Body Fluids

Serous fluids

Cerebrospinal fluid (CSF)

Serous fluids

Pleural fluid
Pericardial fluid
Peritonial fluid
Pleural fluid
Pleural fluid

Between visceral and

parietal pleura
It is normally about 1-
10ml
Mositening the pleural
surface
An increased volum is
called effusion
Pleural effusion

Definition
the accumulation of excess fluid within the
, pleural space in response to injury
inflammation, or both

may represent a local response to disease

or may just be a manifestation of a systemic illness
 Pleural effusion

Rate of Fluid Rate of

Fluid
Accumulation Removal

1. Altered Pleural Membrane Permeability

2. Decreased Intravascular Oncotic Pressure
3. Increased Capillary Hydrostatic Pressure
4. Lymphatic Obstruction
5. Abnormal Sites of Entry
Clinical Manifestations

Pain
Cough
Dyspnea
Dullness to Percussion
Diminished or Absent Vocal Resonance
Diminished or Absent Tactile Vocal Fremitus
Friction Rub
 Radiologic Assessment (1)

Chest X-Ray: PA & Lateral-Decub

blunting of either costophrenic angle is indicative of the
accumulation of between 250 - 500 ml of fluid

Lateral-Decubitus films (that allow fluid to shift to the

dependent portion of the thoracic cavity) help
differentiate fluid from pleural thickening & fibrosis
Radiologic Assessment (2)

Ultrasound: Helpful in Confirming the Presence of a

Small Pleural Effusion & Identifying Loculations

C.T. : Extremely Sensitive !!

also helps to view the underlying lung (which may be
obscured by pleural disease)
can distinguish between Lung Abscess & Empyema
pp= parietal pleura & Pv=viseral pleura
Pleural Fluid Analysis
1. Gross Appearance
2. Cell Count & Differential
3. Gm Stain, C & S
4. Cytology
5. LDH
6. Protein
7. Glucose, Amylase
 Thoracentesis

Thoracentesis ) also known as

thoracocentesis or pleural tap) is an
invasive procedure to remove fluid or air
from the pleural space for diagnostic or
therapeutic purposes. A cannula, or hollow
needle, is carefully introduced into the
thorax, generally after administration of
local anesthesia.
A thoracentesis can be diagnostic, which means
it is being done to determine the cause of the
fluid, for which usually only a syringe of fluid is
removed, or it can be a therapeutic
thoracentesis, in which the procedure is being
done in order to remove as much fluid as
possible to relieve symptoms for a patient, with
sometimes as much as two liters of effusion
fluid being removed.
Pleural effusions do not require
thoracentesis:
- Underlying congestive heart failure
- After recent thoracic or abdominal
surgery.
The recommended location varies
depending upon the source. It is critical
that the patient holds their breath to avoid
piercing the lung. Some sources
recommend the midaxillary line, in the
ninth intercostal space.
Contraindications

Bleeding diathesis,
Systemic anticoagulation,
Cutaneous infection over site,
Severe hemodynamic or respiratory
compromise,
Mechanical ventilation.
Complications

Pain at the puncture site,

Cutaneous or internal bleeding,
Pneumothorax,
Empyema,
Spleen/liver puncture.
 The illustration shows a person having thoracentesis. The person
sits upright and leans on a table. Excess fluid from the pleural space
is drained into a bag
Transudate

colorless, clear, odorless fluid with a

WBC less than 1000 / mm3
Pleural Membranes are Intact
Secondary to Altered Starling Forces
Low in Protein & other Large Molecules

CHF, Cirrhosis, Nephrotic Syndrome

Hypoalbuminemia, Constrictive Pericarditis, SVC
Obstruction, Megi syndrome
 Exudate

Characterized by Increased Protein & LDH

[Pleural Fluid vs. Serum Levels]

Secondary to Disruption of Pleural Membrane or

Obstruction of Lymphatic Drainage

Parapneumonic, Infections, Malignancy,

Vasculitic Disease, GI Disease, TB, PE(pulmonary embolism)
Criteria for Exudative Effusion

criteria value
1. Pleural Protein : Serum Protein > 0.5

2. Pleural LDH : Serum LDH > 0.6

3. Pleural LDH > 200

only need 1 critical value to establish the diagnosis of exudate

Lights criteria: Transudate vs. Exudate

Pleural fluid protein / serum protein > 0.5

Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 ULN serum LDH
Other criteria: Transudate vs. Exudate

Pleural fluid cholesterol > 45 mg/dL

Pleural fluid protein > 3 g/dL
although pleural disease
itself is rarely fatal, it may be a
significant cause of patient
morbidity

appropriate treatment may

produce
dramatic symptomatic relief !
DIFFERENTIAL DIAGNOSIS Table 57-1
 Greater than 10000 per L--- Parapneumonic effusion, pancreatitis,
pulmonary embolism, collagen vascular disease, malignancy,
tuberculosis.
Polymorphonuclear PMN leukocytosis--- Acute disease such as
pneumonia, pulmonary embolism, pancreatitis, intra-abdomen abscess,
early tuberculosis.
lymphocyte- 100%= Tuberculosis
Mononuclear cell--- Malignancy, tuberculosis, resolving acute process.
Eosinophil--- Benign asbestos, drug reaction as nitrofurantoin,
bromocriptine, dantrolene, paragonimiasis low glucose, low pH, high
LDH .
Eosinophils >10%
caused in about two thirds of cases by blood or air in the pleural
space.

More than 50% WBC in exudates are small.

Pleural fluid--- glucose

Glucose typically about the same as blood

glucose levels.
Less than 60 mg/dL-Causes:
Empyema
Malignant effusion
Tuberculosis effusion
Rheumatoid effusion( usually less than 20)
Pleural fluid--- amylase
Elevated above the upper normal limit of serum
amylase---- Esophageal perforation, pancreatic
disease, malignancy 10% .
Acute pancreatitis accompanying pleural
effusion--- 10%.
Chronic pancreatic disease may develop a sinus
tract between the pancrease and the pleura
space.
The amylase associated with malignancy---
salivary type.
Pleural fluid--- lactic acid
dehydrogenase
Pleural fluid lactic acid dehydrogenase---
good indicator of the degree of
inflammation in pleural space.
LDH increase, the inflammation
worsening.
Pleural fluid--- cytology
Establishing the diagnosis of malignant
pleural effusion--- 40-90%.

Depending on--- the tumor type, amount of

fluid, skill of cytologist.
Pleural effusion--- bacteriology

Culture and bateriologic stain--- culture

both aeobic and anaerobic, mycobacteria,
fungi.
Grams stain.
Pleural fluid--- pH and pCO2

Less than 7 (empyema) Complicated

parapneumonic effusion and tube
thoracostomy should instituted.
Less than 7.2--- systemic acidosis,
esophageal rupture, rheumatoid pleuritis,
tuberculosis pleuritis, malignant pleural
disease, hemothorax.
Hemothorax
Blood in the pleural cavity.

Usually results from chest injury.

A blood vessel ruptures into the pleural space or

aortic aneurysm leaks blood into the pleural
space.

Can occur as a result of bleeding from the ribs,

chest wall, pleura, and the lung.
 Pleural Fluid Hct

Because a RBC count as low as 5000 cell /mm3, can cause a pleural
effusion to turn red, the finding of blood-tinged fluid per se has little
diagnostic value (usually from needle trauma)

A True Hemothorax is when the Pleural Fluid Hct exceeds 50 % of the

Peripheral Blood Hct

If Bloody:
Hct <1% not significant
1-20% = CA, PE, Trauma
>50% serum Hct = hemothorax
 Here is an example of bilateral pleural effusions. Note that the fluid appears
reddish, because there has been hemorrhage into the effusion.
 A bloody pleural effusion
occurring in a patient without a history of
trauma or pulmonary infarction
is
Indicative of Neoplasm
!in 90 % of cases
Pleural fluid

Other diagnostic test on pleural fluid---

Chylothorax---Triglycerides > 110 mg/dl,
Pseudochylothorax--- the level of
cholesterol increase.

Bloody effusion: mesothelioma

Break
Pericardial Fluid
Pericardial Fluid

Surrounding the heart is a sac known as

the pericardium, which consists of two
membranes. The outer layer being the
fibrous parietal pericardium and the inner
layer being the serous visceral
pericardium. It is the serous visceral
pericardium that secretes the pericardial
fluid into the pericardial cavity, (the space
between the two pericardial layers).
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
In a healthy individual there is usually 15-
50ml of clear, straw-coloured fluid.
However there is little data on the normal
composition of pericardial fluid to serve as
a reference
Pericardial effusion
A pericardial effusion is the presence of excessive
pericardial fluid, this can be confirmed using an
echocardiogram
Small effusions are not necessarily dangerous and are
commonly caused by infection such as HIV or can occur
after cardiac surgery.
Large and rapidly accumulating effusions may cause
cardiac tamponade, a life-threatening complication, that
puts pressure on the heart preventing the ventricles from
filling correctly.
 Cardiac tamponade

Cardiac tamponade: the accumulation of fluid in the

pericardium in an amount sufficient to cause serious
obstruction to the inflow of blood to ventricle results in
cardiac tamponade.
The three principal features of tamponade are:
1.elevation of intracardiac pressures
2.limitation of ventricular fillng
3.reduction of cardiac output
The amount of fluid
necessary to produce the
critical state:
Acute tamponade: 150-200 ml
Chronic tamponade: 1000-
2000 ml
The most common causes are:
a.neoplastic disease
b.idiopathic pericarditis
c.uremia
d.following cardiac operation
e.trauma
 A.clinical features

1. Shortness of breath
2. Weakness and fatigue
3. Anxiety
4. tachycardia
5. Jugular vein engorged
6. Cyanosis
Beck triad:
1.increased jugular venous pressure
2.hypotension
3.diminished heart sounds
Pulsus paradoxus:
A greater than normal (10 mmHg)
inspiratiory decline in systolic arterial
pressure.
The CXR of
cardiac
tamponade
:
 The
echocardiogram of
cardiac
tamponade:
1. echo free space
between
epicardium and
pericardium
Pericardiocentesis
Pericardiocentesis is a procedure used to
remove the pericardial fluid from the pericardial
cavity. It is performed using a needle and under
the guidance of an ultrasound
It can be used to relieve pressure from
pericardial effusions or for diagnostic purposes,
revealling the cause of abnormalities such as:
Cancer, Cardiac perforation, Cardiac trauma, Congestive
heart failure, Pericarditis rupture of a ventricular aneurysm
Pericardiocentesis
Anesthesia
Light sedation will be given to help you relax. You will be awake during the procedure. A local
anesthesia will be injected at the insertion site. It will numb an area on your chest.

Description of Procedure
You will lie on a table. An IV line will be inserted into your arm. The sedative will be delivered
this way. The area where the needle will be inserted will be washed. Your heart will be
monitored.
The needle will be inserted into the chest. It will be slowly moved toward the heart. Ultrasound
and possibly fluoroscopy will be used to help guide the needle to the correct location. The
needle will be passed into the pericardial sac, but no further.
Once in the pericardial sac, the fluid will be removed. The needle may be used, or a catheter
tube may be inserted over the needle. After some fluid is collected or enough of the fluid has
drained out, the needle or catheter will be removed. Pressure will be applied to the injection
site for several minutes. This is done to stop the bleeding.
In some cases, your doctor may leave the catheter in place. This will allow draining to
continue over several hours or days.
.
Pericardiocentesis needle insertion sites. The subxiphoid
and the left sternocostal margin are the most commonly
used sites (black dots)
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.
The fluid removed from the pericardial sac is sent to a
lab to be analyzed.
How Long Will It Take?
About 20-60 minutes
How Much Will It Hurt?
You may feel pain when the needle is inserted
Average Hospital Stay
Hospital stay can vary from one day to
several days. If the catheter remains in
place to continue draining fluid, you may
need to stay in the hospital several days.
Types

transudative )congestive heart failure, myxoedema,

nephrotic syndrome)

Exudative )tuberculosis, spread from empyema)

haemorrhagic )trauma, rupture of aneurysms, malignant

effusion(

Malignant) due to fluid accumulation caused by

metastasis(
 Exudative pericardial effusion developed in over
80% of cases
Presence of antimyocardial Abs suggests an
immune mediated process
Hct and RBC count have limited value in
differential diagnosis of pericardial effusions.
Total WBC > 10,000/ul suggests bacterial, Tb or
malignant pericarditis
Metastatic Ca of lung and breast are most
frequent cause of malignant pericardial effusion
Break
Peritonial fluid
Up to 50 ml Fluid normally present in
peritoneal cavity
Peritoneal effusion is called Ascites
Laboratory criteria for dividing ascitic fluid
into transudate and exudate is not well
defined as it is for pleural fluid
Ascites: Physical diagnosis

Bulging flanks

Flank dullness

Shifting dullness
Paracentesis :Indications

New onset ascites

Clinical deterioration (fever, pain,
tenderness, mental status change,
hypotension)
Suspicion of infection by labs
(leukocytosis, acidosis, renal dysfunction)
Alleviation of discomfort/dyspnea
Precautions

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

Avoid abdominal
scars
Midline if possible
Midline is avascular
Inferior to umbilicus
Risk of entering bladder
is low
Semirecumbent position is most common
Dullness at site of needle entry
Ultrasound guidance
Metal needle
1.5 inches
22-gauge for diagnostic paracentesis
16-gauge for therapeutic paracentesis
Disinfect skin with iodine solution
Local anesthetic for skin and
subcutaneous tissue
Sterile gloves
Z-tract
Do not aspirate continuously
Fluid analysis
 Cells
Total leukocyte useful in spontaneous bacterial
peritonitis (SBP)
Approximately 90% of (SBP) have leukocyte
count > 500/ml and over 50% neutrophiles
Eosinophilia > 10% most commonly associates
with chronic peritoneal dialysis. Also in CHF,
vasculitis, lymphoma and ruptured hydatid cyst
Overall sensitivity of cytology for malignant
ascitis is 40-65%
 Amylase activity in normal peritoneal fluid is similar to
blood levels
A fluid amylase level greater than three times of serum
value is good evidence of pancreas-related ascitis and
also in GI perforation
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
 Other studies of ascitic fluid to be considered

Lactate: An ascites lactate level of >25 mg/dL was found to be 100%

sensitive and specific in predicting active SBP in a retrospective analysis.

pH: In the same study, the combination of an ascites fluid pH of <7.35 and

PMN count of >500 cells/mL was 100% sensitive and 96% specific.

Blood and urine cultures should be obtained in all patients suspected of

having SBP.
 Albumin

Is portal hypertension present?

SAAG >/= 1.1g/dL
 SAAG

Serum-Ascites Albumin Gradient

= serum albumin ascites albumin
> 1.1 = portal hypertension
< 1.1 = non-portal hypertension
SAAG classification
Spontaneous Bacterial Peritonitis (SBP)
Spontaneous bacterial peritonitis (SBP) is an
acute bacterial infection of ascitic fluid.

Patients with cirrhosis and ascites carry a 10%

annual risk of ascitic fluid infection.
Predisposing factor may be :

Intestinal bacterial overgrowth

Impaired phagocytic function

Low serum and ascites complement levels

Decreased activity of the reticuloendothelial system

Etiologic agents (>90% intestinal flora)

Three forth of infections are due to aerobic gram-negative organisms

(50% of these being Escherichia coli)

One fourth are due to aerobic gram-positive organisms (19%

streptococcal species).

Anaerobic organisms are rare (1%) because of the high oxygen

tension of ascitic fluid.

Clinical presentation and diagnosis of ascitic fluid
infection

A broad range of symptoms and signs are seen in SBP. A high index of

suspicion must be maintained when caring for patients with ascites,

particularly those with acute clinical deterioration.

Completely asymptomatic cases in as many as 30% of patients.

Fever and chills occur in as many as 80% of patients.

Abdominal pain or discomfort is found in 70% of patients.

Worsening or unexplained encephalopathy

Diarrhea
 Diagnostic paracentesis and direct inoculation of routine
blood culture bottles at the bedside with 10 mL of ascitic
fluid must be performed.

The results of aerobic and anaerobic bacterial cultures,

used in conjunction with the cell count, prove the most
useful in guiding therapy for those with SBP.
An ascitic fluid neutrophil count of >500
cells/mL is the single best predictor of
SBP.
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