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Diagnosis of postoperative meningitis using CSF lactate
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Diagnosis of postoperative meningitis using CSF lactate

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  • 1. Postoperative Meningitis Diagnosing using CSF Lactate Shashwat Mishra , Deepak Agrawal, BS Sharma Dept of Neurosurgery, All India Institute of Medical Sciences New Delhi-110029
  • 2. INTRODUCTION
    • POSTOPERATIVE MENINGITIS
    • A neurosurgical diagnostic dilemma
    • Symptoms and signs not dependable
    • CSF pleocytosis due to operative insult
    • Blood and blood degradation products further confuse the diagnosis
  • 3. Diagnose early and reliably!
    • Need for early diagnosis
      • Medical emergency
    • Need for confident diagnosis
      • Indiscriminate antimicrobial therapy promotes antibiotic resistance
  • 4. Recommended criteria
    • Culture positive, which is the gold standard, along with PMN count >250/cumm
    • PMN count>500/cumm (when culture is negative and patient received antibiotics and steroids)
    • Leib et al : Clinical and infectious diseases 1999:29 :69-74
  • 5. Actual Scenario
    • CSF hemorrhagic
    • Cultures rarely positive
    • CSF Sugar may be spuriously low
  • 6. Aims and objectives
    • To determine biochemical markers which may have increased sensitivity in detecting postoperative meningitis
  • 7. Materials & Methods
    • Prospective study over three month period
  • 8. Materials and methods
    • Test group
    • Operated NS patients with fever and clinical suspicion of meningitis
    • Control group
    • Patients who had lumbar drain/EVD placed prophylactically for CSF , no clinical suspicion of meningitis
  • 9. Materials & Methods
    • Parameters assessed
    • CSF cell count (WBC/RBC)
    • CSF Sugar & Protein
    • CSF Lactate (Using ABG machine*)
    • CSF Culture
    • * Validated from a standard lab
  • 10. CSF Sampling frequency
    • Test group
    • Day 1, 3 and 7
    • Control group
    • Day 1, 3 and 5 ,+/- 7
  • 11. Materials & Methods
    • Corrected CSF WBC count
    • (WBC – (RBC /600))
  • 12. Materials & Methods
    • AIIMS protocol
    • All patients with suspected meningitis are started on 3 rd gen Cephalosporin + Aminoglycoside empirically
  • 13. Materials & Methods
    • Statistical tests used
      • Chi square test for association between categorical variables
      • Students t test
      • Pearson’s correlation coefficient
      • SPSS 12.0 software
  • 14. Observations
    • Cases-25
    • Controls-14
  • 15. Observations
    • Age distribution
    39 14 25 TOTAL 5 2 3 More than 50 yrs 22 8 14 18-50 yrs 12 4 8 Less than 18 yrs TOTAL CONTROL CASE AGEGROUP
  • 16. Observations
    • Sex distribution
    39 14 25 TOTAL 7 1 6 FEMALE 32 13 19 MALE TOTAL CONTROL CASE SEX
  • 17. Observations
    • Site of CSF Sampling
  • 18. Observations
    • Fever
    10 0 10 Did not Subside 18 3 15 Subsided 28 3 25 PRESENT TOTAL CONTROL CASE FEVER
  • 19. Observations
    • Incidence of positive culture
    39 29 10 Total 14 14 0 Control 25 15 10 (40 %) Case Total Culture - Culture + Category
  • 20. RESULTS
    • Mean corrected WBC count
    0.04 43 312 Day 5/7 0.556 278 371 Day 3 0.547 405 609 Day 1 Mean Corr WBC/mm3 2 tailed significance CONTROL CASE DAY OF SAMPLING
  • 21. Mean CSF: Blood glucose ratio RESULTS .06 .61 .48 Day 5/7 .002 .62 .38 Day 3 .001 .68 .32 Day 1 Mean CSF:Blood Glucose 2 tailed significance CONTROL CASE DAY OF SAMPLING
  • 22. RESULTS Mean CSF lactate .211 3.571 4.436 Day 5/7 .000 3.157 5.076 Day 3 .001 3.257 5.56 Day 1 Mean CSF Lactate values 2 tailed significance CONTROL CASE DAY OF SAMPLING
  • 23. RESULTS Mean CSF lactate trends correlated with culture positivity
  • 24. RESULTS Mean CSF lactate trends correlated with subsidence of fever .005 3.5 5.7 Day 5/7 .42 5.1 4.9 Day 3 .997 5.6 5.6 Day 1 Mean CSF Lactate values 2 tailed significance Responded Didn’t respond DAY OF SAMPLING
  • 25. RESULTS Combination of CSF lactate>5.0 and Sugar ratio < 0.4 Senstivity = 100% , specificity = 60% CULTURE - 25 15 10 Total 9 9 0 Combination - 16 6 10 Combination + TOTAL CULTURE +
  • 26. RESULTS Conventional CSF analysis (CSF WBC >500/cumm) Senstivity = 27% , specificity = 50% CULTURE - 25 10 15 Total 16 5 11 WBC - 9 5 4 WBC + TOTAL CULTURE +
  • 27. Discussion
    • High CSF lactate levels suggestive of infection
    • Can be easily determined in an ABG machine with good agreement with standard lab values.
    • In combination with low CSF: blood sugar ratio, CSF lactate carries high sensitivity and specificity
  • 28. CONCLUSIONS
    • CSF lactate can be used as single valid parameter in the diagnosis of meningitis.
    • Initial baseline determination can be used to monitor therapy.
    • Rapid and reliable diagnosis.
  • 29. Thank You