idea comes from Danish physicians during the polio epidemic where patients often experienced chronic CO₂ retention. For a standardised numerical way of gauging the degree of disturbance Siggaard-Andersen proposed BE to represent the quantity of acid in a lab that needed to be added to a solution of blood to normalise it to a pH to 7.40 and PCO₂ of 5.3. Not because the plan was to literally add acid, but this way you could easily quantify the degree of disturbance. Rather than use this concept Americans appear obsessed with the more complicated Winter's formula instead. Most blood gas analysers will calculate BE for us, often reported as standardised base excess (SBE), with a normal range of +/- 3. A negative base excess is sometimes described as a base deficit, they're the same thing.
    • SBE <-3 - There is a metabolic acidosis, alone or as compensation for a respiratory alkalosis.
    • SBE >3 - There is a metabolic alkalosis, alone or as compensation for a respiratory acidosis.
    • Mild -4 to -9, moderate -10 to -14, and severe <-15 (same but positive values for alkalosis)
    • It is especially helpful with mixed disorders or causes. A lactate of 4 doesn't explain a BE of -12 alone, are there other contributors to the acidosis? A bicarb of 30 doesn't explain a BE of +10, what else can be causing alkalosis?
  • Anion gap (AG) - I have a more detailed reply here explaining anion gap. It is a theoretical number that exploits the body's need to maintain electroneutrality: we have a bunch of positively charged ions (cations) that are evenly matched with negatively charged ions (anions), and we measure some of these. When we have an excess of some anions that we don't measure like lactate this calculated number rises because one of the measured anions (bicarbonate) drops to compensate to maintain electroneutrality. Like BE, most blood gas analysers will calculate AG for you.
There are far too many causes and detailed physiology to discuss here exhaustively. If you want to read about the Cori cycle, Type A and B lactic acidosis, helpful mnemonics and more, head to this review or this section on Deranged Physiology.

Metabolic acidosis

Symptoms are non-specific, with the most obvious being hyperventilation for compensation. In severely acidotic states (pH <7) seek early ICU help. Awake patients will hyperventilate sometimes down to PCO₂ <2 which can dramatically increase work of breathing. Initiating invasive ventilation in this stage or patient fatigue can be very dangerous if hyperventilation isn't maintained, the acidosis can worsen and precipitate cardiac arrest. Hypotension from vasodilation and reduced cardiac contractility can occur, as well as arrhythmias, confusion, delirium, coma.
  • High anion gap metabolic acidosis - The presence of unmeasured anions including: lactate, ketones (diabetes, starvation, alcoholic), salicylates, formate (metabolite of methanol), oxalate and glycolate (metabolites of ethylene glycol), other toxins.
  • Normal anion gap metabolic acidosis - Losses of base (bicarbonate loss in GI tract via high ouput ileostomy or diarrhoea, renal loss via acetazolamide) or excess of acid (renal tubular acidosis, hyperchloraemia, adrenal insufficiency).
  • Pitfalls: Albumin is an unmeasured anion, so low albumin can mask a high anion gap. Albumin corrected formulas have been developed. Similarly excessively high unmeasured cations like magnesium, calcium, and even lithium, can also lower the gap.
Treatment is aimed at eliminating the underlying cause with specific therapies as required like insulin in DKA, fomepizole for ethylene glycol poisoning, folinic acid in methanol poisoning, etc.

Metabolic alkalosis

Despite metabolic acidosis being the usual focus, metabolic alkalosis is actually the more common abnormality of the two in hospitalised patients and is frequently seen as a mixed disorder (like as a response to prolonged CO2 retention as seen in mechanically ventilated patients). In severe states it can lead to delirium, seizures, obtundation, arrhythmias.
The 'opposite' of acidosis, here we see a gain of alkali or loss of acid, with impaired bicarbonate excretion required to maintain this (via chloride or potassium depletion, impaired renal function, or volume depletion).
  • Gain of alkali - Iatrogenic from bicarbonate infusions, citrate in transfused blood.
  • Loss of acid - From the kidneys via diuretic therapy, or mineralocorticoid excess, hypokalaemia. From the GI tract by vomiting especially with pyloric stenosis or obstruction as there is gastric acid loss (with chloride) only, laxative abuse diarrhoea.
Treating the underlying cause is important as always. Where there is low chloride and hypovolaemia, this usually responds well to fluid replacement with saline and potassium as required. Acetazolamide can be given if there is hypervolaemia although in practice this is rarely required unless continued diuresis with other diuretics is required. Alkalosis results in low ionised calcium that can cause paraesthesias, but as calcium is buffered by albumin this rarely requires treatment and resolves with correction of the alkalosis.


This is another large topic where there was plenty to talk about. I had to cut down the scope significantly as it rapidly spun out of control, however I thought the nuances deserved a detailed writeup. Nothing is ever absolute so don't take any of this as incontrovertible evidence of the incompetence of a hated colleague (or of my brilliance)! It will hopefully have given you some ideas to think about and research further when you see patients with AKI yourself.
Until next time!
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2023.05.28 17:44 AstralSanitizer_TI Claiming 1000 Rewards From Tempoross Pool (AND I GOT THE PET!)

The video link on my last post got taken off, which was the whole point of me sharing this with you guys. Thanks for clickin', my boyz! Here it is:
The vid is a time-lapsed short vid on doing my 1000 point reward pull in the Tempoross reward pool. This video is a good one to watch for all you beginners out there, even beginner ironmen! Tempoross is an easy-ass boss and you have 2 teams of people that are also there to help you. Its a great way to level up fishing at 65k xp/hr, it doesn't sound like much but its one of the top 3 ways to 99. Don't forget, that with your points you get rewards and the rewards are actually a decent way to make money while training. Ive probably received over 50M w/ a 1009 kc. The mini game also gives you a nice little bonus in Construction if you repair the mast on the boat and the wooden post that is on the beach. You get some cooking xp too if you decide to cook your fish (you don't really get much cooking xp either way but I HIGHLY recommend cooking your fish because that's what will get you more points and more rewards.
Thanks for watching!
-Schmick Ripperson
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2023.05.28 17:44 Even_Locksmith_4355 Click for click, existing users needed c:

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2023.05.28 17:43 E1lySym "But Blake clearly had a lot of romantic-angle scenes with Sun in the earlier volumes" is right but not the bmblb-killing argument everyone thinks it is

I am not refuting the idea that the two clearly had a romance angle in the earlier volumes but come on, how many of you people actually ended up marrying your first crush? I'm sure there are a couple people out there who did so, but I'm sure there are also people out there who had many exes before finding "the one", or people who had many crushes they never pursued a relationship with before actually committing to one.
Blake clearly had the hots for Sun at some point but that doesn't instantly guarantee that he's going to be her partner for life. She never committed to a relationship with him so it's not like she's not allowed to be attracted to other people while being attracted to Sun, or pursue other people romantically. People have their crushes but their feelings for said crushes also eventually fizzle out at some point.
As someone who liked both blacksun and bmblb I feel like people are too busy demonizing the writers and pitying Sun to appreciate how they let Sun sign off from the ship in a graceful way while they started nudging the story towards bumblebee. They showed that Sun was still willing to help Blake in V4 without asking for a relationship in return. Instead of having some weird cliche scene where Blake rejects Sun's advances and tells him she's not interested with Sun visibly getting sad after, instead we get Sun just silently acknowledging that Blake's not interested in a relationship with him, and deciding, "you know what, I'm still here for you! If you need help, just give me a holler and I'll be there". I feel like not actually pushing through with Blacksun as a romantic pairing made Blake and Sun's dynamic more powerful. Here we have two people, a male and a female character in particular, who would go above and beyond for each other, because they love each other, but not in a romantic way. Idk, I just really appreciate the platonic Male x Female "I'd die for you" energy oozing out of this pairing. It's the kind of energy that you will see from romantic pairings all the time but not as often from platonic pairings.
Ultimately, Blake is just an ordinary person at heart, and just like any other ordinary person she can have waning romantic interests.
When V10 drops (if it gets greenlit hopefully) I hope we see more of Blacksun anyways (of course this isn't romantic anymore) since they're clearly still very good pals. Even better if we get Yang and Sun interactions too, since you cannot convince me those two won't get along well.
submitted by E1lySym to RWBY [link] [comments]

2023.05.28 17:43 KayNAnt I need 1 new person to sign up.. IN US. Turn penny into $40-50

I need 1 new person to sign up.. IN US. Turn penny into $40-50 Must be able to verify open account and deposit a penny.
submitted by KayNAnt to MakeMoney [link] [comments]

2023.05.28 17:43 AutoModerator Iman Gadzhi Courses (Available)

Contact me if you are interested in Iman Gadzhi Courses by chatting me on +44 759 388 2116 on Telegram/Whatsapp.
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submitted by AutoModerator to CheckImanGadzhi [link] [comments]

2023.05.28 17:43 AutoModerator Iman Gadzhi - Agency Navigator (Final Edition)

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The Core Curriculum for starting an agency A custom e-learning platform just for agency owners Website templates, funnels, ads, and more Template contracts, sales scripts, and agreements With this course, you'll learn how to:
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submitted by AutoModerator to ImanGadzhiUnit [link] [comments]

2023.05.28 17:42 COMPUTER1313 Ideas for a "Total War: Fall of the Qing Dynasty"

Timeline start: Either right before the First Opium War kicks off (giving players the option to find ways to avoid the war, or do things differently from how history played out) or the immediate aftermath of the war.
Timeline end: Somewhere around 1900's
Qing Dynasty
  • Major advantage: Immense population and economy, which could allow the player to grind down small modern forces with sheer manpower, assuming they aren't distracted by multiple ongoing rebellions throughout the map while also dealing with a foreign invasion.
This is also where the Qing and the rebels can have many reinforcement army stacks within the same battle for a long running grind, which will be problematic for the smaller modern forces if they can't break the hordes' morale fast enough. After all, what good are rifles and cannons when they run out of ammunition and the 6th reinforcement full-stack army showed up to replace all of the earlier shattered units?
As an idea of how much manpower the Qing (and the rebels, which will be discussed later) can field:
Some 20 million people died and 17 provinces were ravaged in this political and religious upheaval, which took place from 1850 to 1864
As the Taiping rebels crossed the countryside, their ranks had swelled from several thousand ragged peasants to more than 1 million disciplined and eager soldiers.
A meme video that summarized that rebellion:
  • Challenges: Survive (Think of the Western Roman Empire in TW: Attila, except this time in the industrial era). Corruption is incredibly rampant, but trying to crack down on that too hard and governors/generals may rebel.
Modernization will be necessary to prevent the foreign factions from continuing to carve up the Qing (which will cause even more rebellions in the remaining Qing provinces), but modernize too fast and it will cause its own rebellions (TW: S2 Fall of the Samurai style) or even have governors/generals rebel.
While the Qing and other factions may choose to seek foreign backing for easier modernization, aligning with one foreign faction means that foreign faction has free rein over the other faction, and thus could cause internal unrest, unbalanced trade agreements and other problems. It also means other foreign factions will be more hostile to that other faction if they were already hostile to that particular foreign faction (e.g. aligning with the Russians means the Japanese will not be too happy about that and thus risk getting the player dragged into a Russian vs. Japanese conflict).
Joseon (Korean dynasty)
  • Major advantage: Initially foreign factions will focus on the Qing Dynasty, which gives the player some time to try to deal with the corruption and internal rebellions and prepare for the inevitable showdown.
  • Challenges: Still have to pay tributes to the Qing Dynasty, which the player can opt to break that treaty and accept the consequences for it. Eventually foreign factions will come knocking on the door. Modernization is even harder, unless the player risks significant internal instability to get the Joseon to break its isolationism.
  • Major advantage: Like the Joseon, has some time to prepare for the inevitable conflict.
  • Challenges: A hostile British faction may opt to use its Indian forces to the south of Tibet to invade, especially as the Qing continues to weaken. Modernization is also difficult.
Northern nomadic tribes
  • Major advantage: Mass traditional cavalry go brrr
  • Challenges: Player can choose to stay aligned with the Qing, or rebel (which could risk a war on all sides, against the Qing and the other nomadic tribes). The Russia and Japanese factions will come knocking.
Should a nomadic tribe modernize or get major foreign backing, carbine/revolver cavalry and towed machine guns and light artillery guns go brrr.
Foreign colonial factions (Great Britain, France, Japan, Russia, United States, Germany and etc)
  • All of them have their own flavors and sub-challenges, such as the Russian faction whose main victory condition is a warm water port and a railroad link to it (which predictably pits it against the Japanese faction's victory goal to control Manchuria and German faction's victory goal to dominate the Qingdao region).
  • Some factions won't show up until mid/late game, such as Japan.
  • Major advantage: Generally have a significant technology advantage
  • Challenges: Generally limited quantity of forces and the colonial factions' victory goals conflict with each other, so a player may end up with a situation where on one front their modern forces are going up against other modern forces, and another front is dealing with horde of Qing full-stack armies. Recruiting more modern forces has a very long waiting time, which means losing a modern fullstack when the enemy has plenty of more forces to press forward could be game over (or at least cause a major death spiral).
Diplomacy is required with the Qing and other factions. It's generally cheaper to convince the Qing to give up a "small concession" and sign one-sided trade deals than to fight a grinding attrition war.
For some of the factions, the profitability of their operations dictate how much forces they can field, and if finances go into the red for too long or merchants/missionaries are constantly being harassed/killed, the home country may lose its patience and thus "boot" the player to trigger a game over. There will also be crisis or war events in Europe/America that puts major pressure on the diplomacy between the colonial factions.
Qing rebel factions (such as the Taiping Heavenly Kingdom)
  • Major advantage: The Qing faction is generally going to be busy dealing with other rebels and foreign forces, and the player can quickly recruit hordes of fullstacks of bullet sponge cannon fodder angry peasants after a few provinces are conquered. They may be able to get governors/generals to defect to them and thus bring their provinces or armies over to the player's side without a fight. They will be able to access more advanced units as they continue conquering more provinces
  • Challenges: Access to modern weapons will be difficult unless major favors are gained with a foreign faction. Sufficiently piss off both the Qing and the foreign factions (or a Qing that pulls itself together), and it'll likely be a curbstomp.
A few challenge modes (ultimate victory):
  • As the Qing, declare open war on all of the foreign factions to expel them. This predictably leads to those factions all allying together because they would rather have some of their colonial possessions rather than none.
  • As a Qing rebel faction, overthrow the Qing and then declare open war on all of the foreign factions to expel them.
  • As one of the foreign factions, declare that all of China belongs to you, triggering war with the Qing, Qing rebel factions and all of the other foreign factions.
submitted by COMPUTER1313 to historicaltotalwar [link] [comments]

2023.05.28 17:42 MangoNinjah Sign on bonus - are they worth it?

I’ve been offered a £5k sign on bonus with a basic salary of £55k.
The pay back period is 2 years.
As I’ll lose half of this to tax, is it worth the risk of owing more than I received if I don’t get on in the role for any reason?
Is there anything I’m missing?
submitted by MangoNinjah to UKPersonalFinance [link] [comments]

2023.05.28 17:42 beoto Community Recipe Testers?

Are any of you ATK community recipe testers?
I signed up some time ago ( but never get any emails from the program.
submitted by beoto to AmericasTestKitchen [link] [comments]

2023.05.28 17:42 berry_belle Off my chest: my life has been absolutely tragic from the offset.

I don’t know how it could get worse than this…
I was born to a lesbian couple, Lena and Robyn, in Willow Creek. They were so in love before I was born but as soon as I entered the world they argued constantly, Robyn was constantly tense and angry and this just made Lena sad.
They really struggled having a baby and when I was a toddler, Robyn left in the middle of the night. She ran away to Oasis Springs and I didn’t see her until I was a child. I’d pop in every now and again but we were never close because Robyn hated children. When I was a teenager, we sorta started to hang out more and get closer and I actually moved in with her to give Lena some more space as she’d just had a baby with a new wife, Mindy. My mum Robyn then started dating a toy boy, Trey, who was way younger than her, and they got engaged. I was fine with this, I got on with Trey quite well and was a bridesmaid at their wedding. Unfortunately they didn’t actually manage to get married as right when the vows were about to start, the caterer died and everyone was devastated. Robyn was so sad after this and her and Trey decided not to marry in the end, they took the untimely death as a sign.
By this point, my mum was really old, and we knew she’d die any day. I was living with her and looking after her when I received a phone call that Mindy, my step mum, had drowned. I immediately ran over to the house to find Lena and her three children distraught, crying over Mindy’s death. I couldn’t leave Lena to care for these three young children alone so I moved back in with her. It was nice for a while, just me, my mum and my half-siblings. But then I got a call to say Robyn had died. It was a shock to all of us, as we’d forgotten she was dying.
Whilst living with Lena and the kids I met a guy, Marcus Flex. He wasn’t really my type to start with but he really liked me and was persistent so I gave it a shot. We fell in love incredibly quickly and it was beautiful. By this time, Lena was getting old and only had a few days left. One of her life goals was to see a child get married so, in honour of her, Marcus and I married in the garden of her house, surrounded by family. The ceremony was lovely, despite the fact Marcus showed up in his swim shorts. However that evening Lena died on the living room floor. We were all devastated, and Marcus and I were left to care for the three boys, as well as Marcus’ toddler son Keegan, who we moved in. We were doing well caring for our new family. Marcus fit into the role of step dad perfectly and everyone started to get over the grief of the last few years.
One day, Marcus and I were floating together in the pool. It was incredibly romantic and beautiful until…he drowned. I was absolutely devastated. I didn’t stop crying for weeks. The children didn’t know what to do. Suddenly we were plunged into all living together with no other adults, navigating this grief. I decided to pack up the children and move them to an island in Windenberg. We figured a new, fresh start may be good. We built a beautiful gothic home with the funds from selling the Willow Creek house, and lived there happily for a few years. I stepped into the role of mother quite quickly, and despite having a goth phase to deal with my grief, raised the four children well (Mindy and Lena’s three and Marcus’ son).
They gradually all began to move out. When it was just me and the youngest in the house, I decided to get back into the dating game. That’s when I met Yuki Behr. I didn’t even know I liked girls at this point but we fell in love really fast and actually somehow got accidently pregnant. I was happy, we were both happy and decided to marry. My friend Arya painted a beautiful portrait of us on our wedding day, and it was a lovely ceremony at the Van Haunt Estate.
Once it was just Yuki, the baby (Heather) and I in the house, we decided to move Arya in to make some more money as neither of us had very high paid jobs. Heather and Arya got on great. It took Yuki some time to warm to Arya as we’d had some history and that made her mad but they got on eventually.
One day we went to a party and I was talking to this ghost, just making small talk, and I’m not sure what I did but Yuki became furious with me claiming I’d cheated on her. We had a huge fight (physical) in the Partihaus house and didn’t speak for the rest of the evening. We hated each other. Then, one day, right after Heather turned into a child, I was crushed by a Murphy bed. Yuki and I never resolved our issues, and I died mad at her.
Everyone was shocked and upset, understandably. But quite quickly after I died Yuki and Arya started woo-hooing (maybe as a way to cope with grief?) and had some children of their own. I’m angry. I sometimes show up and break their taps and toilet just to show how angry I am. But I suppose it’s good Yuki moved on and isn’t so sad anymore…
submitted by berry_belle to Sims4 [link] [comments]

2023.05.28 17:41 _Scarlets What can I do to let my date know that I’m horny and ready to have sex with him?

Firstly, my country is conservative and even though we matched on dating apps doesn’t mean we’re going to have sex, most of the guys on the app really just wants to make friends or start a serious relationship. I’m not into either of those just yet and I just want to have fun for now.
I’ve went on 11 different blind dates and met up but only 4 of them we ended up having sex after the date because the others wanted to start a serious relationship with me which I’m not ready for. I realize most of the guys are too timid to talk to me about sex face to face and we just end up doing nothing or I always have to bring up the conversation.
I don’t want to be the one initiating but if I really like my date and I have to take the lead, what can I do during the date that wont make him feel uncomfortable if he doesn’t want to have sex with me but also suggests to him that I’m horny and ready to have sex with him. Any body languages I can use? Or facial expressions? What do guys look for as a sign?
submitted by _Scarlets to dating [link] [comments]

2023.05.28 17:41 Glass_Adhesiveness_6 female main character

I want to read a novel where the female character is a cold,scum,yet badass yet we read it up,some kinda quick transmigration kinda novels,I don't mind reading even raws it just needs to fulfil the criteria.
Few favs of that criteria is 1) 荒海有龙女(dragon girl in the wild sea) I think there were more than 90 stories in it,and i enjoyed it all,The heroine's purpose is clear, she wants the love of human beings, but she doesn't love human beings. After reading each story, I feel a little sad. No one can get the love of the dragon girl, but none of their love is reserved for the dragon girl.
2)Ex-Girlfriend Blackens Every Day Every profound love story must have a cannon fodder ex-girlfriend. If one day the ex-girlfriend blackens… aah, that would be fun!
Blackened quote: Don’t be so quick to say like, I won’t be able to stop myself from hiding you away in the cabinet. Either you die, or I laugh as I watch you die. You thought you fell for an angel all on your own, therefore you deserve to be used by me
submitted by Glass_Adhesiveness_6 to OtomeIsekai [link] [comments]

2023.05.28 17:41 fabbbles Starhub IPTV down for EPL Final Day

Anyone else having the same issues? After having the WHOLE season to prevent what happened on the first weekend, it seems like they just don't care about giving basic service quality to consumers. I guess that's what happens when you essentially have a monopoly and everyone is forced to sign up with you.
submitted by fabbbles to singapore [link] [comments]

2023.05.28 17:41 Mercury-Rover SD free styling suggestions?

My location unfortunately doesn’t offer a lot of viable options on Seeking and many have been scammers, online content sellers, ‘platonic’s etc. it’s disappointing as there are actually quite a few colleges within a 30-40 min radius.
I’ve read on this forum several times that ‘any woman can be a sugar baby’. Inspired by this notion, I wonder what can I do to ‘free style’ as SD?
Anywhere should I frequent? Any ‘signs’ should I look for attractive women in those places? What should I do to signal I’m SD available? What would I do differently to approach vs. in a vanilla situation? I’m married in a dead bedroom and DADT situation but don’t have a ton of free time to spend at bars every night…
I wanted to bring it up for discussion as I might not be the only one who have these questions.
Many thanks in advance for your input!
submitted by Mercury-Rover to sugarlifestyleforum [link] [comments]

2023.05.28 17:40 Big_Perception_5604 Thought you may all appreciate a cringey and embarrassing story

Feel free to laugh at me, I sure do.
Back in the good old days, when I thought I’d met my soulmate (vom) I was telling my ex pwBPD how I always wanted to get a tattoo but could never settle on something. My ex is from the US so I of course had to teach him all the Aussie/NZ and British slang. He thought the word wanker was hilarious (similar to idiot or jerk-off for all the Americans playing at home). I jokingly said I wanted to get a ‘W’ on one finger and a picture of an anchor on another finger so I could secretly remind him from across the room how much of a wanker he is. My ex suggested we both get W⚓️ tattooed on our ring fingers. So we did. -Ragrets-
Half an absolute shitshow of a year later I gave him a tattoo machine and some red and black ink for his birthday. My ex was tattooed from the neck down and at some point I realised that almost half of his tattoos were matching with his victims before me, like some kind of ex graveyard on his body. (No, my ex is not Pete Davidson and I’ve only just realised the many similarities lol)
Fast forward a few months and my loving boyfriend blows up and throws a tantrum over the most stupid thing, followed by a proposal on one knee and then a single text message discard, block, ghost and replacement! Cue PTSD - yay!
Four months, many tears and nightmares later I go back to the US for a friend’s wedding and mini holiday with a friend from Reddit who was in a similar clusterfuck of a situation as me (hey J if you’re reading this!). I convince my ex to drop the suitcase of my things to my hotel and stop by for a quick conversation. I’m desperate for answers at this point. Of course I get absolutely no closure. I did however get an hour of his life updates. He tells me he already dumped my replacement weeks ago for her awful crime of paying more attention to their waiter than him while on a dinner date night. He laughs at her pending IG follow request and tells me how she’s dead to him. He doesn’t ask how I am or apologise, just tries to kiss me and take my clothes off. I tell him not a chance, he’s already told me more than once he doesn’t want me. He checks my finger to make sure I’m still branded. Yep. I fly home feeling slightly better.
Fast forward another month to yesterday and I recognise his rebound in my ‘people you may know’ on FB. We have his mother as a mutual friend! I click on her profile and her cover photo is a picture of them together. Guess they realised they were soulmates and got back together the day that I left! It also appears as though she has used the tattoo machine and red ink I bought him for his birthday to write her name on his FACE and his name on her wrist. I hear that he’s been publicly posting couples pics with accompanying love raps/poems for the last few weeks… so the loyalty world tour has commenced! Thankfully he still has me blocked.
Please join me for a moment of silence on behalf of the girl who just signed her fate in red ink.
Bullet dodged
submitted by Big_Perception_5604 to BPDlovedones [link] [comments]

2023.05.28 17:40 SusWall-Smm2 Chance me with a lower GPA (Class of 2024)

Gender: male
Race: white/hispanic
Income: $60-65k
School: small town public school
State: Pennsylvania
Potential Majors: computer engineering, engineering physics, or physics
Advanced Coursework:
My school only offers 8 APs.
Class Rank: Projected to be somewhere in the T10 out a class of 165 students.
SAT: I have only taken once so far. I got a 1530 (770 R, 760 M).
Colleges I am Interested in:
submitted by SusWall-Smm2 to chanceme [link] [comments]

2023.05.28 17:40 xuankun [Spoiler] Guel's future role (not a "real protag ree" post)

With recent events turning shit up to 11, I wanted to explore what I think Guel's role will be in the future.
What we've seen so far:
All this taken into account, I think Guel is not at all cut out for the world of politics and intrigue. Depending on what happens in the next few episodes there might not even be politics to be had before all out war is declared.
Guel's strengths lie in his piloting skill, his desire to help others, his determination, and his willingness to defer to his smarter allies. All that taken into consideration I think Guel is being set up to be a military leader of some sort. Not a general or strategist, but an on-the-ground, in the thick of things, leader of grunts. I could see him having a good relationship with his subordinates and being a loyal supporter of Miorine&Suletta's leadership.
The only stumbling block is that he is still heavily traumatized by killing his father, and seeing death and destruction up close on earth. Hopefully he can overcome this before getting back in a mobile suit.
What do y'all think?
submitted by xuankun to Gundam [link] [comments]

2023.05.28 17:40 VagrantScrub Mincemeat

How he hated the word.
What an awful state of affairs. To think his glorious army couldn’t subdue the humans. The fleet and those soft admirals and captains had brought them to this moment.
Always trying to slow down any progress.
Always trying to delay.
Caught up in infrastructure and supply. Endless counting. Endless reconnaissance. Endless prattling.
But no more.
The dead human had been their salvation.
A malfunction had cast him off course and rapidly depleted his air supply. The soldier had taken his own life before having to suffer the agonizing consequences of slow decompression.
The plans he carried had been verified. The window to strike with the information they had was closing. A knockout blow could be delivered to the humans at minimal cost to their own forces. It was perfect.
He would convince the Emperor at the next meeting. He had too!
The Emperor of Ten Thousand Stars could hardly bear the infighting of his advisors. Let alone the actual war.
Not for the first time he lamented his lot in life. He had been trained to rule as an able administrator. Not a warrior like his brother. Or his famous father who had struck so deep at the humans and their holdings. Both gone now but their ambitions could not be so easily reigned in even after their deaths.
A 230 year war was winding down with no victor.
History would remember him as a wimp. A loser. A weakling. The Empire might very well be dissolved from within. Every noble on every planet would see any negotiations as a ripe time for overthrowing him.
Or so it had seemed.
The High Marshall of the Infantry had conceived a daring strike with information they had gleaned from a dead human military courier. He had carried immensely important information about a buildup of something of vital importance to the humans.
He was no warrior but he was no technocrat either. He couldn’t quite understand the importance of two planetary sized factories being destroyed.
But he understood numbers.
To put such resources into not one but two stellar factory hubs? And then to lose them both? The loss in industrial capacity would be immeasurable. It could collapse the humans and their republic. The loss of such great technical and manufacturing hubs had brought galactic powers to their knees in the past. No reason to think it wouldn’t work on the humans.
He gave his blessings to the strike.
The war was lost. The High Admiral of the Navy was certain of it.
Former High Admiral he thought to himself.
It wasn’t that the plan was terrible. It was the sheer cost of moving such a large amount of ships and supplies. And at such breakneck speed. How could you move, gather, organize, and push with 9 fleets in less than 4 weeks? How do you even coordinate such a thing? There would be losses just from disrupting the set timetables for supply and patrols. The humans would notice.
These army fools were great at their own narrow expertise. But were wholly unable to grasp the intricacies of void combat and its logistics.
It takes years to build a simple cruiser. A complex dance between hundreds of competing noble bureaucracies to enable thousands of workers and tons of materials, equipment, and supplies to be ready and stockpiled just to ensure everything goes smoothly. Months to fill out the roster. Months more of training. Months still of drills and shakedown cruises. And then you have to keep them alive in battles long enough for that cruiser to start being able to reliably learn their roles and their limits.
He was positive that the plan would work but he simply could not believe that the two manufacturing nodes were so poorly defended. He would lose assets that were sorely needed on other fronts. The game of logistics was a game of expertly navigating catastrophe. And the plan would be all or nothing. That isn’t how you run a campaign even if it was foolproof. There was no proof success would bring down the humans. Hadn’t the last 230 years proven the humans staying power?
The army simply used their infantry forces as fodder. Wave after wave. Brute force. But a navy had to be smart and strategic with its resources. Elegant in its maneuvers. Decisive in its actions. To overextend was death for a fleet. And this would be the mother of all overextensions if it failed. 9 fleets were at risk. Every strategic reserve was being thrown in. They would win but at what cost?
And now, he mused, here I am. Hoping for the best of the people who ruined his career. Was it really so bad to negotiate? The Empire would probably go through violent convulsions but there had been no usurper in over six thousand years. It had always worked itself out.
He really hoped they knew what they were doing.
Why did that word drive them out of their senses!?
Madness. Stupidity. How could so many be so blind?
It was almost certainly a trap. How could it not be? A courier ship just happens to fail. The occupant just happens to hang himself right as his air runs out? The identity easily confirmed. The personal effects were spot on.
It was all too … convenient.
The courier shouldn’t have carried such detailed plans. Though it would be a perfect way to ensure operational security of a defect in their command. He admitted that openly. But … it was simply too perfect.
It was obviously a ruse.
But you can’t convince people who do not want to be convinced.
The Emperor saw a way out of the war he never wanted to inherit and enter history as a mighty Emperor. The High Marshall could retain his position and be remembered in history as a great commander. The High Admiral had been relieved but his main objection had simply been the extent of the plan rather than the obvious bait. Other advisors and technocrats had all sided with the Emperor. Everyone wanted a way to maintain their position. And no one seemed to think on the implications if they failed.
No one listened to him simply because he was not of noble birth. He had risen to his ranks with painful attention to his work. Nothing he pointed out had even hit a nerve with anyone.
Human patrols were noticeably lacking aggression. Why?
Human naval raids had decreased by nearly 18%. Why?
Reduced ship counts in human convoy runs had been observed. Why?
The human munition supplies to 5 different systems had dropped by nearly 55%. Why?
Where the hell was it all going!?
A counterstroke was in the works. But he and his intelligence assets had no idea where and when. And they wouldn’t have any reserves to stop such an attack if their own attack failed.
It was hard not to think that it was coming immediately after the deployment of their best strategic reserves.
What would they really find at those coordinates?
To think it might be finally ending. All of it.
The General stared at the corpse lying on the table.
His old friend. His old battle companion.
It was finally over.
The General looked over his shoulder to ensure his staff had left him alone as he had ordered. He took off his hat and jacket. Untucked his shirt and rolled up his sleeves. And began to clean up the corpse of his friend. A man who had once saved his life on a distant battlefield. It was the least he could do.
The strain had been too much for him. The trauma of it all had driven him to drink. Eventually costing him his marriage. His career. Everything.
He couldn’t even hold onto a job in any of the industries that so sorely needed labor. The despair and the drink eventually had driven him to rage.
And that rage had led to him murdering 2 workers at his local pub one day.
The verdict had been unanimous. The sentence? Death.
But the General had conceived of a new way to honor his friend. Let him get one more blow at the enemy. The corpse of his friend had to be just right.
His friend was now a Colonel in military intelligence. He would be carrying papers to that effect. He carried a digital letter to his wife letting her know he had put the drink behind him. Tickets to a local opera on Halcyon IV. An address tablet filled with appointments with important individuals.
He also carried a report too valuable to send over an open ftl comm line. A very important report. A report that would lead to the end of the war if the enemy bought into it. But they wouldn’t find a largely undefended strategic manufacturing hub. Mines, ftl inhibitors, and death would be all they found there.
The General began rolling down his sleeves. The corpse was cleaned up a bit. But not too much. And it was good they had hung him. It would be that much harder to ascertain anything amiss.
The General wondered what peacetime might be like finally. War was all he had known.
He chided himself. There was still a war to fight. No guarantee the enemy would even believe any of it.
He sure wouldn't.
submitted by VagrantScrub to HFY [link] [comments]

2023.05.28 17:38 KzulPunk69 Questions

If anyone could help me out. The drain line works up until about five feet then the water just stops. I believe it's under negative air, because forced air cones out when the cap is removed. Is it supposed to have a P trap, because it's negative. The unit/set-up is old and has never had a P trap on the condensation line. Maybe, the installation left no room for a trap ? Also, where's the damn drain pan on this thing? Maybe it's blocked. I lack the skill and knowledge to just start taking out screws. The unit runs , even better after I cleaned the outside fresh air intake, and all the returns. No leaks, just water stops flowing halfway to the floor drain. I just raise up the line right at the elbow and continue raising it while walking the line to drain it into the floor. It's just annoying and I'm on a tight budget, so calling in a professional isn't an option. Bonus question: What's behind the panel on the return ducts? There's one on either side .(filter maybe?)
Thanks, JD
submitted by KzulPunk69 to HVAC [link] [comments]