View source for Diagnostic peritoneal lavage

==Overview==
*Largely historical significance
**Supplanted by [[FAST]] and CT<ref>Pryor JP. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-53.</ref>
**Can be done at bedside, but is invasive
**Historical gold standard for evaluation of intra-peritoneal bleed in abdominal trauma

===Two part procedure===
#Diagnostic peritoneal aspiration (DPA)
#*Fluid aspirated from peritoneal cavity for analysis
#Diagnostic peritoneal lavage (DPL)
#*Fluid instilled into peritoneal cavity, then drained for analysis

==Indications==
*Evaluation for intra-peritoneal hemorrhage in hemodynamically unstable patient when FAST and CT are not available or appropriate
**Blunt abdominal trauma
**Tangential gunshot wounds
*Aid in diagnosis of diaphragmatic injury
*Evaluation for peritoneal penetration of flank and anterior abdominal stab wounds when local wound exploration inconclusive

==Contraindications==
===Absolute===
*Clear indication for immediate laparotomy

===Relative===
*Prior abdominal operations
*Coagulopathy
*Advanced cirrhosis
*Morbid obesity

==Equipment Needed==
*Foley catheter and nasogastric tube
**Place prior to DPL to decrease risk of injury to bladder or stomach
*Local anesthetic
**1% [[lidocaine]] with epinephrine
*Commercial DPL kit
**Alternately, abdominal access kit for laparoscopy and rigid peritoneal dialysis catheter

==Procedure==
===Abdominal access===
#Mark insertion site
#*Three possibilities:
#**Infra-umbilical
#***2 cm below umbilicus
#***Standard site
#**Supra-umbilical
#***Preferred in pregnant trauma patients
#***Preferred in presence of pelvic facture
#Prep site with antiseptic

====Open Technique====
#Use scalpel to incise skin
#Dissect through skin, fascia, and peritoneum under direct visualization

Note that this is the preferred technique when precise insertion of catheter is critical (pregnant patients, patients with pelvic fractures who may have large hematoma)

====Semi-Open Technique====
#Open skin and fascia under direct visualisation
#Insert needle through peritoneum
#Use Seldinger technique to pass wire through needle
#Pass catheter over wire and remove wire
#Secure catheter

====Closed Technique====
#Make small nick through skin
#Blindly pass needle through linea alba and into peritoneum
#Use Seldinger technique to pass wire and insert catheter as in the semi-open technique

Note that this technique is faster than open and semi-open techniques but has a higher risk of complications and should be avoided in presence of pelvic fracture or prior midline surgical incision

===Diagnostic peritoneal aspiration (DPA)===
#Aspirate fluid from peritoneal cavity
#If >10 mL blood or enteric contents, test is positive and it is not necessary to instil lavage fluid

===Diagnostic peritoneal lavage (DPL)===
#Instil 1L warm saline into abdomen via catheter
#Allow fluid to immediately drain passively
#*Do not separate catheter and tubing between instillation and removal
#Send fluid for analysis
#*Ideally, send full litre of instilled fluid, but analysis can be performed on as little as 300 mL if unable to obtain entire litre

==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==
*[[Abdominal trauma]]
*[[Theraputic peritoneal lavage]]

==External Links==
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-emergency-medicine-procedures/how-to-do-diagnostic-peritoneal-lavage-dpl?query=diagnostic%20peritoneal%20lavage Merk Manual - How To Do Diagnostic Peritoneal Lavage]
===Videos===
{{#widget:YouTube|id=O9BZamRlXVA}}

==References==
<references/>

[[Category:Procedures]]
[[Category:Trauma]]