Body Fluids l Serous fluids l Cerebrospinal fluid

Body Fluids

l Serous fluids l Cerebrospinal fluid (CSF)

Serous fluids l Pleural fluid l Pericardial fluid l Peritonial fluid

Pleural fluid

Pleural fluid l Between visceral and parietal pleura l It is normally about 110 ml l Mositening the pleural surface l An increased volum is called effusion

Pleural effusion Definition the accumulation of excess fluid within the pleural space in response to injury, inflammation, or both may represent a local response to disease or may just be a manifestation of a systemic illness

Pleural effusion Rate of Fluid Accumulation Rate of Removal 1. Altered Pleural Membrane Permeability 2. Decreased Intravascular Oncotic Pressure 3. Increased Capillary Hydrostatic Pressure 4. Lymphatic Obstruction 5. Abnormal Sites of Entry

Clinical Manifestations l Pain l Cough l Dyspnea l Dullness to Percussion l Diminished or Absent Vocal Resonance l Diminished or Absent Tactile Vocal Fremitus l Friction Rub

Radiologic Assessment (1) l Chest X-Ray: PA & Lateral-Decub blunting of either costophrenic angle is indicative of the accumulation of between 250 - 500 ml of fluid l Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis

Radiologic Assessment (2) l Ultrasound: Helpful in Confirming the Presence of a Small Pleural Effusion & Identifying Loculations l C. T. : Extremely Sensitive !! also helps to view the underlying lung (which may be obscured by pleural disease) l can distinguish between Lung Abscess & Empyema l

pp= parietal pleura & Pv=viseral pleura

Pleural Fluid Analysis 1. Gross Appearance 2. Cell Count & Differential 3. Gm Stain, C & S 4. Cytology 5. LDH 6. Protein 7. Glucose, Amylase

Thoracentesis l Thoracentesis ( also known as thoracocentesis or pleural tap (is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula , or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia.

l A thoracentesis can be diagnostic , which means it is being done to determine the cause of the fluid, for which usually only a syringe of fluid is removed, or it can be a therapeutic thoracentesis , in which the procedure is being done in order to remove as much fluid as possible to relieve symptoms for a patient, with sometimes as much as two liters of effusion fluid being removed.

l Pleural effusions do not require thoracentesis: - Underlying congestive heart failure - After recent thoracic or abdominal surgery.

l The recommended location varies depending upon the source. It is critical that the patient holds their breath to avoid piercing the lung. Some sources recommend the midaxillary line , in the ninth intercostal space.

Contraindications Ø Bleeding diathesis, Ø Systemic anticoagulation, Ø Cutaneous infection over site, Ø Severe hemodynamic or respiratory compromise, Ø Mechanical ventilation.

Complications l Pain at the puncture site, l Cutaneous or internal bleeding, l Pneumothorax, l Empyema, l Spleen/liver puncture.

l The illustration shows a person having thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag

Transudate colorless, clear, odorless fluid with a WBC less than 1000 / mm 3 l Pleural Membranes are Intact l Secondary to Altered Starling Forces l Low in Protein & other Large Molecules CHF, Cirrhosis, Nephrotic Syndrome Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, Megi syndrome

Exudate l Characterized by Increased Protein & LDH [Pleural Fluid vs. Serum Levels] l Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage Parapneumonic, Infections, Malignancy, Vasculitic Disease, GI Disease, TB, PE(pulmonary embolism)

”Criteria for “Exudative Effusion criteria value 1. Pleural Protein : Serum Protein > 0. 5 2. Pleural LDH : Serum LDH > 0. 6 3. Pleural LDH > 200 only need 1 critical value to establish the diagnosis of exudate

l Light’s criteria: Transudate vs. Exudate ¡ Pleural fluid protein / serum protein > 0. 5 ¡ Pleural fluid LDH / serum LDH > 0. 6 ¡ Pleural fluid LDH > 2/3 ULN serum LDH

l Other criteria: Transudate vs. Exudate ¡ Pleural fluid cholesterol > 45 mg/d. L ¡ Pleural fluid protein > 3 g/d. L

although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity appropriate treatment may produce dramatic symptomatic relief !

DIFFERENTIAL DIAGNOSIS Table 57 -1

l l l l Greater than 10000 per μL--- Parapneumonic effusion, pancreatitis, pulmonary embolism, collagen vascular disease, malignancy, tuberculosis. Polymorphonuclear（ PMN） leukocytosis--- Acute disease such as pneumonia, pulmonary embolism, pancreatitis, intra-abdomen abscess, early tuberculosis. lymphocyte- 100%= Tuberculosis Mononuclear cell--- Malignancy, tuberculosis, resolving acute process. Eosinophil--- Benign asbestos, drug reaction as nitrofurantoin, bromocriptine, dantrolene, paragonimiasis（low glucose, low p. H, high LDH）. Eosinophils >10% ¡ caused in about two thirds of cases by blood or air in the pleural space. More than 50% WBC in exudates are small.

Pleural fluid--- glucose l Glucose typically about the same as blood glucose levels. l Less than 60 mg/d. L-Causes: Ø Empyema Ø Malignant effusion Ø Tuberculosis effusion Ø Rheumatoid effusion( usually less than 20)

Pleural fluid--- amylase Elevated above the upper normal limit of serum amylase---- Esophageal perforation, pancreatic disease, malignancy（10%）. l Acute pancreatitis accompanying pleural effusion --- 10%. l Chronic pancreatic disease may develop a sinus tract between the pancrease and the pleura space. l The amylase associated with malignancy--- salivary type. l

Pleural fluid--- lactic acid dehydrogenase l Pleural fluid lactic acid dehydrogenase--- good indicator of the degree of inflammation in pleural space. l LDH increase, the inflammation worsening.

Pleural fluid--- cytology l Establishing the diagnosis of malignant pleural effusion--- 40 -90%. l Depending on--- the tumor type, amount of fluid, skill of cytologist.

Pleural effusion--- bacteriology l Culture and bateriologic stain--- culture both aeobic and anaerobic, mycobacteria, fungi. l Gram’s stain.

Pleural fluid--- p. H and p. CO 2 l Less than 7 (empyema) Complicated parapneumonic effusion and tube thoracostomy should instituted. l Less than 7. 2 --- systemic acidosis, esophageal rupture, rheumatoid pleuritis, tuberculosis pleuritis, malignant pleural disease, hemothorax.

Hemothorax l Blood in the pleural cavity. l Usually results from chest injury. l A blood vessel ruptures into the pleural space or aortic aneurysm leaks blood into the pleural space. l Can occur as a result of bleeding from the ribs, chest wall, pleura, and the lung.

Pleural Fluid Hct l l l Because a RBC count as low as 5000 cell /mm 3, can cause a pleural effusion to turn red, the finding of blood-tinged fluid per se has little diagnostic value (usually from needle trauma) A True Hemothorax is when the Pleural Fluid Hct exceeds 50 % of the Peripheral Blood Hct If Bloody: ¡ Hct <1% not significant ¡ 1 -20% = CA, PE, Trauma ¡ >50% serum Hct = hemothorax

l Here is an example of bilateral pleural effusions. Note that the fluid appears reddish, because there has been hemorrhage into the effusion.

A bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction is Indicative of Neoplasm in 90 % of cases!

Pleural fluid l Other diagnostic test on pleural fluid--l Chylothorax---Triglycerides > 110 mg/dl, l Pseudochylothorax--- the level of cholesterol increase. l Bloody effusion: mesothelioma

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Pericardial Fluid

Pericardial Fluid l Surrounding the heart is a sac known as the pericardium, which consists of two membranes. The outer layer being the fibrous parietal pericardium and the inner layer being the serous visceral pericardium. It is the serous visceral pericardium that secretes the pericardial fluid into the pericardial cavity, (the space between the two pericardial layers).

l The pericardial fluid reduces friction within the pericardium by lubricating the epicardial surface allowing the membranes to glide over each other with each heart beat

l In a healthy individual there is usually 15 - 50 ml of clear, straw-coloured fluid. l However there is little data on the normal composition of pericardial fluid to serve as a reference

Pericardial effusion A pericardial effusion is the presence of excessive pericardial fluid, this can be confirmed using an echocardiogram l Small effusions are not necessarily dangerous and are commonly caused by infection such as HIV or can occur after cardiac surgery. l Large and rapidly accumulating effusions may cause cardiac tamponade , a life-threatening complication, that puts pressure on the heart preventing the ventricles from filling correctly. l

Cardiac tamponade: the accumulation of fluid in the pericardium in an amount sufficient to cause serious obstruction to the inflow of blood to ventricle results in cardiac tamponade. l The three principal features of tamponade are: 1. elevation of intracardiac pressures 2. limitation of ventricular fillng 3. reduction of cardiac output l

The amount of fluid necessary to produce the critical state: Acute tamponade: 150 -200 ml Chronic tamponade: 10002000 ml

l The most common causes are: a. neoplastic disease b. idiopathic pericarditis c. uremia d. following cardiac operation e. trauma

A. clinical features 1. 2. 3. 4. 5. 6. Shortness of breath Weakness and fatigue Anxiety tachycardia Jugular vein engorged Cyanosis

l Beck triad: 1. increased jugular venous pressure 2. hypotension 3. diminished heart sounds l Pulsus paradoxus: A greater than normal (10 mm. Hg) inspiratiory decline in systolic arterial pressure.

l The CXR of cardiac tamponade:

The echocardiogram of cardiac tamponade: 1. echo free space between epicardium and pericardium l

Pericardiocentesis is a procedure used to remove the pericardial fluid from the pericardial cavity. It is performed using a needle and under the guidance of an ultrasound l It can be used to relieve pressure from pericardial effusions or for diagnostic purposes, revealling the cause of abnormalities such as: l Cancer, Cardiac perforation, Cardiac trauma, Congestive heart failure, Pericarditis rupture of a ventricular aneurysm

Pericardiocentesis l Anesthesia l Light sedation will be given to help you relax. You will be awake during the procedure. A local anesthesia will be injected at the insertion site. It will numb an area on your chest. l Description of Procedure l You will lie on a table. An IV line will be inserted into your arm. The sedative will be delivered this way. The area where the needle will be inserted will be washed. Your heart will be monitored. The needle will be inserted into the chest. It will be slowly moved toward the heart. Ultrasound and possibly fluoroscopy will be used to help guide the needle to the correct location. The needle will be passed into the pericardial sac, but no further. Once in the pericardial sac, the fluid will be removed. The needle may be used, or a catheter tube may be inserted over the needle. After some fluid is collected or enough of the fluid has drained out, the needle or catheter will be removed. Pressure will be applied to the injection site for several minutes. This is done to stop the bleeding. In some cases, your doctor may leave the catheter in place. This will allow draining to continue over several hours or days. l l l .

Pericardiocentesis needle insertion sites. The subxiphoid and the left sternocostal margin are the most commonly used sites (black dots)

Immediately After Procedure You will have a chest x-ray to make sure your lung has not been punctured. You will be closely monitored for several hours after the procedure. Your pulse, blood pressure, and breathing will be checked regularly. l The fluid removed from the pericardial sac is sent to a lab to be analyzed. l l How Long Will It Take? l About 20 -60 minutes l How Much Will It Hurt? l You may feel pain when the needle is inserted

l Average Hospital Stay Hospital stay can vary from one day to several days. If the catheter remains in place to continue draining fluid, you may need to stay in the hospital several days.

Types l transudative( congestive heart failure , myxoedema , nephrotic syndrome) l Exudative( tuberculosis , spread from empyema) l haemorrhagic( trauma, rupture of aneurysms, malignant effusion ) l Malignant (due to fluid accumulation caused by metastasis)

l l l Exudative pericardial effusion developed in over 80% of cases Presence of antimyocardial Abs suggests an immune mediated process Hct and RBC count have limited value in differential diagnosis of pericardial effusions. Total WBC > 10, 000/ul suggests bacterial, Tb or malignant pericarditis Metastatic Ca of lung and breast are most frequent cause of malignant pericardial effusion

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Peritonial fluid

l Up to 50 ml Fluid normally present in peritoneal cavity l Peritoneal effusion is called Ascites l Laboratory criteria for dividing ascitic fluid into transudate and exudate is not well defined as it is for pleural fluid

Ascites: Physical diagnosis l Bulging flanks l Flank dullness l Shifting dullness

Paracentesis : Indications l New onset ascites l Clinical deterioration (fever, pain, tenderness, mental status change, hypotension) l Suspicion of infection by labs (leukocytosis, acidosis, renal dysfunction) l Alleviation of discomfort/dyspnea

Precautions l Severe coagulopathy or thrombocytopenia l Pregnancy l Organomegaly l Bowel obstruction l Intraabdominal adhesions l Distended urinary bladder (Foley first)

Procedure l l l l l Identify the patient Obtain consent Perform a “time-out” Identify best site for procedure Sterilize Protect yourself Anesthesia Paracentesis Fluid to the lab for analysis Document procedure and any complications

Technique l Avoid abdominal scars l Midline if possible ¡ Midline is avascular ¡ Inferior to umbilicus ¡ Risk of entering bladder is low

l Semirecumbent position is most common l Dullness at site of needle entry l Ultrasound guidance l Metal needle ¡ 1. 5 inches ¡ 22 -gauge for diagnostic paracentesis ¡ 16 -gauge for therapeutic paracentesis

l Disinfect skin with iodine solution l Local anesthetic for skin and subcutaneous tissue l Sterile gloves l Z-tract l Do not aspirate continuously

Fluid analysis

Cells Total leukocyte useful in spontaneous bacterial peritonitis (SBP) l Approximately 90% of (SBP) have leukocyte count > 500/ml and over 50% neutrophiles l Eosinophilia > 10% most commonly associates with chronic peritoneal dialysis. Also in CHF, vasculitis, lymphoma and ruptured hydatid cyst l Overall sensitivity of cytology for malignant ascitis is 40 -65% l

Amylase activity in normal peritoneal fluid is similar to blood levels l A fluid amylase level greater than three times of serum value is good evidence of pancreas-related ascitis and also in GI perforation l Increase CEA in peritoneal washing suggest a poor prognosis of gastric Ca l CA-125 extremely high in epithelial Ca of ovary, follopian tube or endometrium l

l Other studies of ascitic fluid to be considered l Lactate: An ascites lactate level of >25 mg/d. L was found to be 100% sensitive and specific in predicting active SBP in a retrospective analysis. l p. H: In the same study, the combination of an ascites fluid p. H of <7. 35 and PMN count of >500 cells/m. L was 100% sensitive and 96% specific. l Blood and urine cultures should be obtained in all patients suspected of having SBP.

Albumin Is portal hypertension present? SAAG >/= 1. 1 g/d. L

SAAG l Serum-Ascites Albumin Gradient = serum albumin – ascites albumin l > 1. 1 = portal hypertension l < 1. 1 = non-portal hypertension

SAAG classification

Spontaneous Bacterial Peritonitis (SBP)

l Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of ascitic fluid. l Patients with cirrhosis and ascites carry a 10% annual risk of ascitic fluid infection.

Predisposing factor may be : l Intestinal bacterial overgrowth l Impaired phagocytic function l Low serum and ascites complement levels l Decreased activity of the reticuloendothelial system

Etiologic agents (>90% intestinal flora) ¡ Three forth of infections are due to aerobic gram-negative organisms (50% of these being Escherichia coli) ¡ One fourth are due to aerobic gram-positive organisms (19% streptococcal species). ¡ Anaerobic organisms are rare (1%) because of the high oxygen tension of ascitic fluid.

Clinical presentation and diagnosis of ascitic fluid infection l A broad range of symptoms and signs are seen in SBP. A high index of suspicion must be maintained when caring for patients with ascites, particularly those with acute clinical deterioration. l Completely asymptomatic cases in as many as 30% of patients. l Fever and chills occur in as many as 80% of patients. l Abdominal pain or discomfort is found in 70% of patients. l Worsening or unexplained encephalopathy l Diarrhea

l Diagnostic paracentesis and direct inoculation of routine blood culture bottles at the bedside with 10 m. L of ascitic fluid must be performed. l The results of aerobic and anaerobic bacterial cultures, used in conjunction with the cell count, prove the most useful in guiding therapy for those with SBP.

An ascitic fluid neutrophil count of >500 cells/m. L is the single best predictor of SBP.

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