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Preparation and Patience!

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Preparation and Patience! Aniket Rali, PGY-3 LP IR Procedure Order LP CSF Analysis Normal CSF Glucose: CSF to serum glucose ratio of 0.6 Protein: 23-38 mg/dL ... – PowerPoint PPT presentation

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Title: Preparation and Patience!


1
Preparation and Patience!
  • Aniket Rali, PGY-3

2
Outline
  • Procedures
  • Laboratory orders
  • Analysis

3
Paracentesis
4
Paracentesis - Technique
  • Patient position
  • Ultrasound evaluation
  • Needle insertion site

5
Paracentesis - Technique
  • Necessary tools
  • Z-technique

6
Paracentesis When is it needed?
  • New onset ascites.
  • Hospitalization of a patient with ascites.
  • Management of tense ascites or ascites resistant
    to diuretics.
  • Evaluation of a patient with ascites who has
    signs of clinical deterioration such as fevers,
    abdominal pain, acidosis, worsening renal
    function and hepatic encephalopathy.
  • Relative contraindications
  • DIC or bleeding from needle sticks
  • Primary fibrinolysis
  • Massive ileus

7
Paracentesis Large Volume
  • Removal of gt 5 L of fluid at once.
  • Upper limit is usually felt to be 12-15 L as long
    as you aggressively replete Albumin.
  • How much Albumin?
  • 6 8 grams of Albumin is recommended for every
    liter removed when you remove gt 5 L at once.
  • Why Albumin?
  • Midodrine as an alternate. N 40, no difference
    in serum renin levels as compared to Albumin.

8
Paracentesis - Labs
  • Routine Labs
  • Cell count with differential
  • Albumin
  • Total Protein
  • Optional Labs
  • Gram stain
  • Bacterial culture
  • LDH
  • Amylase
  • Glucose
  • Unusual Labs
  • TB smear and culture
  • Adenosine Deaminase Activity
  • Cytology
  • TGs
  • Billirubin
  • Serum pro-BNP
  • CEA concentration
  • Alkaline Phosphate

9
Paracentesis - Ascitic Fluid Orders
10
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11
Paracentesis IR Procedure Order
12
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13
Paracentesis Serum Ascites Albumin Gradient
  • High Albumin Gradient (SAAG gt 1.1 g/dL)
  • Cirrhosis
  • Alcoholic Hepatitis
  • Heart Failure
  • Massive Hepatic Mets
  • Constrictive Pericarditis
  • Budd - Chiari Syndrome
  • Portal Vein Thrombosis
  • Idiopathic Portal Fibrosis
  • Low Gradient (SAAG lt 1.1 g/dL)
  • Pancreatitis
  • Serositis
  • Nephrotic Syndrome
  • TB
  • Peritoneal Carcinomatosis

14
Paracentesis Spontaneous Bacterial Peritonitis
  • Elevated PMN cells (gt 250 cells/mm3), positive
    ascitic fluid culture and absence of secondary
    perotinitis.
  • Absolute PMN cells can be calculated with total
    cell count and percentage of PMNs.
  • 1 PMN is subtracted from the absolute PMN count
    for every 250 red blood cells/mm3, especially if
    there is concern for traumatic paracentesis.
  • Antibiotic treatment for SBP should not be
    delayed for cultures to return.
  • Other labs
  • Glucose can near zero in secondary peritonitis
    due to high PMN count. Generally remains gt 50
    mg/dL in SBP.
  • Amylase increased with pancreatitis or gut
    perforation
  • LDH increased in SBP (from PMN lysis) and even
    higher in secondary peritonitis. Sterile ascitic
    fluid has levels around 43 units/L

15
Paracentesis Tale of two SBPs
  • Secondary Bacterial Peritonitis
  • Ascitic fluid infection with positive ascitic
    fluid bacterial culture, and PMN count gt250
    cells/mm3 in the setting of a surgically
    treatable intra-abdominal source of infection.
  • Why is it important to distinguish between
    spontaneous and secondary BP?
  • Mortality of secondary bacterial peritonitis
    approaches 100 if treatment only consists
    antibiotics without surgical interventions.
  • Mortality of spontaneous bacterial peritonitis is
    about 80 if a patient receives an unnecessary
    exploratory laparotomy.
  • So how do you differentiate between the two?
  • Runyons Laboratory Criteria (need atleast two)
    total protein lt 1 g/DL, glucose lt50 mg/dL and LDH
    greater than upper limit of normal serum.
  • Polymicrobial growth in culture may suggest gut
    perforation.
  • Proceed with further imaging if the patient meets
    these criteria and/or your clinical suspicion is
    high.

16
Thoracentesis
17
Thoracentesis - Technique
  • Patient position
  • Ultrasound evaluation
  • Needle insertion site

18
Thoracentesis - Technique
  • Necessary tools
  • Lung Sliding Sign on US

Video link https//www.youtube.com/watch?vXxdedx
1HtHo
19
Thoracentesis When is it needed?
  • Evaluation of new pleural effusion.
  • Symptoms management.
  • Assistance with extubation.
  • It is recommended that no more than 1500-1600
    cc of pleural fluid to drained at once to reduce
    the risk of pulmonary re-expansion edema.

20
Thoracentesis Labs
  • Other Labs
  • Cholestrol
  • TGs
  • Amylase
  • Adenosine Deaminase
  • NT-proBNP
  • Tumor Markers
  • Routine Labs
  • Serum and pleural LDH
  • Serum and pleural total protein
  • Cell count with differential
  • Gram stain and culture
  • Cytology
  • pH
  • Glucose

21
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22
Thoracentesis IR Procedure Order
23
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24
Thoracentesis Transudative vs Exudative
  • Lights Criteria (atleast 1 of 3 to be exudative)
  • Pleural fluid protein/serum protein ratio greater
    than 0.5
  • Pleural fluid LDH/serum LDH ratio greater than
    0.6
  • Pleural fluid LDH greater than 2/3rd the upper
    limit of normal serum LDH (lab specific)
  • Two-test Rule (atleast 1 of 2 to be exudative)
  • Pleural fluid cholesterol greater than 45 mg/dL
  • Pleural fluid LDH greater than 0.45 times upper
    limit of normal serum LDH
  • Three-test Rule (atleast 1 of 3 to be exudative)
  • Two-test rule plus,
  • Pleural fluid protein greater than 2.9 g/dL

25
Thoracentesis All that glitters aint Gold
  • Most transudates have absolute total protein
    concentrations below 3.0 g/dL.
  • However, acute diureses in heart failure can
    concentrate pleural fluid and tilt protein levels
    towards exudative range.
  • In such patients serum to pleural fluid albumin
    gradient greater than 1.2 g/dL is diagnostic of
    exudative effusion.

26
Thoracentesis Definitive Diagnoses
  • Empyema positive culture, purulent effusion
  • Malignancy positive cytology
  • Tuberculous pleurisy positive AFB stain, culture
  • Esophageal rupture high salivary amylase, low pH
    (often as low as 6)
  • Fungal related effusions positive fungal stain,
    culture
  • Chylothorax TGs gt 110 mg/dL
  • Hemothorax ratio of pleural fluid to blood
    hematocrit gt 0.5
  • Peritoneal dialysis Protein lt 0.5 mg/dL and
    pleural fluid to serum glucose ratio gt 1 L in PD
    patients
  • Urinothorax pleural fluid creatinine to serum
    ration always gt 1 but diagnostic if gt 1.7
  • Rheumatoid pleurisy cytologic evidence of
    elongated macrophages and distinctive
    multi-nucleated giant cells (tadpole cells).
  • CSF leak Detection of beta-2 transferrin.

27
Lumbar Puncture
28
LP - Technique
  • Patient position (sitting upright or lateral
    recumbent position)
  • Needle insertion site (highest points of iliac
    crests L3/L4 or L4/L5 interspace)
  • CSF collection

29
LP When is it needed urgently?
  • To help diagnose
  • Suspected CNS infection (except brain abscess or
    parameningeal process)
  • Suspected subarachnoid hemorrhage in a patient
    with a negative CT scan

30
LP Where else can it help with diagnoses?
  • Pseudotumor Cerebri
  • Carcinomatous meningitis
  • TB Meningitis
  • Normal pressure hydrocephalus
  • CNS Syphilis
  • CNS Vasculitis
  • LP as a therapeutic modality
  • Spinal anesthesia
  • Intrathecal administration of antibiotics or
    chemotherapy
  • Pseudotumor Cerebri

31
LP Contraindications Complications
  • Contraindications
  • No absolute contraindications to this procedure.
  • Raised intracranial pressure (increased
    herniation risk), bleeding disorders and
    suspected spinal epidural abscess make this a
    risky procedure.
  • Complications
  • Post-LP headache
  • Infection
  • Bleeding
  • Cerebral herniation
  • Back pain
  • Minor neurologic symptoms such as radicular pain
    or numbness

32
LP - Labs
  • Routine Labs
  • Glucose
  • Protein
  • Cell count with differential
  • Gram stain and culture
  • Bacterial antigens
  • Viral PCR/Culture
  • Fungal stain and culture
  • Lactate
  • Cytology

33
LP Lab Orders
34
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35
LP IR Procedure Order
36
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37
LP CSF Analysis
  • Normal CSF
  • Glucose CSF to serum glucose ratio of 0.6
  • Protein 23-38 mg/dL
  • Cell count upto 5 WBCs and 5 RBCs

38
LP CSF Analysis
  • Abnormal CSF

Glucose (mg/dL) lt 10 10-45
More common Bacterial Meningitis Bacterial Meningitis
Less common TB, Fungal Meningitis Neurosyphillis
Protein (mg/dL) gt 250 50-250
More common Bacterial Meningitis Viral Meningitis, Lymes Disease and Neurosyphillis
Less common TB Meningitis
Total WBC gt 1000 100 - 1000 5 - 100
More common Bacterial Meningitis Bacterial, Viral or TB Meningitis Viral, TB, Neurosyphillis or Early Bacterial
Less common Some cases of Mumps Encephalitis Encephalitis
39
Acknowledgements
  • Dr. Cassandra Kovach
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