Body FluidsBody Fluids

FluidsFluids

CSFCSF

Pleural FluidPleural Fluid

Peritoneal FluidPeritoneal Fluid

Pt with fever, nuchal rigidity....Pt with fever, nuchal rigidity....

1.1. Get blood cxGet blood cx2.2. Give AbxGive Abx

S. pneumo (30-50%), N. Meningitidis (10-35%), H. influenza (<5%), S. pneumo (30-50%), N. Meningitidis (10-35%), H. influenza (<5%), Listeria (5-10%), StaphListeria (5-10%), Staph

CeftriaxoneCeftriaxone 2mg IV q12h for GPC, GNR 2mg IV q12h for GPC, GNRVancVanc 1g IV BID for PCN-resistant Strep pneumo 1g IV BID for PCN-resistant Strep pneumoAmpicillinAmpicillin for Listeria (in elderly, young) for Listeria (in elderly, young)DecadronDecadron 0.4mg/kg IV q12 if concern for Bact infxn 0.4mg/kg IV q12 if concern for Bact infxn

Give with first dose of Abx!Give with first dose of Abx!Improves mortality, reduces incidence of hearing lossImproves mortality, reduces incidence of hearing loss

3.3. R/O increased ICP w/Head CT if neededR/O increased ICP w/Head CT if needed4.4. Lumbar punctureLumbar puncture

** Do not delay antibiotics waiting for CT or LP results **** Do not delay antibiotics waiting for CT or LP results **

Who to LP?Who to LP?

IndicationsIndications

Fever, vomiting, HA, photophobia, altered level Fever, vomiting, HA, photophobia, altered level of consciousness, leukocytosis, meningeal of consciousness, leukocytosis, meningeal signs...to r/o infection, malignancysigns...to r/o infection, malignancy

ContraindicationsContraindications

INR > 1.5INR > 1.5

Platelets < 50,000Platelets < 50,000

Risks of LPRisks of LP

First Do No Harm...First Do No Harm...

Post-lumbar puncture HAPost-lumbar puncture HA Have pt lie down 1-3 hrs afterHave pt lie down 1-3 hrs after the procedure the procedure

to prevent CSF leak to prevent CSF leak

Bleeding; spinal hematomaBleeding; spinal hematoma

Infection (poor sterile technique) Infection (poor sterile technique)

HerniationHerniation

ContraindicationsContraindications

infection at desired puncture siteinfection at desired puncture site- obstructive / non-communicating hydrocephalus- obstructive / non-communicating hydrocephalus- intracranial mass- intracranial mass- high intracranial pressure (ICP) / papilledema (relative - high intracranial pressure (ICP) / papilledema (relative contraindication, depends on etiology, especially with contraindication, depends on etiology, especially with intracranial mass lesion secondary to the increased risk intracranial mass lesion secondary to the increased risk of transtentorial or cerebellar herniation)of transtentorial or cerebellar herniation)- focal neurological symptoms/signs, decreased level of - focal neurological symptoms/signs, decreased level of consciousness (LOC) (see CT before LP section below)consciousness (LOC) (see CT before LP section below)- partial / complete spinal block- partial / complete spinal block- acute spinal trauma- acute spinal trauma

WHEN TO GET A CT FIRSTWHEN TO GET A CT FIRST

The absence of The absence of allall these features makes a significant these features makes a significant lesion precluding LP very unlikely:lesion precluding LP very unlikely:1) Age > 60 yrs1) Age > 60 yrs2) Immuno-compromised state (e.g. HIV)2) Immuno-compromised state (e.g. HIV)3) History of CNS disease (eg. grand mal seizures, brain 3) History of CNS disease (eg. grand mal seizures, brain tumour, hydrocephalus, multiple sclerosis)tumour, hydrocephalus, multiple sclerosis)4) Seizure within one week of presentation4) Seizure within one week of presentation5) Abnormal LOC5) Abnormal LOC6) Unable to answer two questions correctly or follow two 6) Unable to answer two questions correctly or follow two commandscommands7) Abnormal neurological examination (visual field 7) Abnormal neurological examination (visual field defect, facial palsy, pronator drift, aphasia)defect, facial palsy, pronator drift, aphasia)

Lumbar PunctureLumbar Puncture

ProcedureProcedurePt lies in L lateral decub position, knees to chestPt lies in L lateral decub position, knees to chestAim for the L3-L4 or L4-L5 intervertebral spaceAim for the L3-L4 or L4-L5 intervertebral space Posterior iliac crest as marker for L4-L5 spacePosterior iliac crest as marker for L4-L5 space Spinal cord ends L1-L2Spinal cord ends L1-L2

Prep/drape lower back in sterile fashion...lidocainePrep/drape lower back in sterile fashion...lidocaineInsert LP needle pointing towards umbilicus with the Insert LP needle pointing towards umbilicus with the bevel up, advance until “pop”bevel up, advance until “pop”Obtain opening pressure (only if pt lying down)Obtain opening pressure (only if pt lying down)Fill tubes #1-4 with CSFFill tubes #1-4 with CSF

CSF EvaluationCSF Evaluation

Tube 1-cell count and differentialTube 1-cell count and differential

Tube 2-glucose, proteinTube 2-glucose, protein

Tube 3-cultures, gram stain, cytology, Tube 3-cultures, gram stain, cytology, “other” studies (HSV PCR, West Nile, “other” studies (HSV PCR, West Nile, India ink, Crypto Antigen, VDRL, Lyme Ab, India ink, Crypto Antigen, VDRL, Lyme Ab, AFB, etc…)AFB, etc…)

Tube 4-cell count and differentialTube 4-cell count and differential

Normal CSF valuesNormal CSF values

Clear colorClear color

< 5 RBC’s< 5 RBC’s

< 5 WBC’s < 5 WBC’s

Protein 23-38mg/dl (alt. 14-45)Protein 23-38mg/dl (alt. 14-45)

Glucose - 60% of serum level (75-100)Glucose - 60% of serum level (75-100)

Opening pressureOpening pressure

Normal = 80-180 mmHg Normal = 80-180 mmHg

Obese pts: up to 250mmHg can be normalObese pts: up to 250mmHg can be normal

Pathologically elevated: > 250mmHgPathologically elevated: > 250mmHg

If elevated, likely due to cerebral edema If elevated, likely due to cerebral edema from intracranial pathologyfrom intracranial pathology Infection (cryptococcal meningitis), tumor, Infection (cryptococcal meningitis), tumor,

benign ICH (pseudotumor)benign ICH (pseudotumor)

RBCsRBCs

Always send tube #1 and #4 for cell count and compare Always send tube #1 and #4 for cell count and compare RBCsRBCs

Traumatic tapTraumatic tap: Elev RBC in tube 1, nl in tube 4: Elev RBC in tube 1, nl in tube 4 The RBC : WBC ratio should be the same as it is in the blood if it The RBC : WBC ratio should be the same as it is in the blood if it

is due to a traumatic tap (Approx 1000 RBC : 1 WBC)is due to a traumatic tap (Approx 1000 RBC : 1 WBC)Can find both values in the CBC (RBCs are in millions and WBCs Can find both values in the CBC (RBCs are in millions and WBCs are in thousands)are in thousands)

SAH or HSV:SAH or HSV: Elev RBC in tube 1 AND tube 4 Elev RBC in tube 1 AND tube 4““Crenated RBCs” and xanthochromia (yellow Crenated RBCs” and xanthochromia (yellow supernatant after centrifuge)supernatant after centrifuge)

Seen in hyperbilirubinemia (ESLD), old SAH, old blood from Seen in hyperbilirubinemia (ESLD), old SAH, old blood from prior traumatic LP or bleedprior traumatic LP or bleed

WBC’sWBC’s

Infection!Infection!

PMN predominance: likely bacterial PMN predominance: likely bacterial meningitismeningitis

Lymphocytic predominance: viral vs. Lymphocytic predominance: viral vs. fungal vs. TB vs. malignancyfungal vs. TB vs. malignancy

ProteinProtein

Normal: protein is excluded from CSF by Normal: protein is excluded from CSF by blood-CSF barrier blood-CSF barrier Increased: nonspecificIncreased: nonspecificElevated in all infectious meningitisElevated in all infectious meningitis May remain elevated for months post-May remain elevated for months post-

meningitis (viral or bacterial)meningitis (viral or bacterial)

Increased in malignancy and inflammatory Increased in malignancy and inflammatory conditions (ex. Guillain-Barre)conditions (ex. Guillain-Barre)

GlucoseGlucose

NormalNormal

Viral infectionViral infection

Low glucoseLow glucose

Bacterial meningitis, TB, fungalBacterial meningitis, TB, fungal

Really lowReally low

< 18 is strongly suggestive of bacterial < 18 is strongly suggestive of bacterial meningitismeningitis

Typical Viral MeningitisTypical Viral Meningitis

CSF WBC elevated, but < 250 (PMNs in CSF WBC elevated, but < 250 (PMNs in early disease, then lymphocytes)early disease, then lymphocytes)

CSF protein elevated, but < 150CSF protein elevated, but < 150

Glucose > 50% of serum concentrationGlucose > 50% of serum concentration

Typical Bacterial MeningitisTypical Bacterial Meningitis

CSF WBC > 1000, PMN predominanceCSF WBC > 1000, PMN predominance

CSF protein > 500mg/dlCSF protein > 500mg/dl

CSF glucose < 45 mg/dlCSF glucose < 45 mg/dl

ExampleExampleA previously healthy 33-year-old lawyer A previously healthy 33-year-old lawyer presents to the ER with acute onset headache presents to the ER with acute onset headache and confusion. He develops generalized and confusion. He develops generalized seizures in the ER. He is treated and sent for seizures in the ER. He is treated and sent for a head CT, which shows bilateral hemorrhage a head CT, which shows bilateral hemorrhage in the temporal lobes (and no hydrocephalus). in the temporal lobes (and no hydrocephalus). CSF: mild pleocytosis (mostly lymphocytes), CSF: mild pleocytosis (mostly lymphocytes), gluc= 60, protein = 30gluc= 60, protein = 30a) Arbovirus encephalitis a) Arbovirus encephalitis b) CNS toxoplasmosisb) CNS toxoplasmosisc) Echovirus encephalitisc) Echovirus encephalitisd) Herpetic encephalitisd) Herpetic encephalitise) Metastatic melanoma e) Metastatic melanoma

HSV MeningoencephalitisHSV MeningoencephalitisAseptic meningitis: CSF w/mild Aseptic meningitis: CSF w/mild ↑ ↑ lymphs, nl gluc, nl protlymphs, nl gluc, nl protMost common etiologic agent of sporadic viral Most common etiologic agent of sporadic viral encephalitisencephalitisPreviously healthy pt with rapid onset of confusion and Previously healthy pt with rapid onset of confusion and seizuresseizuresCT: hemorrhagic necrosis of the temporal lobesCT: hemorrhagic necrosis of the temporal lobesArbovirus encephalitisArbovirus encephalitis: most important cause of epidemic viral : most important cause of epidemic viral encephalitis; clinical course is milder and prognosis is better than encephalitis; clinical course is milder and prognosis is better than herpetic encephalitisherpetic encephalitisCNS ToxoCNS Toxo: in immunocompromised pts; round, ring-enhancing : in immunocompromised pts; round, ring-enhancing intracerebral massesintracerebral massesEchovirus encephalitisEchovirus encephalitis: common cause of asceptic meningitis; mild : common cause of asceptic meningitis; mild symptoms (headache, malaise) with normal CSF symptoms (headache, malaise) with normal CSF Metastatic melanomaMetastatic melanoma: CNS lesions may hemorrhage; but mets : CNS lesions may hemorrhage; but mets appear as space-occupying massesappear as space-occupying masses

Example #2Example #2

A 47 year-old male with HIV/AIDS (CD4 = A 47 year-old male with HIV/AIDS (CD4 = 15), noncompliant with meds, presents 15), noncompliant with meds, presents with altered mental status. He has had with altered mental status. He has had progressively worsening neck stiffness, progressively worsening neck stiffness, photophobia, and confusion over the past photophobia, and confusion over the past several weeks. On exam he appears several weeks. On exam he appears somnolent and confused. You perform an somnolent and confused. You perform an LP, opening pressure is 290 mm Hg, and LP, opening pressure is 290 mm Hg, and you see the following slide in the micro you see the following slide in the micro lab.lab.

Example #2Example #2

Example #2Example #2

What is the diagnosis?What is the diagnosis?

a) Herpes encephalitisa) Herpes encephalitis

b) Disseminated histoplasmosisb) Disseminated histoplasmosis

c) Cryptococcal c) Cryptococcal meningoencephalitismeningoencephalitis

d) Strep pneumo meningitisd) Strep pneumo meningitis

e) Tb meningitise) Tb meningitis

Cryptococcus neoformansCryptococcus neoformans

Fungal infection seen in immunodeficiency & Fungal infection seen in immunodeficiency & immunosuppression, esp. in organ transplants and AIDS (CD4 immunosuppression, esp. in organ transplants and AIDS (CD4 < 50). Signs/sxs of meningitis, but MS changes signify < 50). Signs/sxs of meningitis, but MS changes signify encephalitis. Direct visualization of encapsulated budding yeast encephalitis. Direct visualization of encapsulated budding yeast in CSF with India Ink stain. Can also see elevated opening in CSF with India Ink stain. Can also see elevated opening pressure and positive crypto antigen in the CSF or serum. pressure and positive crypto antigen in the CSF or serum. Requires lifelong suppressive fluconazole, at least until CD4s Requires lifelong suppressive fluconazole, at least until CD4s are reconstituted.are reconstituted.HSV encephalitisHSV encephalitis is seen in immunodeficiency, but the organisms are not is seen in immunodeficiency, but the organisms are not typically seen on microscopy.typically seen on microscopy.HistoplasmaHistoplasma is seen in pulmonary infections locally, but can disseminate to bone is seen in pulmonary infections locally, but can disseminate to bone marrow, liver…marrow, liver…Strep pneumoStrep pneumo is an encapsulated bacterium that can cause meningitis. is an encapsulated bacterium that can cause meningitis. Signs/sxs and CSF analysis is c/w bacterial meningitis (PMNs, Signs/sxs and CSF analysis is c/w bacterial meningitis (PMNs, ↓ glucose, etc)↓ glucose, etc)Mycobacterium tuberculosisMycobacterium tuberculosis can cause CNS disease with similar presenting can cause CNS disease with similar presenting symptoms, but acid-fast organisms are seen on CSF examination.symptoms, but acid-fast organisms are seen on CSF examination.

ExampleExamplePt with AIDS on Combivir (AZT/3TC) and Indinivir c/o leg Pt with AIDS on Combivir (AZT/3TC) and Indinivir c/o leg weakness, incontinence. On exam, reduced strength in weakness, incontinence. On exam, reduced strength in lower extremities with mild spasticity. Also diminished lower extremities with mild spasticity. Also diminished sensation in b/l feet, legs. Brain MRI: nonfocalsensation in b/l feet, legs. Brain MRI: nonfocalCSF: Opening pressure=100 mm H20, CSF: Opening pressure=100 mm H20, Cell count=5 lymphs, Glucose=48, Protein=33Cell count=5 lymphs, Glucose=48, Protein=33Normal serum B12, negative serum RPR, hct nl.Normal serum B12, negative serum RPR, hct nl.What’s he got?What’s he got?A. AIDS dementia complex A. AIDS dementia complex B. CMV polyradiculopathy B. CMV polyradiculopathy C. Cryptococcal meningoencephalitis C. Cryptococcal meningoencephalitis D. Vacuolar (HIV) myelopathy D. Vacuolar (HIV) myelopathy E. AZT neurotoxicity E. AZT neurotoxicity

HIV MyelopathyHIV Myelopathy

Common neurologic complications of AIDSCommon neurologic complications of AIDSDegeneration of spinal tracts in posterior, Degeneration of spinal tracts in posterior, lateral columns (causing them to look lateral columns (causing them to look vacuolated)vacuolated)Physical findings are similar to B12 deficiencyPhysical findings are similar to B12 deficiencyDiagnosis of exclusion!Diagnosis of exclusion!AIDS dementia complex:AIDS dementia complex: progressive memory loss, alterations in progressive memory loss, alterations in fine motor control, urinary incontinence, altered mental statusfine motor control, urinary incontinence, altered mental statusCMV polyradiculopathyCMV polyradiculopathy: CSF has neutrophilic pleocytosis: CSF has neutrophilic pleocytosisCrypto meningoencephalitis:Crypto meningoencephalitis: presents with signs/symptoms of presents with signs/symptoms of meningitis, and CSF shows fungusmeningitis, and CSF shows fungusZidovudine-related toxicity:Zidovudine-related toxicity: can cause asthenia, myopathy can cause asthenia, myopathy

ThoracentesisThoracentesis

IndicationsIndications

Diagnostic - All NEW effusions (except if Diagnostic - All NEW effusions (except if clearly due to heart failure)clearly due to heart failure) Suspected parapneumonic effusions must be Suspected parapneumonic effusions must be

tapped ASAP (“Don’t let the sun set on a new tapped ASAP (“Don’t let the sun set on a new pleural effusion”)pleural effusion”)

Therapeutic – Respiratory distressTherapeutic – Respiratory distress

Don’t do Thoracentesis if...Don’t do Thoracentesis if...

Coagulopathy (INR > 2, platelets < Coagulopathy (INR > 2, platelets < 25,000)25,000)

Severe lung disease on contralateral side Severe lung disease on contralateral side (risk of PTX – then what do you have left?)(risk of PTX – then what do you have left?)

Mechanical ventilation (not due to risk of Mechanical ventilation (not due to risk of PTX from PEEP, but due to decreased re-PTX from PEEP, but due to decreased re-sealing)sealing)

Loculated?Loculated?

Must be > 1 cm and free flowing in lateral Must be > 1 cm and free flowing in lateral decubitus viewdecubitus view

If CT shows free-flowing fluid, you don’t If CT shows free-flowing fluid, you don’t also need lateral X-rayalso need lateral X-ray

Thoracentesis ProcedureThoracentesis Procedure

Confirm fluid is free-flowing, not loculatedConfirm fluid is free-flowing, not loculatedObtain consentObtain consentConsider US mark if medium-size effusion or Consider US mark if medium-size effusion or loculatedloculatedHave pt sitting up and leaning forward over table to Have pt sitting up and leaning forward over table to spread the scapulae out of the wayspread the scapulae out of the wayPercuss fluid level and go 1-2 rib spaces below, in Percuss fluid level and go 1-2 rib spaces below, in midclavicular linemidclavicular lineEnter just ABOVE the rib to avoid neurovascular Enter just ABOVE the rib to avoid neurovascular bundle bundle ALWAYS obtain a post-procedure CXRALWAYS obtain a post-procedure CXR

Pt gets dyspneic after you’ve Pt gets dyspneic after you’ve withdrawn 150cc from L chest....withdrawn 150cc from L chest....

You took 2.3L clear fluid off this pt’s You took 2.3L clear fluid off this pt’s Right chest. F/u CXR shows....Right chest. F/u CXR shows....

Other Thoracentesis Other Thoracentesis ComplicationsComplications

PTXPTX

Re-expansion pulmonary edema Re-expansion pulmonary edema Don’t take off more than 1.5 LDon’t take off more than 1.5 L

HemothoraxHemothorax

InfectionInfection

HypotensionHypotension

Hepatic or Splenic punctureHepatic or Splenic puncture

What to order?What to order?

Serum LDH, total proteinSerum LDH, total proteinPleural fluid:Pleural fluid:

Total Protein, LDHTotal Protein, LDHGlucose, cell count and diff, pH (on ice)Glucose, cell count and diff, pH (on ice)Gram stain, culture, fungal stain and culture, AFBGram stain, culture, fungal stain and culture, AFBCytologyCytologyOther: triglyceride level to r/o chylothorax; Other: triglyceride level to r/o chylothorax; amylase to r/o pancreatitis, esoph perf; Adenosine amylase to r/o pancreatitis, esoph perf; Adenosine deaminase (ADA) to eval for Tb pleuritisdeaminase (ADA) to eval for Tb pleuritis

Light’s CriteriaLight’s Criteria

Fluid is exudative if it meets ANY criteria: Fluid is exudative if it meets ANY criteria:

1. Pleural fluid LDH/serum LDH > 0.61. Pleural fluid LDH/serum LDH > 0.6

2. Pleural fluid protein/serum protein > 0.52. Pleural fluid protein/serum protein > 0.5

3. Pleural fluid LDH > 2/3 upper limit of 3. Pleural fluid LDH > 2/3 upper limit of normal serum LDHnormal serum LDH

If all 3 negative, fluid is transudativeIf all 3 negative, fluid is transudative

TransudateTransudate

Result from imbalances in oncotic and Result from imbalances in oncotic and hydrostatic pressurehydrostatic pressureUsually low serum oncotic pressure +/- high Usually low serum oncotic pressure +/- high serum hydrostatic pressureserum hydrostatic pressurePulm Edema/CHFPulm Edema/CHFCirrhosis with ascitesCirrhosis with ascitesHypoalbuminemia/Nephrotic syndrome, ESLDHypoalbuminemia/Nephrotic syndrome, ESLDFluid overload s/p aggressive IVFFluid overload s/p aggressive IVFPeritoneal dialysisPeritoneal dialysis

ExudateExudate

Caused by local, not systemic, factorsCaused by local, not systemic, factors

InfectionInfection

NeoplasmNeoplasm

PancreatitisPancreatitis

Esoph perfEsoph perf

RARA

SLESLE

Sarcoid, Wegeners, PE, Meig’s, ChylothoraxSarcoid, Wegeners, PE, Meig’s, Chylothorax

LymphocytosisLymphocytosis

Malignancy (50-70% lymphs)Malignancy (50-70% lymphs)

Also TB, sarcoid, RA, chylothorax (>90% Also TB, sarcoid, RA, chylothorax (>90% lymphs)lymphs)

Pleural eosinophiliaPleural eosinophilia

PneumothoraxPneumothorax

HemothoraxHemothorax

Pulm infarctPulm infarct

Parasitic diseaseParasitic disease

Fungal infectionFungal infection

DrugsDrugs

MalignancyMalignancy

Asbestos Asbestos

Why is glucose low?Why is glucose low?(<60)(<60)

RARA

TBTB

EmpyemaEmpyema

SLESLE

MalignancyMalignancy

Esophageal ruptureEsophageal rupture

Who needs a chest tube?Who needs a chest tube?

EmpyemaEmpyema Frank pus OR Frank pus OR Positive gram stain ORPositive gram stain OR pH < 7.0 (consider when pH < 7.2)pH < 7.0 (consider when pH < 7.2)

Parapneumonic EffusionsParapneumonic Effusions

•Alternate to pH is pleural glucose (< 60)

•ACCP recommendations, from Chest, 2000

Parapneumonic EffusionsParapneumonic Effusions

Treatment:Treatment: Small, free-flowing, uninfected effusions (category Small, free-flowing, uninfected effusions (category

1/2) may not require any drainage, or serial 1/2) may not require any drainage, or serial thoracentesis.thoracentesis.

Complicated effusions and empyemas (category 3/4) Complicated effusions and empyemas (category 3/4) require drainage and interventionrequire drainage and intervention

Chest tubeChest tube

FibrinolyticsFibrinolytics

VATSVATS

SurgerySurgery

Example Example

A 59-year old man with HIV and Hepatitis C A 59-year old man with HIV and Hepatitis C develops progressive SOB and presents to the develops progressive SOB and presents to the ER with 90% sats on RA. On CXR, he has a ER with 90% sats on RA. On CXR, he has a large right-sided pleural effusion. large right-sided pleural effusion.

Serum LDH=200, serum protein = 5.6.Serum LDH=200, serum protein = 5.6.

Pleural fluid: LDH 100, protein 2700, WBC 400, Pleural fluid: LDH 100, protein 2700, WBC 400, pH 7.35, glucose=85pH 7.35, glucose=85

Exudate or transudate? Retap? Abx? Chest Exudate or transudate? Retap? Abx? Chest tube? tube?

Pleural fluid LDH/serum LDH=100/200= 0.5Pleural fluid LDH/serum LDH=100/200= 0.5 needs to be > 0.6 to be exudateneeds to be > 0.6 to be exudate

Pleural fluid protein/serum protein=2700/5600= 0.4Pleural fluid protein/serum protein=2700/5600= 0.4 needs to be > 0.5 to be exudateneeds to be > 0.5 to be exudate

Pleural fluid LDH is < 2/3 x (ULN serum LDH)Pleural fluid LDH is < 2/3 x (ULN serum LDH)Transudate Transudate Cause is cirrhosis/ascitesCause is cirrhosis/ascitesPresents w/right sided pleural effusionPresents w/right sided pleural effusionNo Abx or need to retapNo Abx or need to retapTreat the underling problem (ascites) w/ diuretics, Treat the underling problem (ascites) w/ diuretics, aldactone; optimize treatment for Hep C, HIV aldactone; optimize treatment for Hep C, HIV

ExampleExample

A 34 y.o. woman with cystic fibrosis presents to A 34 y.o. woman with cystic fibrosis presents to the ER with fever, cough and night sweats for 10 the ER with fever, cough and night sweats for 10 days. CXR shows LLL consolidation and days. CXR shows LLL consolidation and surrounding free-flowing effusion.surrounding free-flowing effusion.

The lab loses tubes for serum LDH, protein The lab loses tubes for serum LDH, protein

Pleural fluid: cloudy, LDH=1360, pH=6.9, gluc = Pleural fluid: cloudy, LDH=1360, pH=6.9, gluc = 36, gram stain neg36, gram stain neg

Does she need a chest tube? Fibrinolytics?Does she need a chest tube? Fibrinolytics?

ExudateExudate

because LDH > 2/3 upper limits of normal because LDH > 2/3 upper limits of normal serum LDHserum LDH

Category 3 (Moderate risk of poor outcome)Category 3 (Moderate risk of poor outcome)

pH < 7.2 and/or glucose < 60 mg/dL and/or pH < 7.2 and/or glucose < 60 mg/dL and/or Gram stain/culture positive and/or large (≥ ½ Gram stain/culture positive and/or large (≥ ½ hemithorax if free-flowing) and/or loculatedhemithorax if free-flowing) and/or loculated

No frank pusNo frank pus

Chest tube and Abx, consider fibrinolytics or Chest tube and Abx, consider fibrinolytics or surgical interventionsurgical intervention

ParacentesisParacentesis

Indications for paracentesisIndications for paracentesis

A febrile pt with ascites is assumed to A febrile pt with ascites is assumed to have SBP until proven otherwisehave SBP until proven otherwiseNew onset ascites—etiology?New onset ascites—etiology?Increasing abdominal pain/discomfortIncreasing abdominal pain/discomfortRespiratory compromiseRespiratory compromiseUnexplained leukocytosis, acidemia, renal Unexplained leukocytosis, acidemia, renal failurefailureAMSAMS

Risks of ParacentesisRisks of Paracentesis

Bowel perforationBowel perforation

Hemoperitoneum (0.01%)Hemoperitoneum (0.01%)

Hematoma (1%)Hematoma (1%)

Infection (0.01%)Infection (0.01%)

ContraindicationsContraindications

Coagulopathy is NOT a contraindicationCoagulopathy is NOT a contraindication But don’t do paracentesis if pt is in DICBut don’t do paracentesis if pt is in DIC

Must be careful if minimal fluid visualized on U/SMust be careful if minimal fluid visualized on U/S

If peritoneal carcinomatosis, do not do this If peritoneal carcinomatosis, do not do this procedure yourselfprocedure yourself Gut gets tethered to the anterior abdominal wall and Gut gets tethered to the anterior abdominal wall and

can’t move away from your needle; you can perforate can’t move away from your needle; you can perforate it.it.

ParacentesisParacentesis

Percuss pt’s abdomen for dullness/shifting Percuss pt’s abdomen for dullness/shifting dullnessdullnessAvoid obviously visible abdominal wall Avoid obviously visible abdominal wall collateralscollateralsAvoid inferior hypogastric artery (midway Avoid inferior hypogastric artery (midway between ASIS and lateral border of pubis)between ASIS and lateral border of pubis)If therapeutic, can drain > 4L safely for If therapeutic, can drain > 4L safely for symptomatic relief (BP check pre and post)symptomatic relief (BP check pre and post)Large-volume tap: give 1 bottle (12.5g) 25% Large-volume tap: give 1 bottle (12.5g) 25% albumin for each 2L ascitic fluid removedalbumin for each 2L ascitic fluid removed

Inferior hypogastric arteryInferior hypogastric artery

After paracetesis, SBP drops to After paracetesis, SBP drops to 90 and hct drops by 4 points... 90 and hct drops by 4 points...

What to send fluid forWhat to send fluid for

Cell count with diffCell count with diff

AlbuminAlbumin

LDHLDH

Total proteinTotal protein

GlucoseGlucose

Gram stain/cxGram stain/cx

CytologyCytology

Fungal stain and cxFungal stain and cx Esp. if peritoneal Esp. if peritoneal

dialysis catheter.dialysis catheter.

Appearance of fluidAppearance of fluid

Clear—usually indicates uncomplicated Clear—usually indicates uncomplicated ascites, ex. liver failure/cirrhosisascites, ex. liver failure/cirrhosis

Turbid/cloudy—infectedTurbid/cloudy—infected

Pink/bloody—traumatic, punctured Pink/bloody—traumatic, punctured collateral vessel, malignancycollateral vessel, malignancy Correct for bloody tap: 1 WBC: 750 RBCCorrect for bloody tap: 1 WBC: 750 RBC

1 PMN: 250 RBC1 PMN: 250 RBC

Serum-to-ascites albumin Serum-to-ascites albumin gradient (SAAG)gradient (SAAG)

= Serum albumin – ascitic fluid albumin= Serum albumin – ascitic fluid albuminIf the gradient is > 1.1: If the gradient is > 1.1:

Portal HTN (drives fluids into peritoneum)Portal HTN (drives fluids into peritoneum)cirrhosis, alcoholic hepatitis, CHF, massive liver cirrhosis, alcoholic hepatitis, CHF, massive liver metsmets

If the gradient is < 1.1:If the gradient is < 1.1:(protein leaks into peritoneum and fluid follows) (protein leaks into peritoneum and fluid follows)

Peritoneal carcinomatosis, peritoneal TB, Peritoneal carcinomatosis, peritoneal TB, pancreatitis, nephrotic syndrome, peritonitispancreatitis, nephrotic syndrome, peritonitis

Spontaneous Bacterial Spontaneous Bacterial PeritonitisPeritonitis

SAAG > 1.1SAAG > 1.1

Suspect if > 250 PMNs (> 100 PMNs in pt with Suspect if > 250 PMNs (> 100 PMNs in pt with peritoneal dialysis catheter)peritoneal dialysis catheter)

70% GNR (E.coli, Klebsiella)70% GNR (E.coli, Klebsiella)30% GPC (S. pneumo, Enterococcus)30% GPC (S. pneumo, Enterococcus)

Treat with ceftriaxone, cefotaxime, cipro/flagylTreat with ceftriaxone, cefotaxime, cipro/flagyl

““Culture negative SBP” if > 250 PMNs but cx Culture negative SBP” if > 250 PMNs but cx neg; treat the sameneg; treat the same

Bowel PerforationBowel Perforation

GPC in chains, GPR, GNR, fecal flora...GPC in chains, GPR, GNR, fecal flora...Increased PMN’s, Total protein > 1g/dl, Increased PMN’s, Total protein > 1g/dl, Glucose < 50 mg/dl, LDH elevatedGlucose < 50 mg/dl, LDH elevatedPt is SICKPt is SICK