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
  • 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

1. 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
2. Prep site with antiseptic

Open Technique

1. Use scalpel to incise skin
2. 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

1. Open skin and fascia under direct visualisation
2. Insert needle through peritoneum
3. Use Seldinger technique to pass wire through needle
4. Pass catheter over wire and remove wire
5. Secure catheter

Closed Technique

1. Make small nick through skin
2. Blindly pass needle through linea alba and into peritoneum
3. 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)

• 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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