Lab rounds Nadim J Lalani Feb 14 th 2008. Objectives Case Review of Lab criteria.
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Transcript of Lab rounds Nadim J Lalani Feb 14 th 2008. Objectives Case Review of Lab criteria.
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Lab rounds
Nadim J LalaniFeb 14th 2008
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Objectives
Case Review of Lab criteria
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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
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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:
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Case
54 yo M presents to ED with progressive abdominal distension, dypnea, abdo pain and malaise
Likely hx of Etoh abuse No meds/Allergies
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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?
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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
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Clinically: Abdo pain [acute or insidious] Peritonitis Fever[absent in 20-50%]/chills malaise ALOC 1-5% asymptomatic [consider in any pt w/ ascites]
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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]
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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?
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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]
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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]
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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
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Correlation:
GRADE WBC
0 0 PMN/ml
1 25 PMN/ml
2 75 PMN/ml
3 250 PMN/ml
4 500 PMN/ml
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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
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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
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Rest of Evidence
Only published in abstract form Mostly from France?! Small numbers ?Methods
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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
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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
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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
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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]
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Our Patient:
Reagent read 3+ We started treatment with Cefotaxime 2g Q8h PMN count came back at 300/mm3
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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
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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
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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.
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QUESTIONS?