1、Body Fluids,Deborah Goldstein Argy Resident September, 2005,Fluids,CSF Pleural Fluid Peritoneal Fluid,Pt with fever, nuchal rigidity,Get blood cx Give Abx S. pneumo (30-50%), N. Meningitidis (10-35%), H. influenza (5%), Listeria (5-10%), Staph Ceftriaxone 2mg IV q12h for GPC, GNR Vanc 1g IV BID for
2、PCN-resistant Strep pneumo Ampicillin for Listeria (in elderly, young) Decadron 0.4mg/kg IV q12 if concern for Bact infxn Give with first dose of Abx! Improves mortality, reduces incidence of hearing loss 3. R/O increased ICP w/Head CT if needed 4. Do LP,Who to LP?,Indications Fever, vomiting, HA, p
3、hotophobia, altered level of consciousness, leukocytosis, meningeal signs.to r/o infection, malignancyContraindications INR1.5 Platelets 50,000,Risks of LP,First Do No Harm. Post-lumbar puncture HA Have pt lie down 1-3hrs after to prevent CSF leak Bleeding; spinal hematoma Infection (poor sterile te
4、chnique) Herniation,Lumbar Puncture,Procedure Pt lies in L lateral decub position, knees to chest Posterior iliac crest as marker for L3-L4 space Prep/drape lower back in sterile fashion.lidocaine Insert LP needle pointing towards umbilicus until “pop” Obtain opening pressure (only if pt lying down)
5、 Fill tubes #1-4 with CSF,CSF Evaluation,Tube 1-cell count and differential Tube 2-glucose, protein Tube 3-cultures, gram stain, cytology, (HSV PCR, West Nile, India ink, Crypto Antigen, VDRL, Lyme Ab, AFB.) Tube 4-cell count and differential,Normal CSF Composition,Clear color 5 RBCs 5 WBCs Protein
6、23-38mg/dl (can use 14-45) Glucose60% of serum level (75-100),Opening pressure,Normal = 80-180 mmHg Obese pts: up to 250mmHg can be normal Pathologically elevated: 250mmHg If elevated, likely due to cerebral edema from intracranial pathology Infection (cryptococcal meningitis), tumor, benign ICH (ps
7、eudotumor),RBCs,Always send tube #1 and #4 for cell count and compare RBCs Traumatic tap: Elev RBC in tube 1, nl in tube 4 1000 RBC : 1 WBC to adjust WBC count in bloody tap SAH or HSV: Elev RBC in tube 1 AND tube 4 “Crenated RBCs” and xanthochromia (yellow supernatant after centrifuge) Seen in hype
8、rbilirubinemia (ESLD), old SAH, old blood from prior traumatic LP or bleed,WBCs,Infection! PMN predominance: likely bacterial meningitis Lymphocytic predominance: viral vs. fungal vs. TB vs. malignancy,Protein,Normal: protein is excluded from CSF by blood-CSF barrier Increased: nonspecific Elevated
9、in all infectious meningitis May remain elevated for months post-meningitis (viral or bacterial) Increased in malignancy and inflammatory conditions (ie Guillain-Barre),Glucose,Normal Viral infection Low glucose Bacterial meningitis, TB, fungal Really low 18 is strongly suggestive of bacterial menin
10、gitis,Typical Viral Meningitis,CSF WBC elevated, but 50% of serum concentration,Typical Bacterial Meningitis,CSF WBC 1000, PMN predominance CSF protein 500mg/dl CSF glucose 45 mg/dl,Example,A previously healthy 33-year-old lawyer presents to the ER with acute onset headache and confusion. He develop
11、s grand mal seizures in the ER. He is treated and sent for a head CT, which shows bilateral hemorrhage in the temporal lobes (and no hydrocephalus). CSF: mild pleocytosis (mostly lymphocytes), gluc= 60, protein = 30a)Arbovirus encephalitis b)Brain toxoplasmosis c)Echovirus encephalitis d)Herpetic en
12、cephalitis e)Metastatic melanoma,HSV Encephalitis,Aseptic meningitis: CSF w/mild lymphs, nl gluc, nl prot Most common etiologic agent of sporadic viral encephalitis Previously healthy pt with rapid onset of confusion and seizures CT: hemorrhagic necrosis of the temporal lobes Arbovirus encephalitis:
13、 most important cause of epidemic viral encephalitis; clinical course is milder and prognosis is better than herpetic encephalitis CNS Toxo: in immunocompromised pts; round, ring-enhancing intracerebral masses Echovirus encephalitis: common cause of asceptic meningitis; mild symptoms (headache, mala
14、ise) with normal CSF Metastatic melanoma: CNS lesions may hemorrhage; but mets appear as space-occupying masses,Example,Pt with AIDS on Combivir (AZT/3TC) and Indinivir c/o leg weakness, incontinence. On exam, reduced strength in lower extremities with mild spasticity. Also diminished sensation in b
15、/l feet, legs. Brain MRI: nonfocal CSF: Opening pressure=100 mm H20, Cell count=5 lymphs, Glucose=48, Protein=33Normal serum B12, negative serum RPR, hct nl. Whats he got?A. AIDS dementia complex B. CMV polyradiculopathy C. Cryptococcal meningoencephalitis D. Vacuolar (HIV) myelopathy E. AZT neuroto
16、xicity,HIV Myelopathy,Common neurologic complications of AIDS Degeneration of spinal tracts in posterior, lateral columns (causing them to look vacuolated) Physical findings are similar to B12 deficiency Diagnosis of exclusion! AIDS dementia complex: progressive memory loss, alterations in fine moto
17、r control, urinary incontinence, altered mental status CMV polyradiculopathy: CSF has neutrophilic pleocytosis Crypto meningoencephalitis: presents with signs/symptoms of meningitis, and CSF shows fungus Zidovudine-related toxicity: can cause asthenia, myopathy,Thoracentesis,Indications Diagnostic -
18、 All NEW effusions (except if clearly due to heart failure) Therapeutic Respiratory distress Suspected parapneumonic effusions must be tapped ASAP (“Dont let the sun set on a pleural effusion”),Dont do Thoracentesis if.,Coagulopathy (INR2, platelets 25,000) Severe lung disease on contralateral side
19、(risk of PTX) Mechanical ventilation (not due to risk of PTX from PEEP, but due to decreased re-sealing),Loculated?,Must be 1 cm and free flowing in lateral decubitus view If CT shows free-flowing fluid, you dont also need lateral X-ray,Thoracentesis Procedure,Confirm fluid is free-flowing, not locu
20、lated Obtain consent Consider US mark if medium-size effusion or loculated Have pt sitting up and leaning forward over table Percuss fluid level and go 1-2 spaces below, in midclavicular line Enter just ABOVE the rib to avoid neurovascular bundle ALWAYS obtain a CXR post-tap,Pt gets dyspneic after y
21、ouve withdrawn 150cc from L chest,You took 2.3L clear fluid off this pts Right chest. F/u CXR shows,Other Thoracentesis Complications,PTX Re-expansion pulmonary edema Dont take off more than 1L Hemothorax Infection Hypotension Hepatic or Splenic puncture,What to order?,Serum LDH, total protein (Add
22、on to am labs) Pleural fluid: Total Protein, LDH Glucose, cell count and diff, pH (on ice) Gram stain, culture, fungal stain and culture, AFB Cytology Other: triglyceride level to r/o chylothorax; amylase to r/o pancreatitis, esoph perf; Adenosine deaminase to eval TB,Lights Criteria for Exudates,Fl
23、uid is exudate if it meets 1 of 3 criteria: 1. Pleural fluid LDH/serum LDH 0.6 2. Pleural fluid protein/serum protein 0.5 3. Pleural fluid LDH upper limit of normal serum LDH If all 3 negative, fluid is Transudate,Transudate,Result from imbalances in oncotic and hydrostatic pressure Usually low onco
24、tic +/- high hydrostatic pressure Pulm Edema/CHF Cirrhosis with ascites Hypoalbuminemia/Nephrotic syndrome, ESLD Fluid overload s/p aggressive IVF Peritoneal dialysis,Exudate,Caused by local, not systemic, factors Infection Neoplasm Pancreatitis Esoph perf RA SLE Sarcoid, Wegeners, PE, Meigs, Chylot
25、horax,Lymphocytosis,Malignancy (50-70% lymphs) Also TB, sarcoid, RA, chylothorax (90% lymphs),Pleural eosinophilia,Pneumothorax Hemothorax Pulm infarct Parasitic disease,Fungal infection Drugs Malignancy Asbestos,Why is glucose low? (60),RA TB Empyema SLE Malignancy Esophageal rupture,Who needs a ch
26、est tube?,Frank pus OR Positive gram stain OR pH 7.0,Non-TB Parapneumonic Effusions,Class 1 = “Nonsignificant” 10 mm thick on decub, pH7.2 , Glucose40 mg/dL GS neg, cx neg Diagnostic tap, then Abx alone Class 3 = “Borderline complicated” pH7.0, 1,000 and glucose40 mg/dL GS neg, cx neg Abx and serial
27、 thoracenteses,Grading Effusions,Class 4 = “Simple complicated” pH7.0 and/or glucose40 mg/dL and/or Gram stain/culture positive Not loculated or frank pus Chest tube and Abx Class 5 = “Complex complicated” pH7.0 and/or glucose40 mg/dL and/or Gram stain/culture positive Multiloculated Chest tube and
28、fibrinolytics (rarely require thoracoscopy or decortication),Grading Effusions,Class 6 = “Simple empyema” Frank pus Single locule or free flowing Chest tube +/- decortication Class 7 = “Complex empyema” Frank pus present Multiple locules Chest tube and fibrinolytics Often requires thoracoscopy or de
29、cortication,Example,A 59-year old man with HIV and Hepatitis C develops progressive SOB and presents to the ER satting 90% RA. On CXR, he has a large Right-sided pleural effusion. Serum LDH=200, serum protein = 5.6. Pleural fluid: LDH 100, protein 2700, WBC 400, pH 7.35, glucose=85 Exudate or Transu
30、date? Retap? Abx?,Pleural fluid LDH/serum LDH=100/200= 0.5 needs to be 0.6 to be exudate Pleural fluid protein/serum protein=2700/5600= 0.4 needs to be 0.5 to be exudate Pleural fluid LDH is ULN serum LDH Transudate Cause is cirrhosis/ascites Presents w/Right sided pl effusion No Abx or need to reta
31、p Tx the underling problem (ascites) w/diuretics, aldactone; optimize treatment for Hep C, HIV,Example,A 34 y.o. woman with cystic fibrosis presents to the ER with fever, cough and night sweats for 10 days. CXR shows LLL consolidation and surrounding free-flowing effusion. The lab loses tubes for se
32、rum LDH, protein Pleural fluid: cloudy, LDH=1360, pH=6.9, gluc=36, gram stain neg Does she need a chest tube? Fibrinolytics?,Exudate because LDHupper limits of normal serum LDH Class 4 = “Simple complicated” pH7.0 and/or glucose40 mg/dL and/or Gram stain/culture positive Not loculated or frank pus C
33、hest tube and Abx, no fibrinolytics,Paracentesis,Indications for paracentesis,A febrile pt with ascites is assumed to have SBP until proven otherwise New onset ascitesetiology? Increasing abdominal pain/discomfort Respiratory compromise Unexplained leukocytosis, acidemia, renal failure AMS,Risks of
34、Paracentesis,Bowel perforation Hemoperitoneum (0.01%) Hematoma (1%) Infection (0.01%),Contraindications,Coagulopathy is NOT a contraindication But dont do paracentesis if pt is in DIC Must be careful if minimal fluid visualized on U/S If peritoneal carcinomatosis, do not do this procedure yourself G
35、ut gets tethered to the anterior abdominal wall and cant move away from your needle; you can perforate it.,Paracentesis,Percuss pts abdomen for dullness/shifting dullness Avoid obviously visible abdominal wall collaterals Avoid inferior hypogastric artery (midway between ASIS and lateral border of p
36、ubis) If therapeutic, can drain up to 4L safely for symptomatic relief (BP check pre and post safe) Large-volume tap: give 1 bottle (12.5g) 25% SPA for each 2L ascitic fluid removed,Inferior hypogastric artery,After paracetesis, SBP drops to 90 and hct drops by 4 points.,What to send fluid for,Cell
37、count with diff Albumin LDH Total protein,glucose Gram stain/cx cytology,Appearance of fluid,Clearusually indicates uncomplicated ascites, ie liver failure/cirrhosis Turbid/cloudyinfected Pink/bloodytraumatic, punctured collateral vessel, malignancy Correct for bloody tap: 1 WBC: 750 RBC 1 PMN: 250
38、RBC,Serum-to-ascites albumin gradient (SAAG),=Serum albumin ascitic fluid albumin If the gradient is 1.1: Portal HTN (drives fluids into peritoneum) SBP, cirrhosis, Alcoholic hepatitis, CHF If the gradient is 1.1: (protein leaks into peritoneum and fluid follows) Peritoneal carcinomatosis, peritonea
39、l TB, pancreatitis, nephrotic syndrome,SBP,SAAG 1.1 Suspect if 250 PMNs (100 PMNs in pt on peritoneal dialysis) 70% GNR (E.coli, Klebsiella) 30% GPC (S. pneumo, Enterococcus) Treat with ceftriaxone, cefotaxime “Culture negative SBP” if 250 PMNs but cx neg; treat the same,Bowel Perforation,GPC in chains, GPR, GNR, fecal flora. Increased PMNs, Total protein 1g/dl, Glucose 50mg/dl, LDH elevated Pt is SICK,
