Diagnostic Peritoneal Lavage

CHAPTER 204 Diagnostic Peritoneal Lavage



Eric Skye


Diagnostic peritoneal lavage (DPL) is a procedure that consists of two components. The first part involves the attempt to aspirate any free blood that may be present in the peritoneal cavity. If this initial portion of the procedure reveals hemoperitoneum, the test is considered positive and the remainder of the procedure is aborted. Hemoperitoneum in this circumstance is highly predictive of intraperitoneal injury and warrants a laparotomy.


If no free blood is obtained during the initial aspiration, the second portion of the procedure is conducted. This involves the introduction of normal saline or lactated Ringer’s into the peritoneal cavity. The instilled fluid is subsequently drained from the peritoneal cavity and analyzed; results may ultimately indicate the nature of the intra-abdominal pathology.


Physical examination can be misleading in up to 45% of patients with blunt abdominal trauma. Spiral (helical/real-time) abdominal computed tomography and focused abdominal sonography for trauma (FAST; often performed at the bedside; see Chapter 225, Emergency Department, Hospitalist, and Office Ultrasonography [Clinical Ultrasonography]) are generally considered the preferred initial diagnostic choices for evaluation of patients with blunt abdominal trauma that may necessitate surgical intervention. However, DPL continues to be an important diagnostic tool in patients with blunt abdominal trauma who are hemodynamically unstable and for whom bedside ultrasonography is not available or they cannot be transported safely from the emergency department for imaging studies. DPL also serves as an adjunct in the evaluation of the patient with penetrating trauma.



Anatomy


Diagnostic peritoneal lavage is traditionally performed in the midline, 1 to 2 cm below the umbilicus, which allows entry into the peritoneal cavity through the linea alba (the fibrous structure separating the rectus abdominis muscles). This fibrous band is relatively avascular and provides safe access for both the open and closed techniques. If DPL is performed above the umbilicus, the omentum frequently interferes with the catheter. When performed below the umbilicus, it is also usually easier to advance the catheter into a dependent location such as the pelvis.



Indications



• After blunt abdominal trauma in a patient who is either hemodynamically unstable or has an altered mental status or abnormal sensation (e.g., spinal cord injury) to assess for intraperitoneal hemorrhage or organ injury.

• After penetrating injuries (e.g., stab wound or gunshot wound) to the abdomen, flank, back, or lower chest to assess for intraperitoneal hemorrhage or organ injury. (Gunshot wounds that penetrate the peritoneum result in intraperitoneal injury in 98% of cases, so they warrant going straight to laparotomy; therefore, DPL should only be used for tangential gunshot wounds to the abdomen. Likewise, penetration into the peritoneum from a thoracoabdominal wound results in a diaphragmatic injury that, by definition, needs to be repaired, so such injuries warrant going straight to surgery. Penetration through the retroperitoneum from the back or flank will cause a significant injury in 73% of cases; DPL may help determine whether the retroperitoneum has been traversed. Only two thirds of stab wounds to the anterior abdomen will penetrate the peritoneum, and of these, only 50% will require repair. Use of DPL in these cases may reduce the laparotomy rate.)

• After penetrating injuries to the abdomen, flank, back, or lower chest or blunt abdominal trauma in a patient who has an unreliable physical examination or in whom serial physical examinations are not practical (e.g., patient under anesthesia for orthopedic or neurosurgical procedure or taking postoperative analgesics).

• For the patient in shock after trauma that has other potential sources of hemorrhage (e.g., thoracic, retroperitoneal) to determine whether intraperitoneal hemorrhage is contributing to shock.


Contraindications



Absolute


Acute abdomen requiring immediate surgery is the only absolute contraindication.



Relative


If DPL is performed, the open technique should be used.


• Previous abdominal surgery (bowel may be adherent to midline; although DPL may be performed in area away from scar, compartmentalization of abdomen may have occurred, preventing blood circulation and causing false-negative DPL result).

• Coagulopathy.

• Pregnancy (DPL should be performed above the level of the uterine fundus; possibly below umbilicus in early-stage pregnancy).

• Morbid obesity (the locator needle may not be long enough to pierce abdominal wall).

• Pelvic fracture (use open technique above the umbilicus; closed technique may result in penetration of a retroperitoneal hematoma, a false-positive result, and decompression of the hematoma).

• Inability to insert Foley catheter to decompress bladder (e.g., urethral injury or stricture).


Equipment


Commercially prepared kit or the following equipment:


• Skin-cleansing solution (povidone–iodine or chlorhexidine)

• Sterile gloves and mask

• Sterile marking pen (if area has not been marked indelibly before skin preparation)

• Sterile drapes

• 4 × 4 gauze squares

• 1% or 2% lidocaine with epinephrine

• Scalpel, no. 11 (and no. 15 blade for open technique)

• 9- to 18-Fr peritoneal catheter (kit equipped with catheter-over-wire system for closed or Seldinger technique)

• 10-mL syringe for anesthetic

• 10-mL syringe for diagnostic tap

• 50-mL syringe, if using stopcock technique

• 18-gauge, image– to 3-inch locator needle; alternatively, an 18- or 20-gauge, image– to 3-inch spinal needle may be substituted

• 25- or 27-gauge, image-inch needle

• Purple-topped blood collection tube

• Instruments for retractions such as hemostats or Army-Navy retractors

• Needle holder

• Nylon skin suture (4-0 or 5-0) on cutting needle

• Absorbable sutures (2-0 Vicryl) for peritoneum and fascia, if peritoneum is to be opened

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Diagnostic Peritoneal Lavage

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