critical care medicine
How To Do Diagnostic Peritoneal Lavage (DPL)
Step by Step Description of Diagnostic Peritoneal Lavage
Usually the closed technique is appropriate. The semi-open technique is an alternative (eg, for patients with thick abdominal fat). Insert a nasogastric tube (see How To Insert a Nasogastric Tube ). Insert a urinary catheter (see How To Do Urethral Catheterization in a Female or If semi-open DPL is anticipated, shave a broad area about the anticipated incision site. Swab a broad area of skin about the site* with antiseptic solution and allow to dry. Place sterile towels about the site. For semi-open technique, place large sterile drapes to establish a bigger sterile field. Inject anesthetic at and around the needle entry point, covering the length of any anticipated incision (for semi-open technique) and down to the fascia. * Standard entry site is midline, 2 cm inferior to the umbilicus. Closed technique Insert the introducer needle in the midline of the abdomen 2 cm inferior to the umbilicus angled at 45 degrees to the skin and directed inferoposteriorly toward the pelvis. Advance the needle until you feel it pop through the fascia and the peritoneal membrane and then continue another 2 to 3 mm. Hold the needle motionless and gently aspirate: If > 10 mL of blood is aspirated, hemoperitoneum is diagnosed and the procedure is ended. This test result is also positive if there is free aspiration of gastrointestinal contents or bile. If no blood, bile, or gastric contents is aspirated, insert the J-curve end of the guidewire into the needle, with the curve pointing in the same direction as the needle bevel, to steer the guidewire into the right or left pelvic gutter. Advance the guidewire until it stops or until the length of wire protruding from the needle hub remains slightly longer than the peritoneal catheter.If you feel resistance or if the patient experiences pain as you advance the guidewire, stop the procedure and withdraw the needle and guidewire together as a unit (to prevent the needle tip from shearing through the guidewire within the patient). Reinsert the needle at a slightly different site, but still on the midline. Hold the end of the guidewire and withdraw the needle until the point just exits the skin. Grasp the guidewire at the skin surface and slide the needle off the wire. Use the scalpel to make a small incision where the guidewire enters the epidermis, to permit passage of the catheter. Thread the catheter over the guidewire and slide the catheter down to your fingers, grasping the guidewire at the skin. The end of the guidewire should now be protruding from the end of the catheter hub; if it is not, slowly retract the guidewire out of the abdomen until the end protrudes. Grasp and control the guidewire where it protrudes from the catheter hub and advance the catheter over the wire, using a corkscrew motion as necessary, until the catheter is fully inserted. Remove the guidewire and Do the peritoneal lavage . Semi-open technique (alternative) An assistant is useful, particularly if the patient has obesity. Make a 4 to 6 cm vertical, midline incision down to the fascia starting just below the umbilicus. Stop any bleeding using electrocautery or sutures. Grasp the fascia with hemostats to stabilize it and insert the introducer needle directly through the fascia. Continue as per the closed technique. Connect the bag of warmed lavage solution to the catheter with IV tubing and allow the fluid to flow into the peritoneal cavity. Infuse 1 L in adults and 10 mL/kg in children. Once fluid is instilled, lower the nearly empty solution bag well below the level of the abdomen and allow the fluid to return into the bag. Recover as much fluid as possible, but as little as 250 mL is adequate. Send fluid for analysis. The lavage is positive if Initial aspiration of>10 mL of gross blood is considered positive > 100 x 106red blood cells/L (> 100,000 red blood cells per mm3) in blunt trauma > 10 x 106red blood cells/L (> 10,000 red blood cells per mm3) in penetrating trauma > 0.5 x 106red blood cells/L (>500 white blood cells per mm3) Amylase level≥2.92 µkat/L (≥175 U/L) Alkaline phosphatase level≥0.05 µkat/L (≥3 U/L) Positive Gram stain Presence of enteric matter or food particles A negative lavage does not exclude other solid organ injury, viscus perforation, diaphragmatic tears, or retroperitoneal injury. Remove the catheter. Close any skin incision with sutures or staples and dress the site. 