Fluid analysis

Panita Limpawattana 4 April 2010

Cell count

Cell count
1 mm 1 mm 1 mm

WBC count
Vol 3x3x0.1 mm3 = 0.9 mm3 Cell count a cell/0.9 mm3 1mm3 = (a x 10)/9 Practical (A+B+C+D) (a x 10)/ 4

Cell count

Example
1 mm 1 mm 1 mm

WBC count
A+B+C+D = 200 cell Cell count = (200 x 10)/4

AA

BB

D D

WBC count = 500 cell/ mm3

Normal Joint fluid

Clear- yellow color RBC < 2000 cells/mm3 WBC < 200 cells/mm3 ( L 30%, PMN 10%, Mo 60%) High viscosity ( 3-6 cm.) protein : 1-3 g/dl Glucose = plasma glucose ( If NPO)

Classification of joint fluid

Normal non-inflammatory: OA, trauma, aseptic necrosis, SLE inflammatory: RA, SLE, crystal-induced, SNSA septic

Synovial fluid
Type Appearance Viscosity (string sign) Clot (5%acetic acid) Microscopic WBC, PMN Disease Normal Clear, translucent High >5 cm No lysis <200 50% none Non-inflam Inflam Infect Purulent No viscosity Easy to lysis >50,000 >90% Septic, Crystal induced Minimal turbid Cloudy turbid Low <5 cm Difficult to lysis 200-2,000 50-75% OA AVN Charcots jt Low <5 cm Easy to lysis 2,000-20,000 >75% RA, SLE, SpA, crystal induce

CSF examination
Gross : consistency, color, turbidity Microscopic examination
Cell count Centrifuge
Wrights stain : WBC, RBC, abnormal cell Gram stain AFB mAFB

Chem: sugar, protein India ink, cryptococcal Ag

Normal CSF
clear cell < 5 cells/mm3 ( lymph 100%) open pressure < 200 mm.H2O protein:lumbar < 40, ventricle 5-10mg/dl. glucose : lumbar 50-80% plasma glucose

Trauma??

Three-tube test

Trauma??
1. Normal ratio = RBC/WBC = 500-1000/1
eg. report RBC 140000 WBC 500 cells/mm3 corrected RBC = 140000/500 140000/1000 =140 280 cells/mm3 corrected WBC = 220-360 cells/mm3

2. WBC / RBC CSF = WBC / RBC serum

Trauma??

correct protein
RBC 1000 cells/mm3 = protein 1 mg/dl.

Test OP

bacterial elevated

viral normal

fungal vary

TB Vary

WBC

>1000 PMNS* mild to marked normal to marked G/S +ve

<100 Lymp* normal to elevated normal

Vary Lymph* elevated

Vary Lymph* elevated

protein

CSF/serum sugar others

low

low

India ink+ve

AFB+ve rare

SAH Test
OP

abscess
Normal to elevation

GBS
normal

early

late

MS
normal

CA
Normal to elevation

elevated

WBC

Few-10 Mono*

Normal to mild elevate Lymph* Elevated 50-400 100-800

5-10

20-300

protein

Normal to elevated

Mono*

Malig cell

CSF/serum sugar

normal

Normal

normal

Normal

others

HIV-elevated of protein Lymp-inc.

bloody

Xantho chrome

Gamma globulin monoclonal band

Cytology +ve

Pleural fluid examination

Gross : consistency, color, turbidity Microscopic examination
Cell count Centrifuge
Wrights stain : WBC, RBC, Abnormal cell, LE cell Gram stain AFB mAFB

Chem: sugar, protein, LDH Pleural gas Cytology

Pleural Effusion
transudate exudate Malignancy Infection GI : pancreatitis CNT :RA, SLE Drug Others eg. asbestos, ARDS, RT

CHF Cirrhosis NS Hypoproteinemia Peritoneal dialysis Others

Exudate vs Transudate
At least 1 = exudate 1. Pleural fluid protein / serum protein > 0.5 2. Pleural fluid LDH / serum LDH > 0.6 3. Pleural fluid LDH > 2/3 UNL for serum
Lights criteria

Exudate and Transudate

pulmonary embolism hypothyroidism diuresed transudate pericardial disease (inflammatory or constrictive ) atelectasis amyloidosis etc.

Early empyema ?
Need ICD At least 1 of the followings : 1. Loculated pleural effusion 2. Pleural fluid pH < 7.2 3. Pleural fluid glucose < 60 mg/dl 4. Positive G/S or C/S of fluid

Note
Eo > 10% = eosinophilic pleural effusion
PPEAG :plasma - pleural alb. >1.2

= transudate (diuretic effect)

Cause
RA

Exudate/ transudate
exudate

Cell
elevated WBC Mo*

Others
sugar<10 RF-positive unilat (common) moderate effusion low/normal sugar bilat (common) mild effusion ANA-positive low/normal sugar high amylase>160 Somogy unit or >2x serum level** low/normal sugar high amylase>160 Somogy unit or >2x serum level**

SLE

exudate

elevated WBC PMNs*

Esophageal rupture

exudate

elevated WBC PMNs*

Pancreatitis

exudate

elevated WBC PMNs*

Low sugar pleural effusion

Rheumatoid effusion Lupus effusion Bacterial empyema Malignancy TB pleurisy Esophageal rupture, pancreatitis

Ascites examination
Gross : consistency, color, turbidity Microscopic examination
Cell count Centrifuge
Wrights stain : WBC, RBC, Abnormal cell, LE cell Gram stain AFB mAFB

Chem: sugar, albumin Cytology

Serum Ascites Albumin Gradient(SAAG)

High > or = 1.1 g/dl Cirrhosis Alcoholic hepatitis HF Fulminant hepatic Failure Portal -V Thrombosis Low < 1.1 g/dl Peritoneal carcinomatosis Pancreatic, biliary ascites Infection NS Serositis Bowel obstruction or infarction

Ascites Analysis
cause Cirrhosis Neoplasm 2 bac peritonitis SBP TB CHF Pancreatitis Clear, blood, Chylous Straw Turbid, bloody, chylous
0

appearance Straw Straw, bloody, Mucous, chylous Turbid, purulent

Protein g/dl <2.5 >2.5 >2.5 <2.5 >2.5 >2.5 >2.5

SAAG >1.1 Variable <1.1 >1.1 <1.1 >1.1 <1.1

Cell count RBC WBC L <250 H L L Occ a. H L Vary >1000 >50%=L >10000 >250 =PMN >1000 70%=L <1000 vary

Other

Cytology G/S,C/S G/S, C/S AFB,C/S

amylase