Pleural Effusions and Light’s Criteria

Dr. Vadia discussed the topic of pleural effusions during afternoon report today. Below is an outline to the diagnostic and therapeutic approaches to pleural effusion management.

Who needs a thoracentesis?: Any new pleural effusion should be tapped, UNLESS:

1. There is not enough fluid to tap
2. The patient has CHF, bilateral effusions, is afebrile and the effusion resolves within 3 days.

Step 1: Is the effusion exudative? 

  • Ddx for Transudative Effusion includes: CHF (90%), cirrhosis (hepatic hydrothorax), pulmonary embolism, nephrotic syndrome, peritoneal dialysis, myxedema, constrictive pericarditis, SVC syndrome.
  • Ddx for Exudative Effusion includes: Infection, cancer, connective tissue disease, pancreatitis, uremia, chylothorax, drug reaction, post-MI/CABG, esophageal rupture.
  • Check serum and fluid LDH and total using Light’s criteria (Satisfying any ONE criterium means it is exudative):
    • Pleural Total Protein/ Serum Total Protein > 0.5
    • Pleural LDH/ Serum LDH > 0.6
    • Pleural LDH > 2/3s of the upper limit of normal for serum LDH
    • **For patient with high suspicion for transudate, but meets Light’s Criteria (ie CHF patient recently diuresed), Dr. Light recommends a serum albumin – pleural albumin < 1.2 mg/dl, to confirm the effusion is exudative.

Step 2: If exudative, obtain the following pleural fluid tests:

  • Cell Count with differential:
    • PMNs > 50%: Parapneumonic, PE, pancreatitis.
    • Lymphs >50%: Cancer, TB, fungus or post-surgery
    • Eos >10%: PTX, hemothorax, drug reaction, asbestos, parasite infection, Churg-Strauss
  • Culture and Smear/Gram Stain: Yield is increased if fluid sent in blood culture bottles. Send for fungus and mycobacteria if pleural lymphs > 50 % or clinical picture is suspicious. Yield in Tb is <50%. 
  • Glucose: Level <60 mg/dL is seen in complicated parapneumonic effusion, malignancy, hemothorax, Tb, RA, SLE, Churg-Strauss, parasite infection.
  • Cytology: A case series of 971 lung cancer patients reported 7% prevalence of pleural effusion on chest xray and 40% of these pleural effusions had positive cytology. If cytology is negative and cancer is suspected, pleural biopsy should be performed.
  • Consider Adenosine Deaminase(ADA) for Tb: At least 50% of tuberculous pleural effusions do not involve other organs and are therefore difficult to diagnose. ADA levels >40-60 U/L in the setting of a lymphocytic effusion are specific for Tb.
  • Consider Amylase: Elevated in patients with pancreatitis, esophageal rupture, and malignancies.

Step 3: What if the diagnosis is unclear from these tests?

The cause of 15% of exudative effusions is not determined. For both transudative and exudative effusions without a cause, pulmonary embolism should be considered. Further evaluation by pleural biopsy via thoracoscopy or open biopsy is indicated for undiagnosed, unresolved exudative effusion.

Palliative Care Resources

We had a great discussion today regarding palliative care at morning report. Below are some interesting resources worth checking out. Special thanks to Dr. Kazi for mentioning these resources!

Knocking on Heaven’s Door

Written by Katy Butler, a best-selling memoir that details her own experience with the medical system and end of life care of her parents.

http://www.amazon.com/Knocking-Heavens-Door-Better-Death/dp/1451641982/ref=sr_1_1?ie=UTF8&qid=1403103159&sr=8-1&keywords=knocking+on+heaven%27s+door

National Cancer Institute Palliative Care Webpage

Great Q&A format that explains what palliative care is and available resources to patients and their family.

http://www.cancer.gov/cancertopics/factsheet/Support/palliative-care

Letting Go – Atul Gawande 

Article from 2010 in the New Yorker about Dr. Gawande’s own experience as a physician and helping patients with end of life care. Thought provoking article that asks the question, “What should medicine do when it can’t save your life?”

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all

USA!

20140617-000102-62183.jpg

Clint Dempsey and John Brooks propelled the US national soccer team to a rousing victory over Ghana, in what was a thrilling, epic match! However, it looks like we are not doing so well when it comes to the delivery of highly effective and efficient patient care. As Dr. Johnson discussed with us in afternoon report, the 2014 Commonwealth Fund Report, which evaluated 11 developed countries on more than 40 parameters related to healthcare, noted the United States to be last among its peers. Head over to the website for in-depth information and analysis of the healthcare system, from top to bottom.

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

While you’re at it, check out Dr. Johnson’s twitter feed: https://twitter.com/dhjutsw1/status/478611362097020928

Ceftaroline: What’s the big deal?

Today at morning report we talked about the antibiotic, ceftaroline, and its increasing use. Below is a link to a great review article about ceftaroline from The Journal of Antimicrobial Chemotherapy.

http://jac.oxfordjournals.org/content/66/suppl_3/iii11.full.pdf+html

Key points:
– Considered a “fifth generation” cephalosporin.
– In regards to community acquired bacterial pneumonia, ceftaroline has potent activity against gram positive species such as S. aureus, S. pneumoniae, Streptococcus pyogenes. It also has activity against gram negative species including H. influenzae and Moraxella catarrhalis.
– For acute skin and soft tissue infections, ceftaroline has strong activity against S. aureus including MRSA and vancomycin resistant staph as well as Streptococcus pyogenes.
– May have synergistic effect with aminoglycosides against gram negative species.
– Eliminated by the kidneys.
– Typical dosing is 600mg q12h, 1 hour infusion, in adults over 18 years old.

Grand Rounds: “Brain Metastases: Finally a Light at the End of this Long Dark Tunnel”

Today Dr. Elizabeth Maher gave a fantastic talk on the current clinical management and her research on brain metastases. She gave a great summary of the current guidelines for the management of brain mets by the The American Society of Radiation Oncology outlined below:

1. Single brain mets, larger than 3-4 cm, amenable to surgery with good prognosis (survival >3 months) –> Surgical reserction and WBRT (level 1 evidence). If smaller than 3-4 cm consider radiosurgery alone or WBRT and radiosurgery. If non resectable single brain met, WBRT can be considered (level 3)

2. Multiple brain mets and good prognosis (survival < 3 months) –> Radiosurgery + WBRT, Radiosurgery alone or WBRT alone can be considered (level 3)

3. Patients with poor prognosis (survival < 3 months) and single or multiple brain mets –> Palliative care +/- WBRT (level 3)

During her talk she also referenced a recent publication by our own Chair of Internal Medicine, Dr. David Johnson. Read his article here:

http://jco.ascopubs.org/content/32/10/973.long

 

 

Project ECHO in NY Times Article

Very interesting article from The New York Times about Project ECHO which combines video teleconferencing and training from specialists that equip primary care providers with the knowledge to take care of complex patients. For example, a family medicine doctor treating a patient’s hepatitis C with antiviral therapy with the guidance of liver specialists remotely because the patient lives too far from the liver clinic. Check out the article below:

http://opinionator.blogs.nytimes.com/2014/06/11/the-doctor-will-stream-to-you-now/?_php=true&_type=blogs&emc=eta1&_r=0

The Chief Resident’s Role

What we actually do as your chief residents?

We are in a unique position, as we have just finished residency training and are now overlooking the house staff. Our roles are comprised of administrative, clinical and educational components.

Clinical Role: We will be attendings on the wards at both PMH and the VA. This entails the typical duties of any other attendings. Furthermore, we are involved in resolving conflicts between services, ensuring patient safety across all of our services, and fielding patient transfer requests from outside hospitals.

Administrative Role: This a role that you are used to seeing us in as we make your schedules, organize the noon conferences, speakers, intern chart conference, arrange coverage for fellow residents. We work with Dr. Johnson, Dr. Kazi, and the associate program directors on improving the residency and its curriculum as well as trouble-shooting problem areas that you, as residents, bring to our attention. We represent the house staff at many administrative meetings at Parkland, University and VA hospital. We organize the events, transportation, dinner venue for the interview season for upcoming applicants. We run morning report at Parkland and the VA as well as Weissler Conference.

Teaching: In addition to arranging the conferences and working on curriculum, we are most excited about the opportunity to teach directly, at the individual level. This will occur in places like morning/afternoon report, on rounds while on service.

Mentors: This is the role that is often not seen, as it’s typically on an individual level, though it’s a role we are very excited about. Throughout the year, some of you may experience hardships or obstacles, have questions or concerns regarding patient care, or have ideas for systems improvement. As your chief residents, we will work with you to get things back on track, help solve patient care issues, and discuss the systems changes that may help to improve our experience here as housestaff. This usually involves frequent meetings to check how you’re doing, reviewing the care of your patients together, and having you complete short courses of modules.

What are our expectations of you?

We want you to be a more knowledgeable, professional and caring clinician by the end of your second year. It is our hope that you’re not content with “getting by,” but want to improve, learn more, and build on the foundation that has been laid this past intern year.

Thus we expect you to be on time for morning report and conferences, to dress appropriately (shirt, tie and slacks for men, business casual for women), particularly at morning report and on the Ward services. Beyond this, we want you to become excellent educators, making an effort to teach to your medical students and interns whenever possible during rounds and with short dedicated lectures. We hope your interactions with nurses, med techs, pharmacists and other specialty services are respectful.

What are our expectations for ourselves? And we want you to hold us accountable to this.

We want to be the tools and resources that allow you to flourish as an upper level resident in this residency. This is a quote from a paper from Yale about the chief resident’s role regarding the house staff.

“The chief residents are responsible for creating a space, both physical and psychological, where the house staff feels safe to express their neediness, fragility, doubt, fear, and anxiety while receiving encouragement and support.”
We hope to encourage and support you this coming year and will go out of our way to help you become the best resident physician you can be.

Just like you guys have big learning curve becoming upper level residents, we also have a learning curve as chief residents and we will learn together what works and what doesn’t. We look forward to the transition to the new hospitals and rotations and working together to enhance this residency.

What to do with all that fluid?

EXAMPLE:
At yesterday’s morning report in Parkland we had a great discussion about treating ascites. Below is a link to the most updated guidelines regarding ascites management in cirrhosis from the American Association for the Study of Liver Diseases (AASLD) published in February 2013.

http://www.aasld.org/practiceguidelines/Documents/ascitesupdate2013.pdf

Some key points from the guidelines include:
-Since bleeding is uncommon during diagnostic paracentesis, routine prophylactic use of platelets and fresh frozen plasma are not recommended (Class III, Level C).
-Initial laboratory tests for ascitic fluid should include cell differential count, ascitic total protein and SAAG (Class I, Level B).
-Sodium restriction (less than 2000mg per day) and diuretics (spironolactone with or without furosemide) is first line therapy in cirrhotics with ascites (Class IIa, Level A).

UTSW Internal Medicine

%d bloggers like this: