Diagnostic peritoneal lavage

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Overview

  • This invasive bedside procedure was once the gold standard for the evaluation of abdominal trauma
  • DPL is highly sensitive for detecting the presence of intraperitoneal blood and organ injury in blunt abdominal trauma
  • FAST scan (and CT), has led to a diminishing role for this procedure primarily because of low specificity and high rates of unnecessary laparotomy[1]

Two part procedure

  1. Diagnostic peritoneal tap or aspirate (DPA)
    • A catheter is inserted into the peritoneal cavity, initially to aspirate blood or fluid.
  2. Diagnostic peritoneal lavage (DPL)
    • Fluid is infused for a peritoneal lavage, if necessary.

Indications

  • Evaluation to detect or rule out intraabdominal hemorrhage in a hemodynamically unstable blunt trauma patient who is 1) unable to go to CT AND 2) when FAST is not available or technically inadequate
  • Aid in the diagnosis of diaphragmatic injury in select patients.
    • Lavage fluid exiting from a chest tube is pathognomic for diaphragmatic injury
  • Anterior or flank stab wounds with inconclusive local wound exploration
  • Hemodynamically stable patient with tangential gunshot wounds

Contraindications

Absolute

  • Presence of a clear indication for immediate laparotomy

Relative

  • Prior abdominal operations
  • Coagulopathy
  • Advanced cirrhosis
  • Morbid obesity

Equipment Needed

  • Foley catheter and nasogastric tube must be placed prior to performing DPL to avoid injuring the bladder or stomach
  • Local anesthesia with 1% lidocaine with epinephrine generally provides adequate anesthesia
  • Several kits are commercially available
    • If not, may use tray for abdominal access for laparoscopy with a rigid peritoneal dialysis catheter

Procedure

Abdominal access

  • Insertion sites
    • Infraumbilical (2 cm below) location is the standard site
    • Supraumbilical insertion site is preferred in pregnant trauma patient or in the presence of a pelvic fracture
    • Periumbilical site
  • Open method
    • All three layers (skin, fascia, peritoneum) are opened under direct vision
    • Method of choice when precise insertion of the catheter is critical
      • Patient with pelvic fracture, to avoid large hematoma that may be tracking anteriorly
      • Pregnant patient
  • Semi-open method
    • Fascia is opened under direct vision
    • Then Seldinger technique used where a needle is used to penetrate the peritoneum, wire passed through the needle, and the catheter is advanced over the wire.
  • Closed method
    • A small nick is made through the skin
    • Then Seldinger technique used where the needle is blindly passed through the linea alba and the peritoneum
    • The wire and catheter are then inserted following the same method as above.
    • Faster, but greater risk of complications and catheter malposition
    • Avoid this method in the presence of a pelvic fracture or prior midline incision

Diagnostic peritoneal aspiration (DPA)

  • Aspiration of >10mL of blood or enteric contest is considered grossly positive, instillation of the lavage fluid is not necessary

Diagnostic peritoneal lavage (DPL)

  • If no fluid or <10mL fluid is aspirated, instill 1L of warm NS into abdomen, then immediately allow to drain passively
  • Important not to separate catheter and tubing when transitioning from instillation to removal
  • Fluid analysis is performed on a sample of the returned fluid
  • Optimally, most of the liter should be returned but analysis can be performed on as little as 300 cc of the returned fluid

Diagnostic Criteria

  • Blunt abdominal trauma
    • RBC >100,000/mm3
    • WBC >500/mm3
    • Elevated fluid amylase
    • Presence of enteric contents or bacteria
  • Penetrating abdominal trauma (controversial)
    • RBC >1000/mm3
    • WBC >500/mm3
  • Results from cell analysis take 30 to 60 minutes
    • If an immediate decision is necessary, may use the density of cells in the IV tubing
    • If text can be read through the tubing it can be considered unofficially negative until the official cell counts return.
    • If the density of cells in the tubing is so high that you cannot read through it, then it can be considered a positive lavage.

Complications

  • Catheter misplacement
  • Hemorrhage
  • Intraabdominal or retroperitoneal organ injury
  • Wound infection

See Also

External Links

References

  1. Pryor JP. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-53.