Body Fluids

Fluids
CSF Pleural Fluid Peritoneal Fluid

Pt with fever, nuchal rigidity....

1. Get blood cx 2. 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 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, photophobia, altered level of consciousness, leukocytosis, meningeal signs...to r/o infection, malignancy
Contraindications INR>1.5 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 technique) 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) 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 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 (pseudotumor)

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 hyperbilirubinemia (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 in all infectious meningitis
May remain elevated for months postmeningitis (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 meningitis

Typical Viral Meningitis

CSF WBC elevated, but <250 (first PMNs, then lymphocytes) CSF protein elevated, but <150 Glucose > 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 develops 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 = 30 a)Arbovirus encephalitis b)Brain toxoplasmosis c)Echovirus encephalitis d)Herpetic encephalitis 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: 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, malaise) 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/l feet, legs. Brain MRI: nonfocal CSF: Opening pressure=100 mm H20, Cell count=5 lymphs, Glucose=48, Protein=33 Normal 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 neurotoxicity

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 motor 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 - 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 (INR>2, platelets <25,000) Severe lung disease on contralateral side (risk of PTX) Mechanical ventilation (not due to risk of PTX from PEEP, but due to decreased resealing)

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 loculated 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 youve 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 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

Fluid 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 oncotic +/- 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, Chylothorax

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 chest tube?

Frank pus OR Positive gram stain OR pH < 7.0

Non-TB Parapneumonic Effusions

Class 1 = Nonsignificant <10 mm thick on decub. Dont tap, just observe Class 2 = Typical parapneumonic >10 mm thick on decub, pH>7.2 , Glucose>40 mg/dL GS neg, cx neg Diagnostic tap, then Abx alone Class 3 = Borderline complicated pH>7.0, <7.2 and/or LDH>1,000 and glucose>40 mg/dL GS neg, cx neg Abx and serial thoracenteses

Grading Effusions
Class 4 = Simple complicated pH<7.0 and/or glucose<40 mg/dL and/or Gram stain/culture positive Not loculated or frank pus Chest tube and Abx Class 5 = Complex complicated pH<7.0 and/or glucose<40 mg/dL and/or Gram stain/culture positive Multiloculated Chest tube and 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 decortication

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 Transudate? 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 retap 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 serum LDH, protein Pleural fluid: cloudy, LDH=1360, pH=6.9, gluc=36, gram stain neg Does she need a chest tube? Fibrinolytics?

Exudate because LDH>upper limits of normal serum LDH Class 4 = Simple complicated pH<7.0 and/or glucose<40 mg/dL and/or Gram stain/culture positive Not loculated or frank pus Chest 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 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
Gut 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 pubis) 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 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 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, peritoneal 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