Weird paracentesis

[alreadylernd]

Hey, in MICU today, did a diagnostic paracentesis and got back the following:
500,000+ RBCs
0 (!) WBCs

I can't remember the protein, glucose etc off the top of my head, but they weren't remarkable.

Brief history: 50s guy, s/p renal transplant, significant cardiac hx, DM, but no liver history, no known cancer history.

I've never seen anywhere near that many RBCs and the fact that there were ZERO WBCs seems weird too. Any idea what this could be?

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[ThedarnmikeDO]

What was his white count? Was he on some hardcore immunosuppressant?

 

[alreadylernd]

He was on an immunosuppressant (I can't remember which), he had a history of neutropenia months ago, but yesterday, his WBC was like 13 or something, I checked a CBC around the same time as the paracentesis and WBC was like 6 or 7 or something, so it dropped (his HCT was like 25-26, a drop from 30 or so yesterday). Why?

 

[southerndoc]

Did he have a FAST done? Seriously, I would think the patient had some sort of bleed (hemangioma, hit the inferior epigastric artery, etc).

 

[ThedarnmikeDO]

I just thought that his lack of wbc in the tap might be explained by a generalized severe leukopenia. However knowing that his WBC is 6-7 pretty much throws that hypothesis out the window.

 

[matt_mt19]

If his ascites wasn't tense before it may be now... a FAST may not help too much since he'll already have free fluid, but I'd sure do serial exams and consider a couple crit's thereafter. If done in the proper locale on the abd its a very safe and effective diagnostic and therapeutic intervention. Serial abd girth measurements may also be helpful, but if bleeding briskly (epi art) then clinically the pt may have an acute abd. (eventually)

 

[southerndoc]

If his ascites wasn't tense before it may be now... a FAST may not help too much since he'll already have free fluid, but I'd sure do serial exams and consider a couple crit's thereafter. If done in the proper locale on the abd its a very safe and effective diagnostic and therapeutic intervention. Serial abd girth measurements may also be helpful, but if bleeding briskly (epi art) then clinically the pt may have an acute abd. (eventually)

Yea, good point. Not sure what I was thinking when I suggested the FAST.

With so many RBC's, I would consider this almost as if the patient had a positive DPL. Even though there isn't trauma, there is some reason why the patient is bleeding.

 

[matt_mt19]

Oh by the way -- if you didn't actually visualize entering the peritoneum (US guidance) and you didn't get "peritoneal fluid via a blind approach" -- Did the glucose happen to be the same as serum and did the protein near the same? Since you only got blood, you may have essentially just put in an IV... where on the abdomen were you? I've had really bloody abd taps, but they have always had leuk's as well... but I've also always marked it with US or under direct visualization of the needle entering the peritoneum into the fluid cavity.

 

[alreadylernd]

Didn't have ultrasound (the fellow has it in his office and he had already gone home). Tapped it out pretty well and only advanced into the belly may 2-3 cm before I got draw back (I was using an 18G). I wondered if I had maybe got a vascular structure but wouldn't there be WBCs? Also, the fluid wasn't viscous like blood would be sitting in the collection tubes, and it was transparent-ish.

Oh well, I guess I'll find out this morning what is up.

 

[ThedarnmikeDO]

any new info?

 

[docB]

How long post transplant was this guy? A day, a week, a year?

What did the patient's UA look like. Was he putting out urine? I'd consider a rupture in the ureteral anastomosis. They put the transplanted kidney in the pelvis and hook it into the iliac vessels and then attach the ureter to the bladder. If there was a rupture there could be bloody urine collecting in the abdomen. It's also a little odd that the protein was normal given that there were so many RBCs. RBCs are made of protein so it should have been elevated.

 

[kungfufishing]

No, they are made of swiss cheese and everyone knows it.

 

[alreadylernd]

So we ended up getting a crit on the fluid, it was 2.6, GI wasn't too concerned and they seemed to think it was bleeding from a vessel although I still don't understand why there weren't any WBCs. CT abd/pelvis was unremarkable, HCT has been stable since, belly is still soft. Just weird I guess...

His immunosuppressant was sirolimus by the way...