1. Body Fluids Serous, Synovial, CSF

2. Types of Fluids Serous Fluids Other Fluids Synovial Fluid Joints
Pleural Fluid (Thoracic) Chest
Peritoneal Fluid (Ascitic) Abdomen
Pericardial Fluid Heart
Other Fluids
Synovial Fluid Joints
Cerebral Spinal Fluid (CSF) Brain and Spinal chord
Amniotic Fluid Uterus
Semen

3. Types of Fluids Serous Fluids
Pleural Fluid - thoracic or chest
Thorocentesis - procedure used to obtain Pleural Fluid
Empyema - pus in pleural fluid
Peritoneal Fluid - (Ascitic) Fluid in Abdomen
Paracentesis is procedure used to obtain fluid from body cavity
Chylous Effusion Chyle or Lymph fluid
Pericardial Fluid Fluid around the heart
Other Fluids
Synovial Fluid from joints
Cerebral Spinal Fluid Brain and Spinal chord
Amniotic Fluid
Semen

4. Formation of Serous Fluids
Serous fluid is an ultrafiltrate of plasma
An Increase in the following causes Fluid to form
Hydrostatic Pressure drives fluid out of capillaries into body cavity
Capillary Permeability
A Decrease in the following causes a fluid to form
Colloid Osmotic Pressure(COP) Protein in capillaries is impermeable
Protein in capillaries absorbs fluid from cavity. Albumin contributes more than globulins The greater the amount of albumin the greater the COP.
Lymphatic Drainage Absorb fluid, protein and particulate matter from extravascular space.

5. Effusion
Abnormal increase in fluid
Transudate vs Exudate

6. Transudate
Increased Capillary Hydrostatic Pressure Congestive Heart Failure Retention of Salt and Fluid
Decreased Oncotic Pressure (Low serum protein) Nephrotic Syndrome Hepatic cirrhosis Malnutrition Protein losing enteropathy

7. Exudate
Increased Capillary Permeability Microbial infections Membrane Inflammations Malignancy
Decreased Lymphatic Drainage Tumors Infection and inflammation Thoracic Duct Injury

8. fluid protein/ serum protein
Transudate vs Exudate
Transudate
Exudate
Main causes
Increased hydrostatic pressure, Decreased colloid osmotic pressure
Inflammation
Appearance
Clear[1]
Cloudy[1]
WBC count
< 1000uL
>1000uL
Spontaneous Clotting No
Yes
Specific gravity
< 1.012
> 1.020
Protein content
< 2.5 g/dL
> 2.9 g/dL[2]
fluid protein/ serum protein
< 0.5
> 0.5[3]
Difference of (SAAG)
(S Alb minus F Alb) albumin content with blood albumin
> 1.2 g/dL
< 1.2 g/dL[4]
fluid LDH upper limit for serum
< 0.6 or < 2⁄3
> 0.6[2] or > 2⁄3[3]
Cholesterol content
< 45 mg/dL
> 45 mg/dL[2]
References[edit]
^ Jump up to: a b The University

9. Transudate or Exudate John Smith Billy Rubin Serum Protein 7.0 gm/dL
Fluid Protein
2.5 gm/dL
2.0 gm/dL
Fluid/Serum Ratio
Transudate or Exudate
Cause of Effusion
Diagnosis

10. Transudate or Exudate John Smith Billy Rubin
Serum Protein (6.0 – 8.0 gm/dL)
7.0 gm/dL
5.0 gm/dL
Fluid Protein
2.5 gm/dL
2.0 gm/dL
Fluid/Serum Ratio
2.5/7.0 = 0.35
2.0/5.0 = 0.4
Transudate or Exudate
Transudate
Cause of Effusion
Increased Capillary Hydrostatic Pressure
Decreased COP
Diagnosis
Congestive Heart Failure
Nephrotic Syndrome, Malnutrition, Hepatic Cirrhosis

11. Transudate or Exudate Bobby Biuret Billy Rubin Serum Protein 7.0 gm/dL
Fluid Protein
5.0 gm/dL
2.0 gm/dL
Fluid/Serum Ratio
Transudate or Exudate
WBC count
12,000
500
Cause of Effusion
Diagnosis

12. Transudate or Exudate Bobby Biuret Billy Rubin Serum Protein 7.0 gm/dL
Fluid Protein
5.0 gm/dL
2.0 gm/dL
Fluid/Serum Ratio
5.0/7.0 = 0.7
> 0.5
2.0/7.0 = 0.3
< 0.5
Transudate or Exudate
Exudate
Transudate
Fluid WBC
12,000
> 1000
500
< 1000
Cause of Effusion
Increased Capillary Permeability or Lymphatic Obstruction
Decrease in COP
Diagnosis
Infection, Malignancy, Inflammation
Nephrotic Syndrome, Malnutrition

13. Pleural Fluid Hematology
Normal
Disease
Macrophage
64 – 80 %
Lymphocytes %
Increased TB
Viral Infections
Autoimmune disorders (Rheumatoid Arthritis)
Malignancy
Neutrophils
1- 2%
Increased Bacterial Infection
Pancreatitis
Pulmonary Infarction
Mesothelial cells
Decreased in TB
Eosinophils
>10% Trauma air (pneumothorax)or
blood (hemothorax)
Allergic reactions
Parasitic infections

14. Transudate vs Exudate

15. Synovial Fluid

16. Synovial Fluid Crystals Viscosity Hyaluronic acid
Fluid should be viscous
Test WBC, Dif, Gram stain, culture, and crystal ID

17. Synovial Fluid Crystals
Monosodium Urate (MSU) Gout
Calcium Pyrophosphate (CPPD) Pseudogout
Cholesterol

18. IV. Microscopic Examination
Cell Count – WBCs
Method
Use Neubauer counting chamber
May pretreat viscous fluids with hyaluronidase & incubate at 37oC for 5 min.
Dilution with hypotonic saline is used to lyse any RBCs OR
Dilute with normal saline/methylene blue mixture to differentiate WBCs from RBCs
Normal = <200 / uL
Differential Count
Cytocentrifuge specimen and prepare typical blood smear
Normal: 60% monocytes, macrophages
neutrophils: <20%
lymphocytes: <15%
(* values vary between texts)
Increased neutrophils – possible septic condition
Increased lymphocytes – indicate nonseptic inflammation

19. Other cell abnormalities:
Increased eosinophils – rheumatic fever, parasitic infections, metastatic carcinoma, post radiation therapy or arthrography
LE cells – patients with lupus erythematosus
Reiter cells – macrophages with ingested neutrophils
RA cells (ragocytes) – precipitated rheumatoid factor appearing as cytoplasmic granules in neutrophils
Hemosiderin granules – due to hemorrhagic process or cases of pigmented villonodular synovitis
Cartilaginous cells – observed in cases of osteoarthritis
Rice bodies – found in septic and rheumatoid arthritis and Tuberculosis
Fat droplets – indicate traumatic injury

20. Synovial lining cell

21. Neutrophils in synovial fluid

22. Lymphs in synovial fluid

23. Uric acid crystals GOUT

24. Calcium Pyrophosphate Crystals
Pseudogout

25. Hydroxyapatite (HA) (Calcium phosphate)
Cholesterol
Nonspecific indications
Associated with chronic inflammation
Exhibit negative birefringence (compensated polarized light)
Usually seen extracellularly
Polarized light – strongly birefringence
Rhombic plates
Hydroxyapatite (HA) (Calcium phosphate)
Associated with calcific deposition conditions
May produce an acute inflammatory reaction
Intracellular
Not birefringent
Require an electron microscope to examine
Small, needle shaped
Corticosteroid
Associated with intra-articular injections; NO clinical significance
Primarily intracellular
Exhibit positive and negative birefringence
Can closely resemble MSU and CCPD
Flat, variable shaped plates

26. Birefringent Artifacts:
Calcium Oxalate
Following renal dialysis
Birefringent Artifacts:
Anticoagulant crystals (calcium oxalate, lithium heparin)
Starch granules
Prosthesis fragments
Collagen fibers
Fibrin
Dust particles

27.                                                                                                                                                                       page 3 of 6

28. Cerebral Spinal Fluid (CSF)

29. CSF Protein

30. CSF is a clear colorless fluid which is an ultrafiltrate of plasma.
It maintains a constancy of intracranial pressure and provides mechanical protection for the brain and spinal chord.
Volume ml

31. Collection Lumbar Puncture 5 - 10 ml in 1 to 4 tubes
A certain amount of risk and trauma to the patient is involved. Specimen should always to handled with extreme care!! CSF is a precious Fluid
Risks to patient include - Coning, paresis or paralysis, infection, dermoid tumor, and headache.
Lumbar Puncture - Patient is placed in the fetal position on their side. A stylet with a 3 -way stopcock is inserted into the spinal chord usually in the lumbar region.. After checking for increased pressure using a manometer, fluid is allowed to drip into four different test tubes
Tubes #1 and #4 Hematology
Tubes #2 or # Chemistry or Microbiology

32. Tests Ordered on CSF Color and turbidity Culture, VDRL
Cell Counts Tubes 1 and 4
Total Protein and Glucose, sometimes LDH, Bilirubin, and Protein Electrophoresis, are also performed

33. Blood in Specimen
 May be the result of a Traumatic Tap or Brain Hemorrhage
May be able to determine which by counting cells in both tubes #1 and #4. If blood in tube `#1 is much more prevalent than in tube #4 it is likely that there was a traumatic tap.
Total Protein will also be elevated.
Serum contains times more protein than CSF
Brain Hemorrahge 
Xanthochromia - yellow pigmentation due to the presence of bilirubin

34. CSF Total Protein Normal Value
Lumbar ( mg/dl) adults
(up to 400 mg/dl) premature infants
( mg/dl) mature infants

35. Clinical Significance
CSF tap is indicated in suspected Meningitis Subarachanoid hemorrhage Encephalitis, CNS syphilis Spinal chord tumor Multiple Schlerosis (MS) Cerebral infarction Intracerebral hemorrhage