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M

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Smoker, Severe COPD, HTN, CAD, ESRD/on dialysis, hyperthyroidism. Meds-Lisinopril, Cardizem, Amiodarone, Asprin, Methimazole,, Levalbuterol, ... – PowerPoint PPT presentation

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Title: M


1
MM7/3/07
  • Ajith Uliyargoli

2
  • 68 AA, F, Chr. Smoker, Severe COPD, HTN, CAD,
    ESRD/on dialysis, hyperthyroidism
  • Meds-Lisinopril, Cardizem, Amiodarone, Asprin,
    Methimazole,, Levalbuterol, Spiriva(cefditoren),
    Advair, Prednisone, Aranesp, Xanax
  • Quit smoking in April 07
  • NKDA

3
  • Had 2 recent admissions within the last 1 month
    for recurrent bronchitis, pneumonia,.
  • WBC ?
  • CXR suggestive of B/L infiltrates.
  • CT scan on 7/13 showed B/L effusions RgtL with
    scanty infiltrate.
  • Blood Cultures were negative
  • Treated with several antibiotics, steroids, also
    requiring Bipap and oxygen

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  • Was re-admitted on 6/16/07, with SOB, no fevers,
    no cough
  • WBC ?,
  • Cxray- B/L pleural effusion right greater than
    left
  • Underwent a Right Thoracentesis with drainage of
    1 L of fluid
  • Immediate post-procedure- developed increased SOB
    with decreased breath sounds and a chest tube
    placed for PTX

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  • Over the next few days several attempts were made
    to place chest tube to water seal but pt
    developed recurrent PTX
  • Fluid Cultures Neg
  • Transudate
  • Cytology -Neg

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  • Suction increased to -40cm
  • Chest tube output of approx. 400 cc/day with a
    persistent air leak.
  • Advised Talc pleurodesis. After initial refusal,
    finally agreed and underwent pleurodesis on
    7/2/07

14
  • Complication- Post thoracentesis PTX
  • Persistent PTX - Sec to underlying lung disease

15
Thoracentesis
  • Several studies lt1 incidence of PTx following
    thoracentesis
  • If small and symptomatic may be observed
  • Tube thoracostomy if large, progressive,
    symptomatic
  • Other complications- Injuries to Liver , spleen ,
    bowel
  • Bleeding
  • Needle tract seeding
  • Retention of catheter fragments
  • Reactive pulmonary odema- post drainage

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Physiology
  • Mean pleural fluid vol- 8.4ml per hemithorax
  • Rate of fluid formation- 0.6ml/hr
  • Mostly formed by parietal pleura and is drained
    by lymphatics
  • Rate of absorption can increase many fold from
    normal (0.01ml/kg/hr) upto 0.22 to
    0.28ml/kg/hr-approx 300ml/day (hence when chest
    tube outputs less than 200 per day, chest tubes
    may be removed)

17
Transudate
  • Lights criteria
  • Fluid protein /serum protein ratio gt 0.5
  • Fluid LDH/Serum LDH ratio gt0.6
  • Fluid LDH gt 2/3 of serum LDH
  • Two-test rule- Fluid chlesterolgt45mg/dl and LDH
    gt2/3 of serum LDH
  • Three test rule- Fluid protein gt2.9mg/dl plus
    above

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Technique
  • A line midway between the spine and posterior
    axillary line
  • Needle 1 to 2 spaces below the level of dullness
  • Under U/S guidance for smaller and loculated
    effusions
  • Approx 30ml of fluid required for studies

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Recurrent effusions- treatment options
  • Indwelling catheters
  • Pleurodesis
  • Pleurectomy
  • Pleuroperitoneal shunts
  • Antitumor theraphy- Lymphoma, Breast Ca, Ovarian
    Ca, Germ cell tumors
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