Serous fluid 2 By Dr Mohammed Shaat Anatomy

Serous fluid 2 By Dr. Mohammed Shaat

Anatomy Serous pericardium is thin double layered membrane. n The outer layer of parietal pericardium is fused with the fibrous pericardium. n The inner layer (visceral/Epicardium)is fused to heart. n The pericardial cavity is a potential space between the parietal and visceral pericardium. n

Cont… It is the serous visceral pericardium that secretes the pericardial fluid into the pericardial cavity n 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. n In a healthy individual there is usually 15 -50 ml of clear, straw - coloured fluid n

Pericardial Effusion A pericardial effusion is the presence of excessive pericardial fluid within the potential space of pericardium. n Rapid accumulation of pericardial fluid may cause elevated intrapericardial pressures with as little as 80 m. L of fluid, while slowly progressing effusions can grow to 2 L without symptoms. n

Cardiac Tamponade Pericardial effusion or blood compressing the heart enough to impair filling and pumping n The three principal features of Tamponade are: 1. Elevation of intracardiac pressures 2. Lmitation of ventricular filling 3. Reduction of cardiac output n

Causes Any condition lead to pericarditis can lead to pericardial effusion. n The most common cause are: A. Neoplastic disease B. Idiopathic pericarditis C. Uremia D. Following cardiac operation E. Trauma n

Sign and Symptoms 1. 2. 3. 4. 5. 6. Shortness of breath Weakness and fatigue Anxiety tachycardia Jugular vein engorged Cyanosis

Special feature n Beck triad: 1. Increased jugular venous pressure 2. Hypotension 3. Diminished heart sounds n Pulsus paradoxus: A greater than normal (10 mm. Hg) inspiratiory decline in systolic arterial pressure.

investigations n ECG : low voltage QRS complex n CXR: large globular n Echocardiograph: is the most useful technique. n Pericardicentesis

Pericardicentesis is a procedure used to remove the pericardial fluid from the pericardial cavity. It is performed either to establish the diagnosis or to drain the fluid in emergency cause ( Tamponade) n

procedure

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. n The fluid removed from the pericardial sac is sent to a lab to be analyzed n

Analysis Macroscopic ( Gross Appearance) n Chemical n Microscopic n

Macroscopic ( Gross Appearance) n n the normal appearance of a sample of pericardial fluid is straw colored and clear. Abnormal results may give clues to the conditions or diseases present and may include: Milky appearance—may point to lymphatic system involvement Reddish pericardial fluid may indicate the presence of blood Cloudy thick pericardial fluid may indicate the presence of microorganisms and/or white blood cells

Chemical Most common Protein & glucose n Protein used to differentiate between trasudate and exudate effusion. n Glucose in pericardial fluid samples is typically about the same as blood glucose levels. It may be lower with infection.

Microscopic examination n n Normal pericardial fluid has small numbers of white blood cells (WBCs) but no red blood cells (RBCs) or microorganisms. Increased WBCs may be seen with infections and other causes of pericarditis. WBC differential—determination of percentages of different types of WBCs. An increased number of neutrophils may be seen with bacterial infections. Cytology –. This may be done when a mesothelioma or metastatic cancer is suspected. The presence of certain abnormal cells, such as tumor cells or immature blood cells, can indicate what type of cancer is involved. Presence of Antimyocardial Abs suggests an immune mediated process

Again … Trasudate: n Physical characteristics—fluid appears clear n Protein or albumin level—decreased n Cell count—few cells are counted n Trasudate usually require no further testing. They are most often caused by either cirrhosis or congestive heart failure. Exudate: n Physical characteristics—fluid may appear cloudy n Protein or albumin level—higher than normal n Cell count—increased n Exudates can be caused by a variety of conditions and diseases and usually require further testing to aid in the diagnosis. Exudates may be caused by, for example, infections, trauma, various cancers, or pancreatitis.

BREAK

Peritoneal Fluid

Anatomy The parietal peritoneum lines the wall of abdominal and pelvic cavities, and visceral peritoneum cover the organ. n The potential space between the two layer is called peritoneal cavity n Up to 50 ml Fluid normally present in peritoneal cavity n

Peritoneal Effusion n n An accumulation of fluid in the peritoneal cavity is called Peritoneal effusion which is known as Ascites. Other name: Hydroperitoneum Abdominal dropsy

Sign and Symptoms Abdomen related: Everted umbilicus flank fullness Flank dullness( if absent this means that there is < 10% chance of having Ascites) there is at least 1. 5 liters of Ascites if dullness is present], shifting dullness Fluid thrill Keeping in mind other clinical feature related to the cause.

Investigation n USG : confirm the diagnosis of minimal amount of Ascites. n Paracentesis

Paracentesis n A relatively simple bedside procedure in which one inserts a needle into the abdomen, thereby evacuating either a small amount of ascites fluid for diagnostic purposes, or large amounts of fluid for therapeutic purposes. n It is the most cost-effective means of determining the cause of ascites.

Indication New-onset ascites n Anyone admitted to the hospital with ascites n Anyone with ascites who is showing signs/symptoms of infection n Clinical deterioration (fever, pain, tenderness, mental status change, hypotension) n

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

Procedure

Procedure n n n n n 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

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

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

Technique Avoid abdominal scars n Midline if possible n Midline is avascular n Inferior to umbilicus n Risk of entering bladder is low n n Lower quadrant approach

Analysis Macroscopic ( Gross Appearance) n Chemical n Microscopic n

Macroscopic Straw – Coloured Malignancy, Cirrhosis, infection, CCF and NS n Chylous Obstruction of lymphatic duct and cirrhosis n Hemorrhagic Malignancy, trauma, pancreatitis and ruptured ectopic pregnancy n

Fluid analysis

Cell Count: Normal ascetic fluid contain WBC<500/ mm 3 n Neutrophils count > 250/mm 3 strongly suggest SBP or secondary peritonitis due to perforation n Elevated WBC with predominance of lymphocytes suggest TB or CA. n Eosinophilia > 10% most commonly associates with chronic peritoneal dialysis n

Amylase &Glucose If the ascites is secondary to pancreatitis the amylase levels can be as great as five-fold higher than the serum levels n In uncomplicated ascites, usually similar to serum levels. n In later SBP (but often not in early), ascites glucose levels can drop to as low as zero mg/dl secondary to bacterial consumption n

Others n Lactate: An ascites lactate level of >25 mg/d. L was found n to be 100% sensitive and specific in predicting active SBP in a retrospective analysis. 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. n n n Blood and urine cultures should be obtained in all patients suspected of having SBP. Increase CEA in peritoneal washing suggest a poor prognosis of gastric Ca CA-125 extremely high in epithelial Ca of ovary, follopian tube or endometrium

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

Underlying cause of Ascites High gradient Ascites >1. 1 g/dl ( > 11 g/l) Cirrhosis Myexedma Budd Chiari syndrome Cardiac Ascites Low gradient Ascites <1. 1 g/dl ( <11 g/l) TB , Nephrotic syndrome, Pancreatic , Biliary Ascites postoperative lymphatic leakage Remember at least 4 causes each

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

Cont… Three forth of infections are due to aerobic gram-negative organisms (50% of these being Escherichia coli) n One fourth are due to aerobic gram-positive organisms (19% streptococcal species). n Anaerobic organisms are rare (1%) because of the high oxygen tension of ascitic fluid. n

• For large volume Ascites • Patients with complication s secondary to portal hypertension • Dietary • Drug incompliance Hospitalization Precipitating causes Guidelines of Ascites treatment • Salt restriction: • < 2 g /day or 88 mmol/day • If Na < 120 -125 water restriction is needed. Restriction Diuretics • Furosemide : spironolactone • 40: 100 ratio • Max: 160: 400 • If Gynecomastia amiloride 1040 mg po/day

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