lab rounds nadim j lalani feb 14 th 2008. objectives case review of lab criteria

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?