Fluid Analysis

幾種常見要判讀的體液 Ascites Pleural effusion Synovial fluid CSF (cerebrospinal fluid)

Ascites Analysis Routine tests: Optional tests Unusual tests Cell count and differential : 1 PMN for 250 red cells/mm3 Albumin Total protein Culture in blood culture bottle Optional tests Glucose LDH Gram stain Amylase Unusual tests TB smear/culture Cytology Triglyceride Bilirubin

Ascites Analysis 10~20mL fluid in 100mL blood culture  increase culture positive rate. Several mL of fluid in red-top tube for biochemistry: albumin, total protein, glucose, LDH, amylase, Bilirubin. 1 mL in puple-top tube for cell count Gram stain

Ascites Analysis SBP(spontaneous bacterial peritonitis) Ascites PMN ≧ 250 cell counts/mm3 Positive ascites bacterial culture Serum-ascites albumin gradient High SAAG (≧1.1 g/dL) Cirrhosis Alcoholic hepatitis Congestive heart failure Massive hepatic metastasis Constrictive pericarditis Budd-Chiari syndrome Low SAAG (< 1.1 g/dL) Peritoneal carcinomatosis Peritoneal tuberculosis Pancreatitis serositis Nephrotic syndrome

Ascites Analysis Secondary bacterial peritonitis Ascites PMN ≧ 250 cell counts/mm3 Positive ascites bacterial culture A surgically treatable intraabdominal infection Total protein >1 g/dL Glucose < 50 mg/dL LDH > upper limit of normal serum level Amylase increases in pancreatitis or gut perforation Bilirubin level should be checked when ascites reveals brown or dark orange color(>serum level/>6mg/dL)

Ascites Analysis The importance between SBP and 2nd bacterial peritonitis: The mortality of 2nd bacterial peritonitis approaches 100% if treatment consists only antibiotics with no surgical intervention. The mortality is approximately 80 % if a patient with SBP receives an unnecessary exploratory laparotomy.

Pleural effusion Transudate or Exudate Light’s Criteria: Pleural effusion protein/serum protein ratio > 0.5 Pleural effusion LDH/serum LDH > 0.6 Pleural effusion LDH > 2/3 upper limit of normal LDH level. Two-test rule Pleural effusion cholesterol > 45 mg/dL Pleural effusion LDH > 0.45 times the upper limit of serum level Three-test rule Pleural effusion protein > 2.9 g/L Pleural effusion LDH > 0.45 times the upper limit of serum LDH level

Pleural effusion Complicated pleural effusion tubal thoracotomy? Complicated parapneumonic effusion pH < 7.20 LDH > 1000 Glucose < 40 mg/dL

Synovial fluid Number of joints Possible problem 1 = monoarthritis Trauma-induced arthritis Septic arthritis Crystal induced arthritis Osteoarthritis (acute) Lyme disease Avascular necrosis tumor 2~3 = oligoarthritis Reiter’s syndrome Ankylosing spondilitis Gonococcal arthritis Acute rheumatic fever > 3 = polyarthritis SLE RA Viral arthritis Chronic osteoarthritis

Measure Normal Noninflamm-atory Inflammatory Septic Hemorrhagic Volume, mL (knee) <3.5 Often > 3.5 Often >3.5 Usually >3.5 clarity Transpar- ent Transparent Translucent-opaque Opaque bloody Color Clear Yellow Yellow to opalescent Yellow to green Viscosity high low Variable WBC <200 200~2000 2000~10000 >100000 PMN(%) <25 ≧ 50 ≧ 75 50~75 Culture Negative Often positive negative Total protein 1~2 1~3 3~5 4~6 LDH Very low High similar glucose Equal >25 lower <25 much lower equal