Pemeriksaan dan Interpretasi Cairan Pleura

Transkripsi

1 Pemeriksaan dan Interpretasi Cairan Pleura Cairan Pleura - Berada pada rongga Pleura, sbg pelicin gesekan antara pleura visceralis dan pleura parietalis - Normal : cairan sedikit, Vol ml -Dihasilkan secara kontinu berdasarkan : * tekanan hidrostatik kapiler * tekanan onkotik plasma * permeabilitas kapiler. - Direabsorbsi melalui limfatik dan venule - Akumulasi cairan disebut efusi, terjadi karena imbalance produksi dan reabsorbsi - Berdasarkan penyebabnya, efusi pleura biasanya diklasifikasikan atas Transudat dan Eksudat 1

2 Transudasi adalah akumulasi cairan akibat : - Peningkatan tek. hidrostatik dalam paru - Penurunan tek. onkotik Mis. Albumin plasma menurun atau tek. vena meninggi (CHF, hipoproteinemia, sirosis, neprotik sindrom, dll) Eksudasi adalah akumulasi cairan akibat : - Proses inflamasi yg menyebabkan perubahan permeabilitas membran pleura atau - Penurunan reabsorbsi limfatik - Penyebab a.l : Infeksi TBC, infeksi bakteri atau jamur, Neoplasma, rheumatoid disease, SLE. Cairan juga dapat berasal dari : - Pancreatitis (amilase tinggi) - Rupture esophagus (ph rendah dan amilase tinggi) - Urine ( ph rendah dan creatinine tinggi) Indikasi pengambilan cairan pleura 1. Pemeriksaan lab. (mengetahui etiologi efusi transudat atau eksudat) 2. Mengurangi gejala klinik (mis.sesak, sakit) 3. Menghindari terjadinya kumpulan darah atau nanah (hemitoraks, empiema) 4. Mengurangi cairan dalam rongga pleura untuk diganti dgn obat kedlm rongga tsb 2

3 Indikasi pemeriksaan cairan pleura 1. Mengetahui penyebab (diagnosis) 2. Penunjang diagnosis 3. Follow up penyakit, komplikasi dll 4. Follow up terapi Pemeriksaan yg dianjurkan: Rutin : 1. Makroskopis 2. Mikroskopis : Hitung sel, Hitung jenis 3. Analisa kimia : Protein, Glucose Pemeriksaan Cairan Pleura: Berguna utk sbgn besar pasien : 1. Pulasan langsung dan kultur m.o 2. Sitologi Perlu utk kasus tertentu : 1. Cholesterol atau ratio fluid/ 2. Albumin gradient 3. ph 4. CRP 5. Tumor marker 6. Enzymes (Amylase, LD) 7. Lactate 8. Alkaline Phosphatase, dll 3

4 Kriteria Lab utk Eksudat : - Secara Umum : * Total Protein * Light s Criteria - Khusus Pleural fluid : 1. Cholesterol > 45 mg/dl 2. Pleural fluid/ cholesterol ratio = atau > 0, pleural fluid albumin gradient = atau < 1,2 g/dl 4. Pleural fluid/ bilirubin ratio = atau > 0,6 - Sens 98%, spec 80% Pembedaan transudat dan exudat secara umum Total Protein (TP) : exudat jika TP > 3.0 g/dl Light s Criteria Rasio TP TP Cairan (E > 0.5) TP Serum Rasio LDH : LDH cairan (E > 0.6) LDH Rasio LDH : LDH cairan (E > 0.67) nilai tertinggi LDH normal 4

5 PLEURAL EFFUSION : PLEURAL FLIUD PROFILES IN VARIOUS DISEASE STATES Diagnosis Gross Appearan ce Protei n (g/dl) Glucose (mg/dl) Normal Clear Equal to TRANSUDATES Congestive heart failure Nefrotic syndrome Hepatic cirrhosis EXUDATES Tuberculosis Malignancy serous <3: some times 3 Equal to Serous <3 Equal to serous <3 Equal to Usually serous; can be bloody Usually turbid, bloody; 0cc serous 90% 3; mey exceed 5 g/dl Equal to ; 0 cc <60 90% 3 Equal to ; <60 in 15% of cases WBC & Differenti al (per mcl) 1000, mostly MN RBC (per mcl) Microscopic Exam 0 or few Neg Neg Culture Comments <1000 < neg Neg Most common cause of pleural effusion. Effusion right-sided in 55-70% of patients <1000 <1000 neg Neg Occurs in 20 % of patiens. Cause is low protein osmotic pressure <1000 <1000 Neg Neg From movement of ascites diaphragm. Treatment of underlying ascites usually sufficient , mostly MN mostly MN < Concentrate Pos for AFB in <50% > Post cytology in 50% May tield MTb Neg PPD usually positive; pleural biopsy positive; eosinophils (>10%) or mesothelial cells (>5%) make diagnosis unlikely Eosinophils uncommon; fluid tends to reaaccumulate after removal. Diagnosis Gross Appearanc e Protei n (g/dl) Glucose (mg/dl) WBC & Differential (per mcl) RBC (per mcl) Micro scopi c Exam Cult ure Comments Empyema Turbid to purulent 3 Less then, often < <5000 Pos Pos Drainage necessary; putrid odor suggest anaerobic infection Parapneumo nic-effusion, uncomplicate d Clear to turbid 3 Equal to <5000 Neg Neg Tube thoracostomy unnecessary; associated infiltrate on chest X-ray; fluid ph 7,2 Pulmonary embolism, infarction Serous to grossy bloody 3 Equal to > Neg Neg Variable findings; 25% are transudates Rheumatiod athritis or other collagenvascular disease Turbid or yelloy-green 3 Very low (<40 in most); in Ra, 5-20 mg/dl <1000 Neg Neg Rapid clotting time; secondary empyema common Pancreatitis Turbid to serosanguin eous 3 Equal to Neg Neg Effusion usually left-sided; highamylase level Esophageal Rupture Turbid to purulent; redbrown 3 Usually low <5000- over , mostly PMN <5000 Pos Pos Effusion usually left-sided; high fluid amylase level (salivary); pneumothorax in 25% of cases; ph <6.0 strongly suggest diagnosis 5

6 TERIMA KASIH 6