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Difference between revisions of "Diagnostic peritoneal lavage"
From WikEM
(Created page with "==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 intraper...") |
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*Anterior or flank stab wounds with inconclusive local wound exploration | *Anterior or flank stab wounds with inconclusive local wound exploration | ||
*Hemodynamically stable patient with tangential gunshot wounds | *Hemodynamically stable patient with tangential gunshot wounds | ||
− | |||
==Contraindications== | ==Contraindications== | ||
Line 33: | Line 32: | ||
==Procedure== | ==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 | *Important not to separate catheter and tubing when transitioning from instillation to removal | ||
*Fluid analysis is performed on a sample of the returned fluid | *Fluid analysis is performed on a sample of the returned fluid |
Revision as of 22:44, 10 May 2017
Contents
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
- CT and ultrasound imaging, has led to a diminishing role for this procedure primarily because of low specificity and high rates of unnecessary laparotomy[1]
- Two part procedure
- Diagnostic peritoneal tap or aspirate (DPA)
- A catheter is inserted into the peritoneal cavity, initially to aspirate blood or fluid.
- 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 unable to go to CT and 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 contraindication:
- Presence of a clear indication for immediate laparotomy
- Relative contraindications:
- 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
- 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
- ↑ Pryor JP. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-53.