SEROUS FLUID

 The closed cavities of the body are each lined by two membrane s referred to as the serous fluid
o Pleural
o Pericardial
o Peritoneal

 One membrane lines the cavity wall – PARIETAL MEMBRANE

 One membrane covers the organs within the cavity – VISCERAL MEMBRANE
 The fluid between the membranes is called SEROUS FLUID
o It provides lubrication between the parietal and visceral membranes
 Lubrication is necessary to prevent the friction between the two membranes that
occurs as a result of movement of the enclosed organs
 Ex: expansion and contraction of the lungs

FORMATION
 Serous fluids are formed as ULTRAFILTRATE OF PLASMA
 Production and reabsorption are subject to HYDROSTATIC PRESSURE and ONCOTIC PRESSURE
from the capillaries that serve the cavities and the capillary permeability
o Hydrostatic pressure in the parietal and visceral capillaries cause fluid to enter between the
membranes
o Filtration of the plasma ultrafiltrate results in increased oncotic pressure in the capillaries

**This action produces a continuous exchange of serous fluid and maintains the normal
volume of fluid between the membranes

 Disruption of the mechanisms of serous fluid formation and reabsorption causes an increase in fluid
between the membrane
** EFFUSION (Increased in fluid between the membrane)
o Primary causes of effusion
 Increased hydrostatic pressure (congestive heart failure)
 Decreased oncotic pressure (hypoproteinemia)
 Increased capillary permeability (inflammation and infection)
 Lymphatic obstruction (tumors)

PATHOLOGIC CAUSES OF EFFUSIONS

INCREASED CAPILLARY HYDROSTATIC PRESSURE - Congestive heart failure

- Salt and fluid retention
DECREASED ONCOTIC PRESSURE - Nephrotic syndrome
- Hepatic cirrhosis
- Malnutrition
- Protein-losing enteropathy
INCREASED CAPILLARY PERMEABILITY - Microbial infections
- Membrane inflammations
- Malignancy
LYMPHATIC OBSTRUCTION - Malignat tumors
- Lymphomas
- Infection
- Inflammation
- Thoracic duct injury

SPECIMEN COLLECTION AND HANDLING

 Fluid are collected by needle aspiration from the respective cavities
o Thoracentesis – Pleural
o Pericardiocentesis – Pericardial
o Paracentesis – Peritoneal
 >100 mL is usually collected; therefore, suitable specimens are available for each section of the
laboratory
 EDTA - For cell counts and the differential
Sterile heparinized or SPS - For microbiology and cytology
Plain tubes or in heparinized tubes - Chemistry
Heparinized tube and maintained - For pH determination
anaerobically in ice

TRANSUDATES AND EXUDATES

 TRANSUDATES – An effusions that form because of systemic disorder that disrupts the balance in
the regulation of fluid filtration and reabsorption
o Changes in hydrostatic pressure created by congestive heart failure
o Hypoprotenemia associated with the nephrotic syndrome
 EXUDATES – Produced by conditions that directly involve the membranes of the particular cavity,
including infections and malignancies

** Classifying a serous fluid as transudates or exudate can provide a valuable initial diagnosis step
and aid in the course of further laboratory testing, because it is usually not necessary to test
transudate fluids

LABORATORY DIFFERENTIATION OF TRANSUDATES AND EXUDATES

TRANSUDATE EXUDATE
APPEARANCE Clear Cloudy
FLUID : SERUM PROTEIN RATIO <0.5 >0.5
FLUID : SERUM LD RATIO <0.6 >0.6
WBC COUNT <1000/uL >1000/uL
SPONTANEOUS CLOTTING NO POSSIBLE
PLEURAL FLUID CHOLESTEROL <45 TO 60 mg/dL >45 TO 60 mg/dL
PLEURAL FLUID : SERUM CHOLESTEROL RATIO < 0.3 >0.3
PLEURAL FLUID : BILIRUBIN RATIO <0.6 >0.6
SERUM-ASCITES ALBUMIN GRADIENT >1.1 <1.1

GENERAL LABORATORY PROCEDURE:

 Classification as transudate or exudate
o Appearance
o Cell count and differential
o Chemistry
o Microbiology and cytology
 The significance of the test results and the need for specialized tests vary among fluids

PLEURAL FLUID
 It is obtained from the pleural cavity, located between the parietal pleural membrane lining the chest
wall and the visceral pleural membrane covering the lungs
 THORACENTESIS
o Surgical puncture into the thoracic cavity to collect pleural fluid
 Pleural effusions may be either transudative or exudative
o There are two additional procedures are helpful when analyzing pleural fluid :
1. Pleural fluid cholesterol and fluid : Serum cholesterol ratio
2. Pleural fluid : Serum total bilirubin ratio
 A pleural fluid cholesterol greater than 60 mg/dL or a pleural fluid:serum
cholesterol ratio greater than 0.3 --- THE FLUID IS TRANSUDATE
 A fluid:serum total bilirubin ratio of 0.6 or more also indicates the presence of
an EXUDATE

Appearance
 Normal and transudate pleural fluids are clear and pale yellow
 Turbidity is usually related to the presence of WBCs and indicates:
 o Bacterial infection
o Tuberculosis
o Immunologic disorder
 Rheumatoid arthritis
 Presence of blood can signify a hemothorax (traumatic injury) – appears streaked and uneven
o Membrane damage
 Malignancy
 Traumatic aspiration
o To differentiate between a hemothorax and hemorrhagic exudate
 HEMATOCRIT CAN BE RUN ON THE FLUID
 Hemothorax: The fluid hematocrit is more than 50% of the whole blood
hematocrit, because the effusion comes from the inpouring of blood from the
injury
 Milky pleural fluid may be due to the presence of chylous material from thoracic duct leakage or to
pseudochylous material produced in chronic inflammatory conditions
o CHYLOUS material contains a high concentration of TRIGLYCERIDES
o PSEUDOCHYLOUS material has a higher concentration of CHOLESTEROL

CHYLOUS EFFUSION PSEUDOCHYLOUS EFFUSION

CAUSE Thoracic duct damage - Chronic inflammation
- Lymphatic obstruction
APPEARANCE Milky/white Milky/green tinge
LEUKOCYTES Predominantly lymphocytes Mixed cells
CHOLESTEROL CRYSTALS Absent Present
TRIGLYCERIDES >110 mg/dL <50 mg/dL
SUDAN III STAINING Strongly positive Negative /weakly positive

Hematology tests
 Primary cells associated with pleural fluid include
o Macrophages – 64% to 80% of a nucleated cells
o Neutrophils – 1% to 2%
o Lymphocytes – 18% to 30%
o Eosinophils
o Mesothelial cells
o Plasma cells
o Malignant cells

Significance of cells seen in Pleural Fluid

CELLS SIGNIFICANCE
Neutophils - Pancreatitis
- Pulmonary infarction
Lymphocytes - Tuberculosis
- Viral infection
- Autoimmune disorders (SLE, RA)
- Malignancy
Mesothelial cells - Normal and reactive forms have no clinical significance
- Decreased mesothelial cells are associated with tuberculosis
Plasma cells - Tuberculosis
Malignant cells - Primary adenocarcinoma
- Small-cell carcinoma
- Metastatic carcinoma

Chemistry tests
 The most common chemical tests performed on pleural fluid are:
o Glucose
o pH
o Adenosine deaminase (ADA)
o Amylase

Significance of chemical testing of pleural fluid

 TEST SIGNIFICANCE
Glucose - Decreased in rheumatoid inflammation
- Decreased in purulent infection
Lactate - Elevated in bacterial infection
Triglycerides - Elevated in chylous effusions
pH - Decreased in pneumonia not responding to antibiotics
- Markedly decreased with esophageal rupture
ADA - Elevated in tuberculosis and malignancy
Amylase - Elevated in pancratitis
- Esophageal rupture
- Malignancy

PERITONEAL FLUID
 Accumulation of fluid between the peritoneal membrane is called ASCITES, and the fluid is
commonly referred to as ASCITIC FLUID rather than peritoneal fluid
 PARACENTESIS
o Surgical puncture into the abdominal cavity to obtain peritoneal fluid
 PERITONEAL LAVAGE
o Diagnostic peritoneal aspirate and lavage is a rapid and easily performed but invasive
bedside procedure that was once the gold standard for the evaluation of abdominal trauma.
The procedure was initially used in patients with blunt abdominal trauma, but its use quickly
evolved to include some patients with penetrating trauma. It can provide information about
injury to the solid or hollow organs, peritoneal penetration, and may also aid the diagnosis of
diaphragm injury

PERICARDIAL FLUID
 Normally, only a small amount (10 to 50 mL) of fluid is found between the pericardial serous
membranes
 An effusion is suspected when cardiac compression (tamponade) is noted during the physician’s
examination
o TAMPONADE: Buildup of pericardial fluid affecting the heart
 PERICARDIOCENTESIS
o Surgical puncture into the pericardial cavity to obtain pericardial fluid