Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing Emergency Department Paracentesis

Brian Chinnock, Hagop Afarian, Hal Minnigan, Jack Butler, Gregory W. Hendey

Research output: Contribution to journalArticle

35 Citations (Scopus)

Abstract

Study objective: We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis. Methods: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result. Results: There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization. Conclusion: Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.

Original languageEnglish (US)
Pages (from-to)268-273
Number of pages6
JournalAnnals of Emergency Medicine
Volume52
Issue number3
DOIs
StatePublished - Sep 2008

Fingerprint

Paracentesis
Peritonitis
Hospital Emergency Service
Physicians
Ascites
Confidence Intervals
Vital Signs
Abdominal Pain
Observational Studies
Hospitalization
Neutrophils
Outcome Assessment (Health Care)
Prospective Studies
Sensitivity and Specificity
Pain

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing Emergency Department Paracentesis. / Chinnock, Brian; Afarian, Hagop; Minnigan, Hal; Butler, Jack; Hendey, Gregory W.

In: Annals of Emergency Medicine, Vol. 52, No. 3, 09.2008, p. 268-273.

Research output: Contribution to journalArticle

@article{14a68049efb542d6995931b5475f08f8,
title = "Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing Emergency Department Paracentesis",
abstract = "Study objective: We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis. Methods: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result. Results: There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8{\%}) patients. Physician clinical impression had a sensitivity of 76{\%} (95{\%} confidence interval [CI] 62{\%} to 91{\%}) and specificity of 34{\%} (95{\%} CI 28{\%} to 40{\%}) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85{\%} of patients without spontaneous bacterial peritonitis. Six patients (4.2{\%}) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization. Conclusion: Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.",
author = "Brian Chinnock and Hagop Afarian and Hal Minnigan and Jack Butler and Hendey, {Gregory W.}",
year = "2008",
month = "9",
doi = "10.1016/j.annemergmed.2008.02.016",
language = "English (US)",
volume = "52",
pages = "268--273",
journal = "Annals of Emergency Medicine",
issn = "0196-0644",
publisher = "Mosby Inc.",
number = "3",

}

TY - JOUR

T1 - Physician Clinical Impression Does Not Rule Out Spontaneous Bacterial Peritonitis in Patients Undergoing Emergency Department Paracentesis

AU - Chinnock, Brian

AU - Afarian, Hagop

AU - Minnigan, Hal

AU - Butler, Jack

AU - Hendey, Gregory W.

PY - 2008/9

Y1 - 2008/9

N2 - Study objective: We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis. Methods: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result. Results: There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization. Conclusion: Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.

AB - Study objective: We determine whether clinical characteristics and physician assessment are useful in the exclusion of spontaneous bacterial peritonitis in emergency department (ED) patients with ascites requiring paracentesis. Methods: We conducted a prospective, observational study of ED patients with ascites undergoing paracentesis. Predefined clinical characteristics including historical features and ED vital signs were recorded. Each patient was assessed by 2 separate, blinded physicians for severity of abdominal tenderness and overall clinical suspicion for spontaneous bacterial peritonitis. The primary outcome measures were sensitivity, specificity, and likelihood ratios (LR) of the individual clinical characteristics and the physician assessments. Spontaneous bacterial peritonitis was defined by absolute neutrophil count greater than 250 cells/mm3 or positive fluid culture result. Results: There were 285 separate physician assessments in 144 patients enrolled with complete data. Spontaneous bacterial peritonitis was diagnosed in 17 (11.8%) patients. Physician clinical impression had a sensitivity of 76% (95% confidence interval [CI] 62% to 91%) and specificity of 34% (95% CI 28% to 40%) for the detection of spontaneous bacterial peritonitis. The lowest negative LR was associated with the presence of any abdominal pain or tenderness (negative LR=0.4); however, the presence of pain/tenderness was also observed in 85% of patients without spontaneous bacterial peritonitis. Six patients (4.2%) with spontaneous bacterial peritonitis had at least 1 physician assessment of little to no risk for spontaneous bacterial peritonitis, and 3 of the 6 subsequently died during their hospitalization. Conclusion: Clinical characteristics and physician assessment were insufficient in the diagnosis or exclusion of spontaneous bacterial peritonitis in the ED patient undergoing diagnostic or therapeutic paracentesis. This finding supports routine laboratory fluid analysis after ED paracentesis.

UR - http://www.scopus.com/inward/record.url?scp=49549104202&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=49549104202&partnerID=8YFLogxK

U2 - 10.1016/j.annemergmed.2008.02.016

DO - 10.1016/j.annemergmed.2008.02.016

M3 - Article

C2 - 18433932

AN - SCOPUS:49549104202

VL - 52

SP - 268

EP - 273

JO - Annals of Emergency Medicine

JF - Annals of Emergency Medicine

SN - 0196-0644

IS - 3

ER -