Transcript Body Fluids and Infectious Complications

Body Fluids and
Infectious Complications
Body Fluids
• Intracellular
• Extracellular
• Plasma (fluid component of blood)
• Interstitial fluid (surrounds the cells)
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Pleural fluid
Ascites
Joint fluid
CSF
Pleural Effusion
• Collection of fluid in
pleural space resulting
from excess fluid
production, decreased
absorption, or both.
• Normal
• 1cc of fluid
• pH 7.6-7.64
• <1000 WBC
• Glucose = Plasma
• LDH < 50% of
plasma
Pleural Effusion
• Most common causes
• Cardiac Failure
• Pneumonia
• Malignancy
• 20-40% of pneumonias
will develop an infected
pleural effusion
Transudate
• Due to imbalance in
oncotic/hydrostatic
pressures
• pH > 7.2
• LDH <200
• Glucose >60
• Common causes
• CHF
• Cirrhosis
• Hypoalbuminemia
Exudate
• Due to inflammation
or decreased
lymphatic drainage
• pH <7.2
• LDH >3x normal
• Glucose ≤ 60
• Common Causes
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Pneumonia
Malignancy
Pancreatitis
Collagen-Vascular disorders
Light et al. criteria
• Exudate if:
• LDH > 2/3 upper limit of nl serum value
• Pleural:Serum LDH >.6
• Pleural:Serum Protein >.5
Pleural Fluid Testing
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Cell Count with Differential
Gram Stain
Culture
Cytology
Tumor Markers
Triglyceride
Cholesterol
Ascites
Abdominal Fluid
• Common Causes of Ascites
• Cirrhosis (80% of cases)
• Malignancy
• Heart Failure
• Can develop over days or months
Paracentesis
• Essential to determine diagnosis and to rule
out or confirm spontaneous bacterial
peritonitis (SBP)
• In presence of SBP, mortality
delay of paracentesis
by 3.3%/hr
• Is infection present? Is portal HTN present?
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Appearance (clear, bloody, cloudy, milky)
Serum:Ascites albumin gradient (SAAG)
Cell count & differential
Total protein
Ascites Fluid
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Culture with bedside
Glucose concentration
LDH
Amylase
Cytology
Triglyceride concentration
Ascites Fluid
• Appearance
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Clear (uncomplicated)
Cloudy (infected)
Milky (chylous / malignant)
Bloody (traumatic tap / cirrhosis / malignancy)
Brown (high bilirubin concentration)
• SAAG
• Identifies presence of portal HTN
• Ascites fluid albumin – serum albumin
• ≥ 1.1g/dL = portal HTN
Ascites Fluid
• Cell count & differential
• >250 WBC = consider infection
• Needs corrected in bloody taps
• WBC # - 1 for every 750 RBCs
• Neutrophil # - 1 for every 250 RBCs
• Protein
• ≥ 2.5-3 g/dL = exudate
• < 2.5 g/dL = transudate
• < 1g/dL = high risk of SBP
• LDH (ascitic fluid/serum ratio)
• ~ .4 = uncomplicated, likely due to cirrhosis
• ~ 1.0 = SBP
• Amylase
• ~2000 int. unit/L = pancreatic ascites
Septic Arthritis
Synovial Fluid
• Analysis is used to determine
presence of inflammation
• Unexplained inflammatory fluid
should be considered infected until
proven otherwise
• Repeat aspirates may be needed to
monitor response to treatment
• Normal synovial fluid
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Highly viscous
Clear
Acellular
Protein ~1/3 of plasma
Glucose = to plasma
Synovial Fluid Analysis
• Inflammatory
• Gout
• Rheumatologic conditions
• Non-inflammatory
• DJD
• Trauma
• Hemorrhagic
• Trauma
• Tumor
• Anticoagulation
• Septic
• Bacterial
• Viral
• Fungal
Synovial Fluid Analysis
• Cell count
• < 2000 WBC = non-inflammatory
• > 2000 WBC = inflammatory
• 50k – 150k WBC = bacterial
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Crystals
Gram stain & Culture
Cytology
Lower WBC counts can do not rule out
infection.
• Septic joints can coincide with inflammatory
“gouty” joints.
Cerebrospinal fluid
Cerebrospinal Fluid
• Produced in Choroid Plexus
& ventricles
• Normal volume = 125-150cc
• Normal production = 20cc/hr
• Reabsorbed in
Arachnoid Villi
• One-way valve for CSF
into blood
• Alteration of CSF Balance
• Infection
• Bleeding
• Tumor
Meningitis
• Inflammation of meninges (tissue surrounding the brain and
spinal cord)
• Bacteria enter through blood-brain barrier
• Bacteria rapidly replicate due to low concentration of
immunoglobulins
• Inflammatory response can lead to cerebral edema, increased
ICP, and neuronal damage
• Nuchal rigidity, Brudzinksi sign, Kernig sign
• Viral / Aseptic / Bacterial
Meningitis
Cerebrospinal Fluid
• Diagnosis of infection / malignancy
• Consider CT or MRI before LP
• Immunocompromise
• h/o CNS disease (mass, stroke,
infection)
• New onset seizure
• Mental status change
• Focal neurological deficit
• Papilledema (optic disc swelling)
CSF Composition
• Clear & Colorless
• Xanthochromia – discoloration of CSF due to RBC
• WBC: 0-5
• Increase WBC can be seen in infectious/non-infectious
etiologies
• RBC: 0-5
• Protein: 20-50 mg/dL
• Can be elevated by SAH, traumatic LP, infection, noninfectious etiologies (flow obstruction)
• Glucose (CSF:Serum ratio): ~ .6
• Typically low in infections
Pleural Fluid
Normal
• pH 7.6 – 7.64
• WBC <1000
• Glucose =
Plasma
• LDH <50% of
plasma
Exudate
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pH < 7.2
WBC >1000
Glucose < 60
LDH >3x
normal of
plasma
Ascites
Normal
• WBC < 250
• Protein <
2.5g/dL
• LDH (ascites:
serum) ~ .4
Infectious/
Inflamed
• WBC >250
• Protein > 2.5
g/dL
• LDH
(ascites:serum)
~ 1.0
SAAG
• Ascites
albumin –
serum Albumin
• > 1.1g/dL =
Portal HTN
Synovial Fluid
Normal
• WBC = none
Infected
• WBC
• <2000 = noninflammatory
• >2000 =
inflammatory
• > 50K = septic
CSF
Normal
• WBC 0-5
• Glucose:
CSF:Serum
ratio = ~ .6
• Protein 20-50
mg/dL
Abnormal
• WBC =
elevated
• Glucose =
decreased
• Protein =
elevated
Jessica Doiron, DNP, ANP-BC
Washington University School of Medicine
[email protected]