我的網誌清單

2013年7月13日 星期六

Pleural Effusion

CXR上可以看到的最少量(ml):
(a) PA: 300~500, (b) Lat.: 75, (c) Decubitus: 25 per 1cm

Indications for thoracentesis: Asymmetry, Fever, Pleuritic chest pain, failure to resolve

Light’s criteria                                               (98% Se, 83% Sp; 三項符合一項就夠)
(a) PF/serum protein > 0.5, (b) PF/serum LDH > 0.6 ,(c) PF LDH > 2/3 ULN of serum LDH

但會把25%transudate誤判成exudate, 故仍強烈懷疑transudate時改用Sp較高的test:
(a) Serum-PF Alb-gradient < 1.2                   (87% Se, 92% Sp)
(b)  PF cholesterol >45 and PF LDH >200       (90% Se, 98% Sp)

Transudate:     CHF, cirrhosis (hepatic hydrothorax), nephrotic syndrome, CAPD, myxedema, SVC-obstruction, pul.embolism()
Exudate:          Infection, malignancy, pul.embolism, collagen-vascular disease (RA, SLE, Wegener’s, Churg-Strauss), GI (pancreatitis, esophageal rupture, abdomominal abscess), Others (見麻2-11)

Parapneumonic:     Underlying bacterial lung infection (pneumonia or abscess)
定義Complicated       = (+) gram stain/ culture or pH < 7.2 or glucose < 60
定義Empyema           = Gross pus
Tintinalli: Gross pus + [(+) gram stain/ culture or pH < 7.1 or glucose < 40 or LDH>1000]
õ Complicated parapneumonicempyema(exudative stage)需要thoracostomy drainage

# Amylase:             Esophageal rupture, pancreatic, malignancy
Glucose < 60:         Malignancy, infection, RA

Etiology
WBC
RBC
pH
Glc

CHF
< 1,000
< 5,000
Normal
Serum
Bilateral
Cirrhosis
Right,
chest tube
Parapneumonic
Uncomplicated
5~40,000
$
$

Parapneumonic
Complicated
< 7.2
< 60
Drainage
Empyema
25~100,000
< 7.1
< 40
TB
5~10,000 lymp
<10,000
Normal
Serum
AFB, ADA
Malignancy
1~100,000
lymp
<100,000
Cytology
PE
1~50,000
no infarct à transudate
RA/SLE
1~20,000
<1,000
$
RA $$$
SLE nl

Pancreatitis
1~50,000
<10,000
Normal
Serum
Left
# Amylase
Esophageal rupture
<5,000
>50,000
$$$
$$

(From Tintinalli)
Empyema        Piperacillin-tazobactam 3.375~4.5 gm         q6h
                        or

                        Imipenem                        0.5~1 gm                 q6h