A 27-year-old patient with a prolonged ICU stay following a subarachnoid haemorrhage has developed fever with an altered consciousness level.
The CSF specimen result below was taken from the external ventricular drain.
Parameter |
Patient Value |
Adult Normal Range |
Red Blood Cells |
1946 x 106/L* |
0 – 5 |
Neutrophils |
198 x 106/L* |
0 – 5 |
Mononuclear cells |
74 x 106/L |
a) List your treatment decisions to be made based on the CSF. (10% marks)
b) Explain your rationale for the above. (10% marks)
Not available.
The question that needs to be answered about the CSF is:
For CSF following SAH, analysis is challenging because there is usually enough blood in the CSF to confuse everything, and the process of clot dissolution brings out the neutrophils and macrophages, producing leukocytosis. Annoyingly, the patient can also be febrile purely from the blood in the CSF, leaking inflammatory chemicals into the delicate sensory filaments of the hypothalamic thermostat.
So, what to do with this result? Pfausler et al (2004), reviewing the literature and their own retrospective case series, concluded that there were "no specific CSF features that distinguish in the early diagnosis of ventriculitis after SAH" and suggested that everyone should just give antibiotics anyway, because nosocomial bacterial ventriculitis has a very high morbidity and mortality. These can then be ceased two or three days later, when the CSF culture comes back negative.
Thus, one possible approach is:
a)
b)
Hoogmoed, J., et al. "Clinical and laboratory characteristics for the diagnosis of bacterial ventriculitis after aneurysmal subarachnoid hemorrhage." Neurocritical care 26.3 (2017): 362-370.
Pfausler, B., et al. "Cell index–a new parameter for the early diagnosis of ventriculostomy (external ventricular drainage)-related ventriculitis in patients with intraventricular hemorrhage?." Acta neurochirurgica 146.5 (2004): 477-481.
Beer, Ronny, Bettina Pfausler, and Erich Schmutzhard. "Management of nosocomial external ventricular drain-related ventriculomeningitis." Neurocritical care 10.3 (2009): 363-367.
Beer, R., et al. "Nosocomial ventriculitis and meningitis in neurocritical care patients." Journal of neurology 255.11 (2008): 1617-1624.
Panic, Hana, et al. "Etiology and Outcomes of Healthcare-Associated Meningitis and Ventriculitis—A Single Center Cohort Study." Infectious Disease Reports 14.3 (2022): 420-427.