lab rounds nadim j lalani feb 14 th 2008. objectives case review of lab criteria
DESCRIPTION
Movie? In which Bogart says “We will always have... a)Whiskey b)Tophi c)Spontaneous bacterial peritonitis d)Paris Significance of this line? # 7 all-time most romantic lines [Daily Mail 2008] CasablancaTRANSCRIPT
Lab rounds
Nadim J LalaniFeb 14th 2008
Objectives
Case Review of Lab criteria
Movie?In which Bogart says
“We will always have...
a)Whiskeyb)Tophic)Spontaneous bacterial peritonitisd)Paris
Significance of this line?
# 7 all-time most romantic lines [Daily Mail 2008]
Casablanca
1. "I'm scared of walking out of this room and never feeling the rest of my whole life the way I feel when I'm with you" – Jennifer Gray, Dirty Dancing
2. "You make me want to be a better man" – Jack Nicholson, As Good As It Gets
3. "I would rather share one lifetime with you than face all the ages of this world alone... I choose a mortal life" – Liv Tyler, Lord of the Rings
4. "The greatest thing you'll ever learn is just to love and be loved in return" – Ewan McGregor, Moulin Rouge
5. "You had me at hello" – Renee Zellweger, Jerry Maguire
6. "I want to tell you with my last breath that I have always loved you" - Chow Yun-Fat, Crouching Tiger, Hidden Dragon
The other 6 most romantic quotes are:
Case
54 yo M presents to ED with progressive abdominal distension, dypnea, abdo pain and malaise
Likely hx of Etoh abuse No meds/Allergies
O/e: 38.0, 100, 20, 133/52 Looks dry, ?icteric Distended abdo with +ve fluid wave and poorly-
localisable tenderness. Lab:
Hb 127, WBC 11, platelets 500, INR 1.4 Doctor?
SBP
Definition: Infected ascitic fluid Incidence 10-30% of cirrhotic pts Mortality 20% Only 30-50% 1-y survival after 1st episode
Path: Translocation of gut flora [slow transit & edema in portal
HTN] + impaired immunity Gm –ves [E coli + Klebsiella]
Gm +ve rarer, but on the rise
Clinically: Abdo pain [acute or insidious] Peritonitis Fever[absent in 20-50%]/chills malaise ALOC 1-5% asymptomatic [consider in any pt w/ ascites]
SBP Diagnostic Paracentesis
Perform in the following: Any new ascites Known ascites and suggestive sympts Known liver dis and ALOC Cirrhotic inpts with GIB
What about INR? Not a contraindication [<1% complication rate]
Diagnostic Criteria
Cell count: PMN > 250 cells/mm3
Sens 84% ; Spec 90% [pooled] Pmn > 500 cells/mm3 [Sens 80% Spec 97% ]
Culture? Bedside innoculation of Blood Culture bottles
10 ml in each Sens 80-90% cf 40-50% for conventional
Any other tests?
Urine Dipstic?“A positive result from a urine reagent strip for leukocyte
esterase has a high degree of correlation with a clinically significant elevation of neutrophil cell count” [Rosen 2007]
Dipstick
Rationale:studied in meningitis and peritonitis in pts on
receiving peritoneal dialysis. How it works:
Leukocyte esterase in fluid reacts with compound causing a colour change [purple]
228 Paracentesis on 128 cirrhotic patients suspected of SBP
Reagent strips read at 90 sec [Aution sticks brand] 2 independent readers
Also did cell count and culture [1 bottle] SBP defined as >250 PMN/mm3
Calculated Sens/Spec/LR’s 52 pts SBP +ve
Only 50% culture pos
Correlation:
GRADE WBC
0 0 PMN/ml
1 25 PMN/ml
2 75 PMN/ml
3 250 PMN/ml
4 500 PMN/ml
Authors conclusions:Reagent strips useful:
Cutoff > 3 or 4 highly specific [96%, PPV 99%]Cutoff > 0-1 NPV 99% rules out SBPCutoff > 2 yields best Sens [96%]
Good correlation b/w strip and PMN count
Limitations: Small studyCHR uses Chemstrip 10
Chemstrip 10
Made to be used with analyser/eyeball Read at 60-120 sec
NEG 1+ 2+ 3+ 10-25 75 >500 leuks/muL
Cost $55/100
Rest of Evidence
Only published in abstract form Mostly from France?! Small numbers ?Methods
Multistix
Paracentises on 72 cirrhotic ptsSBP [defined as > 250/mm3 ] positive in 9/72Multistix defined as: neg, trace, positiveAll pts with >250/mm3 had “positive” Multistix63 pts with <250/mm3:
17 had “trace” 46 had negative
State that the 250/mm3 has 100% sens/spec
2123 paracenteses in cirrhotic pts 117 had SBP Cutoff 2+ Sens 45% Spec 99% PPV 76% NPV 97% Conclude: Can’t use to r/o
Two centres 184 paracenteses in76 cirrhotic pts
[40% of whom were on prophylaxis] Used Nephur and Multistix Nephur:
Sens 86%, Spec 100%, PPV100% , NPV99%, Acc99% Multistix:
Sens 83%, Spec 96%, PPV83% , NPV96%, Acc94% Conclude can use to screen, but need to send fluid
80 paracenteses Negative or positive [violet = >500neut/muL] Sens 80%, Spec 100%, NPV 99%, PPV 100%,
Acc 99% Conclude can use to rule in Cost effective [strip = 15c VS lab $55]
Our Patient:
Reagent read 3+ We started treatment with Cefotaxime 2g Q8h PMN count came back at 300/mm3
Nadim’s Bottom Line
Really only one good study PMN count has been validated in several Value > 3 can rule in start treatment Any other value wait for PMN count
More Rosen...
“an ascitic fluid pH of less than 7.34 or a pH gradient between arterial blood and ascitic fluid of more than 0.10 is also a reliable early indicator of SBP.”
Um... Don’t think so
ReferencesRisk factors for the development of bacterial infections in hospitalized patients with cirrhosisMarc Deschênes, Jean-Pierre Villeneuve,
The American Journal of GastroenterologyVolume 94 Issue 8 Page 2193-2197, August 1999
Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.Copyright © 2006 Mosby, Inc.
QUESTIONS?