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Diagnostic criteria for empyema, Thoracentesis fluid with :
- Positive Gram stain or culture
- Pleural fluid glucose < 40 mg/dL
- pH < 7.2
- LDH >1000 IU/L
- PE 可以是 Transudate (25%) or Exudate (75%)
- CHF : Chronic or post diuresis 可能會變成 pseudoexudate
- Malignancy 最常見前三名 : Lung, Breast, Lymphoma
Light's criteria
三者符合一個以上即可
- TP of effusion / TP in serum > 0.5
- LDH of effusion / LDH in serum > 0.6 --> Sensitivity 最高
- LDH of effusion > 2/3 ULN of serum LDH (200) --> Specificity 最高
** Rivalta test (+) : Exudate
** In CHF effusion :
Total protein increased with diuresis or chronicity → Pseudoexudates
Light's criteria 會不準
所以要用 :
- Serum – pleural protein > 3.1 g/dL → True transudate
- Serum effusion albumin gradient > 1.2 g/dL → True transudate
若 Very high pleural NT-proBNP (ie, > 4000 ng/L) → Confirms Dx
Symptoms signs :
- Asymptomatic
- Dyspnea
- Cough
- Pleuritic pain : 合併發炎成分時
- Decreased chest expansion
- Contralateral mediastinal shift
- Percussion : Dullness ( 不再 Resonance )
- Diminished breath sounds
- Egophony (E-to-A change)
- Friction rubs
Thoracentesis indication :
- Diagnostic purpose : Obtain pleural effusion for study
- Therapeutic purpose : Relieve respiratory distress
- All pleural effusions > 1 cm in decubitus views
- In CHF, 75% resolves with diuresis within 48 hrs
Thus, Asymmetry, fever, chest pain or failure to resolve → pleural tap !
To improved safety :
- Ultrasound Guidance
- Insert the needle 1 or 2 intercostal spaces below the level of the effusion
5 - 10 cm lateral to the spine
- To avoid intra-abdominal injury, Do not insert the needle below the 9th rib
- Along the superior edge of the rib
- No more than 1500 ml of fluid be removed.
- Remove the needle at end expiration
Laceration of the posterior intercostal artery
CT angiography study in elderly patients and found that the lateral side (9-10 cm from spine)
had a larger percentage area of safety than the medial side (5-6 cm from spine)
CT angiography : At 3 cm from the spine, the superior rib shielded only 17% of the ICA,
but this increased to 97% at 6 cm from the spine.
ICA exposure also increased in more caudal intercostal spaces
and were found to be more tortuous in the elderly
Triangle of safety
Great variability in the ICA course more exposed in more posterior positions
Vascular ultrasound probe with color flow to identify the ICA (Limited evidence)
Complications :
- Pneumothorax (5-10% -> 5%)
- Hemothorax (1-3%)
- Re-expansion pulmonary edema (if > 1.5 L removed)
- Spleen/liver laceration
* Post-tap CXR not routinely needed
* Coagulopathy is not considered as contraindications (Relative contraindication)
正常 Pleural fluid :
Alkaline pH 7.60 – 7.64 鹼性
Amount: 10 – 20 cc
Protein 15 g/L
Cells 1500/ µL
Lubrication
Daily amount: 0.15 mL/kg/hr by the parietal pleura
需要抽的套餐 :
Pleural fluid routine
Glucose (Pleural fluid)
LDH & Total protein (Blood & Pleural fluid)
Hct (Pleural fluid + Blood)
Gram stain, Culture, AFS
CEA
Gas (Pleural fluid)
ADA
Neutrophils > 50% : Acute response to pleural injury
- Parapneumonic / empyema (50000/microL)
- PE
- Pancreatitis (10000/micro/L)
Lymphocytes > 50% : Chronic process
- Cancer, TB, Rheumatologic
Eosinophils > 10% : Commonly due to blood or air in pleural space
- Pneumothorax, hemothorax
- Asbestos, paragonimiasis, fungal, PE, Drug reaction
Glucose low :
- Infection, Cancer
- RA !!!!!
ADA >70 + mesothelial cell < 1% --> Suspect TB
Amylase : pancreatitis, esophageal rupture
TG : Chylothorax
Hct > 50% : Hemothorax
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