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I love it when consultants (or PMDs) agonize over a wbc. Like it effin matters!

 

From an ACEP talk (and btw, once youve been in an ED for a few years, considering going to ACEP. Well worth it):

 

-wbc & fever not clinically useful to rule in/out appendicitis.

-11% of appendicitis had normal WBC. with gangrene / abscess / peritonitis no difference between normal / elevated wbc.

-52% of septic patients had no wbc elevation. +blood cx had similar values.

-CAP- age >65 with normal wbc and no fever had HIGHER mortality.

-wbc doesnt correlate with severity of PNA.

-80% of pyelo have wbc bump

 

bottom line: not predictive of bacterial disease, severity of disease, or cause of disease.

 

as always. treat the patient.

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Anyone got a link to a good article about this? I'd love to learn more.

 

lots of them:

 

1. Ahkee S, Srinath L, Ramirez J. Community Acquired Pneumonia in the Elderly:

Association of Mortality With Lack of Fever and Leukocytosis. Southern Medical

Journal. 1997; 90: 296-298.

2. Alpern E, Alessandrini E, Bell L, Shaw K, McGowan K. Occult Bactermia from a

Pediatric Emergency Department: Current Prevalence, Time to Detection, and Outcome.

Pediatrics. 2000; 106: 505-11.

3. Alvarado A. A Practical Score for the Early Diagnosis of Acute Appendicitis. Annals

of Emergency Medicine. 1986; 15: 557-564.

4. American College of Emergency Physicians. Clinical Policy for Children Younger

Than Three Years Presenting to the Emergency Department With Fever. Annals of

Emergency Medicine. 2003; 42: 530-545.

5. Anderson R E. Meta-analysis of the Clinical and Laboratory Diagnosis of

Appendicitis. British Journal of Surgery. 2004; 91: 28-37.

8. Birchley D. Patients with Clinical Acute Appendicitis Should Have Pre-Operative

Full Blood Count and C-Reactive Protein Assays. Ann R Coll Surg Engl. 2006; 88: 27-

32.

9. Bonsu B, Harper M, MD. Identifying Febrile Young Infants with Bacteremia: Is the

Peripheral White Blood Cell Count an Accurate Screen. Annals of Emergency Medicine.

2003; 42: 216-25.

10. Brown L, Shaw T, Wittlake W A. Does Leukocytosis Identify Bacterial Infections in

Febrile Neonates Presenting to the Emergency Department. Emerg Med J. 2005;

22:256-59.

11. Callaham M, MD. Inaccuracy and Expense of the Leukocyte Count in Making

Urgent Clinical Decisions. Annals of Emergency Medicine. July 1986; 15: 7. 774-81.

12. Cardall T, Glasser J, Guss D, MD. Clinical Value of the Total WBC Count and

Temperature in the Evaluation of Patients with Suspected Appendicitis. Academic

Emergency Medicine. October 2004; 11:10. 1021-27.

13. Howell JM, Eddy OL, Lukens TW, Thiessen M, Weingart SD, Decker WW. Clinical

Policy: Critical Issues in the Evaluation and Management of Emergency Department

Patients With Suspected Appendicitis. Annals of Emergency Medicine. 2010; 55: 71-

116.

15. Kwan K, Nager A, MD. Diagnosing Pediatric Appendicitis: Usefulness of

Laboratory Markers. American Journal of Emergency Medicine. 2010; 28: 1009-1015.

18. Rollino C et al. Acute Pyelonephritis: Analysis of 52 Cases. Renal Failure. 2002;

24:5. 601-08.

19. Rudinsky S et al. Serious Bacterial Infections in Febrile Infants in the Post-

Pneumococcal Conjugate Vaccine Era. Academic Emergency Medicine. July 2009;

16:7. 585-89.

20. Seigel T, MD et al. Inadequacy of Temperature and White Blood Cell Count in

Predicting Bacteremia in Patients with Suspected Infection. Journal of Emergency

Medicine. 2012. 22;3: 254-59.

21. Snyder B, Hayden, S, MD. Accuracy of the Leukocyte Count in the Diagnosis of

Appendicitis. Annals of Emergency Medicine. 1999; 33: 565-74.

22. Stoll M L, Rubin L, MD. Incidence of Occult Bacteremia Among Highly Febrile

Young Children in the Era of the Pneumococcal Conjugate Vaccine. Arch Pediatr

Adoles Med. 2004; 158: 671-75.

23. Ward M, MD et al. The Degree of Bandemia in Septic ED Patients does not Predict

Inpatient Mortality. American Journal of Emergency Medicine. 2012; 30: 181-83.

24. Young G, MD. CBC or Not CBC? That is the Question. Annals of Emergency

Medicine. March 1986; 15:3. 367-71.

 

 

Want more? I could probably pubmed dozens more for various clinical categories. Just dont tell our surgeons or urologists.

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... Dismissing the wbc out of hand seems short sighted.

 

 

Yep...!!!

 

And the reallity is... If YOU are seated next to the dude in the black robe, being castigated by someone in expensive shoes ... they are gonna LOVE the fact that YOU the MID-LEVEL/NON-Physician was so Cavalier that you "dismissed" that elevated WBC while "playing doctor" after completing your MERE 2 yrs of community college PA classes.

 

No Thanks...

I'll continue to pay attention to that WBC...

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Point is that its not useful for judging infectious etiologies or how bad an infection is. its useful in only a handful of cases- like detecting lymphomas or if someone with a low ANC and any infection at all automatically gets admitted.

 

appendicitis. pneumonia. pyelo. wbc essentially useless. damn near all the literature says as such.

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Yep...!!!

 

And the reallity is... If YOU are seated next to the dude in the black robe, being castigated by someone in expensive shoes ... they are gonna LOVE the fact that YOU the MID-LEVEL/NON-Physician was so Cavalier that you "dismissed" that elevated WBC while "playing doctor" after completing your MERE 2 yrs of community college PA classes.

 

No Thanks...

I'll continue to pay attention to that WBC...

 

EXACTLY

 

hate to say it but it is defensive medicine at it's best/worst....

 

what about the peds EM guideline for rocephen for fever with WBC > 15k with no id source?

 

gotta use the WBC somewhere because the atty's say so and there is some logical sense to it...

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Point is that its not useful for judging infectious etiologies or how bad an infection is. its useful in only a handful of cases- like detecting lymphomas or if someone with a low ANC and any infection at all automatically gets admitted.

 

appendicitis. pneumonia. pyelo. wbc essentially useless. damn near all the literature says as such.

 

 

I've taken care of innumerable pts whose infectious source was first w/u based on a wbc.

What to do about an ambulatory pt with a prosthetic valve and a wbc?

A hospitalized pt w/ indwelling lines?

Do we disregard their wbc as well?

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