Diagnostic peritoneal lavage

Overview

• Largely historical significance
  • Supplanted by FAST and CT
  • Can be done at bedside, but is invasive
  • Historical gold standard for evaluation of intra-peritoneal bleed in abdominal trauma

Two part procedure

1. Diagnostic peritoneal aspiration (DPA)
   • Fluid aspirated from peritoneal cavity for analysis
2. 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 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

• Abdominal trauma
• Theraputic peritoneal lavage

External Links

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