Download Serous fluid 2

Serous fluid 2
By
Dr.Mohammed Shaat
Anatomy
Serous pericardium is thin double layered
membrane.
 The outer layer of parietal pericardium is
fused with the fibrous pericardium.
 The inner layer (visceral/Epicardium)is fused
to heart.
 The pericardial cavity is a potential space
between the parietal and visceral
pericardium.

Cont…
It is the serous visceral pericardium that
secretes the pericardial fluid into the
pericardial cavity
 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

Pericardial Effusion
A pericardial effusion is the presence of
excessive pericardial fluid within the
potential space of pericardium.
 Rapid accumulation of pericardial fluid may
cause elevated intrapericardial pressures
with as little as 80 mL of fluid, while slowly
progressing effusions can grow to 2 L
without symptoms.

Cardiac Tamponade
Pericardial effusion or blood compressing
the heart enough to impair filling and
pumping
 The three principal features of
Tamponade are:
1.Elevation of intracardiac pressures
2.Lmitation of ventricular filling
3.Reduction of cardiac output

Causes
Any condition lead to pericarditis can lead to
pericardial effusion .
 The most common cause are:
A. Neoplastic disease
B. Idiopathic pericarditis
C. Uremia
D. Following cardiac operation
E. Trauma

Sign and Symptoms
1.
2.
3.
4.
5.
6.
Shortness of breath
Weakness and fatigue
Anxiety
tachycardia
Jugular vein engorged
Cyanosis
Special feature
 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.
investigations

ECG : low voltage QRS complex

CXR: large globular

Echocardiograph: is the most useful
technique.

Pericardicentesis
Pericardicentesis
Pericardicentesis is a
procedure used to
remove the pericardial
fluid from the
pericardial cavity.
It is performed either to
establish the diagnosis
or to drain the fluid in
emergency cause
( Tamponade)

procedure
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

Analysis
Macroscopic ( Gross Appearance)
 Chemical
 Microscopic

Macroscopic ( Gross
Appearance)




the normal appearance of a sample of
pericardial fluid is straw colored and clear.
Abnormal results may give clues to the
conditions or diseases present and may
include:
Milky appearance—may point to lymphatic
system involvement
Reddish pericardial fluid may indicate the
presence of blood
Cloudy thick pericardial fluid may indicate the
presence of microorganisms and/or white blood
cells
Chemical
Most common Protein & glucose
 Protein used to differentiate between
trasudate and exudate effusion.

Glucose in pericardial fluid samples is
typically about the same as blood glucose
levels. It may be lower with infection.
Microscopic examination

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


Normal pericardial fluid has small numbers of white blood
cells (WBCs) but no red blood cells (RBCs) or
microorganisms.
Increased WBCs may be seen with infections and other
causes of pericarditis.
WBC differential—determination of percentages of
different types of WBCs. An increased number of
neutrophils may be seen with bacterial infections.
Cytology –.This may be done when a mesothelioma or
metastatic cancer is suspected. The presence of certain
abnormal cells, such as tumor cells or immature blood
cells, can indicate what type of cancer is involved.
Presence of Antimyocardial Abs suggests an immune
mediated process
Again …
Trasudate:
 Physical characteristics—fluid appears clear
 Protein or albumin level—decreased
 Cell count—few cells are counted
 Trasudate usually require no further testing. They are most
often caused by either cirrhosis or congestive heart failure.
Exudate:
 Physical characteristics—fluid may appear cloudy
 Protein or albumin level—higher than normal
 Cell count—increased
 Exudates can be caused by a variety of conditions and
diseases and usually require further testing to aid in the
diagnosis. Exudates may be caused by, for example,
infections, trauma, various cancers, or pancreatitis.
BREAK
Peritoneal Fluid
Anatomy
The parietal peritoneum lines the wall of
abdominal and pelvic cavities, and visceral
peritoneum cover the organ.
 The potential space between the two layer is
called peritoneal cavity
 Up to 50 ml Fluid normally present in
peritoneal cavity

Peritoneal Effusion


An accumulation of
fluid in the peritoneal
cavity is called
Peritoneal effusion
which is known as
Ascites.
Other name:
Hydroperitoneum
Abdominal dropsy
Sign and Symptoms
Abdomen related:
Everted umbilicus
flank fullness
Flank dullness( if absent this means that there is
< 10% chance of having Ascites) there is at
least 1.5 liters of Ascites if dullness is present],
shifting dullness
Fluid thrill
Keeping in mind other clinical feature related to
the cause.
Investigation

USG : confirm the diagnosis of minimal
amount of Ascites.

Paracentesis
Paracentesis

A relatively simple bedside procedure in
which one inserts a needle into the
abdomen, thereby evacuating either a small
amount of ascites fluid for diagnostic
purposes, or large amounts of fluid for
therapeutic purposes.

It is the most cost-effective means of
determining the cause of ascites.
Indication
New-onset ascites
 Anyone admitted to the hospital with ascites
 Anyone with ascites who is showing
signs/symptoms of infection
 Clinical deterioration (fever, pain,
tenderness, mental status change,
hypotension)

Precautions
Severe coagulopathy or thrombocytopenia
 Pregnancy
 Organomegaly
 Bowel obstruction
 Intraabdominal adhesions
 Distended urinary bladder (Foley first)

Procedure
Procedure



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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
Cont…
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

Technique
Avoid abdominal
scars
 Midline if possible

Midline is avascular
 Inferior to umbilicus
 Risk of entering
bladder is low


Lower quadrant
approach
Analysis
Macroscopic ( Gross Appearance)
 Chemical
 Microscopic

Macroscopic
Straw – Coloured
Malignancy, Cirrhosis, infection, CCF and NS
 Chylous
Obstruction of lymphatic duct and cirrhosis
 Hemorrhagic
Malignancy, trauma, pancreatitis and ruptured
ectopic pregnancy

Fluid analysis
Cell Count:
Normal ascetic fluid contain WBC<500/ mm3
 Neutrophils count > 250/mm3 strongly
suggest SBP or secondary peritonitis due to
perforation
 Elevated WBC with predominance of
lymphocytes suggest TB or CA.
 Eosinophilia > 10% most commonly
associates with chronic peritoneal dialysis

Amylase &Glucose
If the ascites is secondary to pancreatitis the
amylase levels can be as great as five-fold
higher than the serum levels
 In uncomplicated ascites, usually similar to
serum levels.
 In later SBP (but often not in early), ascites
glucose levels can drop to as low as zero
mg/dl secondary to bacterial consumption

Others

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.
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
SAAG
Serum-Ascites Albumin Gradient
= serum albumin – ascites albumin
 > 1.1 = portal hypertension
 < 1.1 = non-portal hypertension

Underlying cause of Ascites
High gradient
Ascites
>1.1 g/dl ( > 11g/l)
Low gradient
Ascites
<1.1 g/dl ( <11g/l)
Remember at least 4 causes each
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.

Cont…
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.

Hospitalization
Precipitating
causes
Guidelines of Ascites treatment
Restriction
Diuretics
Questions