Diagnostic Peritoneal Lavage


INDICATIONS
  • To determine or exclude the presence of intraperitoneal hemorrhage in the hemodynamically unstable blunt or penetrating trauma patient
  • Useful when ultrasound is unavailable, is technically difficult, or results are indeterminate, especially when the patient is hemodynamically unstable
  • May be useful in evaluating patient with CT demonstrating free fluid without evidence of solid organ damage
CONTRAINDICATIONS
  • Relative: Prior abdominal surgery or infections, obesity, coagulopathy, second or third trimester pregnancy
TECHNIQUE
  • Stomach and bladder should be decompressed. Patient is supine. Sedation and analgesia provided if appropriate. Use sterile technique.
  • In the open technique, a 4- to 6-cm incision is made infraumbilically in the midline to reach the linea alba. A 2- to 3-mm opening is made in the linea alba in the semiopen technique and extended in the fully open technique for direct visualization of the peritoneum. Clips are placed to grasp each side of the rectus fascia to lift it and advance the catheter caudally into the peritoneum. The fully open technique is preferred when more direct view is needed such as with pelvic fractures, pregnancy, prior abdominal surgery, infections, and obesity.
  • In the closed technique, a guide needle is inserted into the peritoneal cavity in the infraumbilical midline. The Seldinger (guidewire) method is then used to allow over-the-wire placement of a catheter.
  • In the event of second- or third-trimester pregnancy, a suprauterine approach is used. With pelvic fractures, a supraumbilical approach should be used.
  • Once cathether is in place, aspiration is attempted. If 10 mL of frank blood is aspirated, the DPL is positive and terminated. If there is little or no blood, the cavity is lavaged with 1 L of NS or LR in adults or 15 mL/kg in children. Fluid is then allowed to return to bag by gravity.
COMPLICATIONS
  •  Infection, hematoma, wound dehiscence, bowel/bladder/vascular injury
INTERPRETATION OF RESULTS
  • Immediate aspiration of 10 mL of blood is considered positive.
  • RBC counts >100,000/mm3 is considered positive after lavage with 1 L of NS.
  • When the diaphragm is at risk of injury as with penetrating chest trauma the RBC criterion should be lowered
NOTE
  • Consider DPL for blunt trauma victims with free fluid on ultrasound and obvious signs of liver disease and suspected ascites. A DPL with no blood may spare the patient a nontherapeutic exploratory laparotomy.