A Case for the Early Tap: Spontaneous Bacterial Peritonitis
Spontaneous bacterial peritonitis (SBP) is an infection in the peritoneum. It can occur in patients OTHER THAN those with cirrhosis (nephrotic syndrome patients, for example), and has a high mortality. This is where we can actually make a difference - by making the diagnosis early. Every hour of delayed diagnosis (and then delayed treatment) raises mortality by 3%.
So if you are suspicious of it, TAP THAT BELLY. And you have to have a high degree of suspicion because up to 10% of patients with SBP will not have signs and symptoms of it!
Once you get that tap back, look at the poly number: greater than 250? Treat that! Go to that 3rd generation cephalosporin, ESPECIALLY if there has been no nosocomial or beta lactam exposure recently.
Next, after getting the elevated polys on tap, look at 3 things: the BUN, the creatinine, and the T Bili. If the BUN is >30, the Creatinine is >1, or the T Bili is >4, give 1.5g/kg albumin within 6 hours of diagnosis. Why? SBP carries an increased risk of renal failure and this maneuver decreases renal failure and decreases mortality.
Belly taps don’t need to be hard or intimidating; chlorhex the belly, grab your sterile gloves and sterile probe cover for your ultrasound, and use a long PIV to insert the catheter into the peritoneum and draw back fluid from that catheter. Sending more fluid in your culture bottles increases the ability to detect bacteria, so pull off at least 20cc just for the culture bottles. Risk of complications w/ a paracentesis is less than 1%- most commonly bleeding and infection. Look at the skin before going in, be sterile, and look with the ultrasound to make sure there are no blood vessels in your way.
Don’t let INR elevations or low platelets skew you away from doing a paracentesis. Patients with cirrhosis, specifically, have a new balance in their pro/anti coagulant balance, so regardless of an elevated INR, it is STILL SAFE TO TAP.
- Think about SBP and tap early.
- Take off enough fluid to obtain a good culture.
- Give albumin if BUN >30, Cr >1, or T Bili >4.
Sammy Boyd is a current third year resident at Stony Brook Emergency Medicine and Captain in the United States Air Force.
this is a list of guidelines from the American Association for the Study of Liver Diseases re: pts w/ ascites.
here is a podcast that Britt Long and Rob Orman did; starting around 18:47 they start talking about ascites and c/f SBP. The whole podcast is awesome, though.
here’s rebel EM’s summary of the evidence of albumin in SBP (*use it*)
a good article on secondary bacterial peritonitis (look out for peritoneal signs, HIGH neutrophil count/wbc count, multiple organisms, free air)
Edited by Ashley Mogul, MD