Diagnostic peritoneal lavage - Revision history

Blsimpso: /* External Links */

2021-07-16T00:33:51Z

External Links

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	==External Links==		==External Links==
	*[https://~~emedicine~~.~~medscape~~.com/~~article~~/~~82888~~-~~overview#showall Medscape~~ - Diagnostic Peritoneal Lavage]		*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-other-emergency-medicine-procedures/how-to-do-diagnostic-peritoneal-lavage-dpl?query=diagnostic%20peritoneal%20lavage Merk Manual - How To Do Diagnostic Peritoneal Lavage]
	===Videos===		===Videos===
	{{#widget:YouTube\|id=O9BZamRlXVA}}		{{#widget:YouTube\|id=O9BZamRlXVA}}

Blsimpso: /* External Links */

2021-07-02T16:19:52Z

External Links

← Revisión anterior		Revisión del 16:19 2 jul 2021
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	==External Links==		==External Links==
			*[https://emedicine.medscape.com/article/82888-overview#showall Medscape - Diagnostic Peritoneal Lavage]
			===Videos===
	{{#widget:YouTube\|id=O9BZamRlXVA}}		{{#widget:YouTube\|id=O9BZamRlXVA}}

SLuckettG: /* Diagnostic peritoneal lavage (DPL) */

2019-05-15T22:17:36Z

Diagnostic peritoneal lavage (DPL)

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	===Diagnostic peritoneal lavage (DPL)===		===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		#Instil 1L warm saline into abdomen via catheter
	*~~Important~~ not to separate catheter and tubing ~~when transitioning from~~ instillation to removal		#Allow fluid to immediately drain passively
	*Fluid analysis ~~is performed on a sample of the returned fluid~~		#*Do not separate catheter and tubing between instillation and removal
	*~~Optimally~~, ~~most~~ of ~~the liter should be returned~~ but analysis can be performed on as little as 300 ~~cc of the returned fluid~~		#Send fluid for analysis
			#*Ideally, send full litre of instilled fluid, but analysis can be performed on as little as 300 mL if unable to obtain entire litre

	==Diagnostic Criteria==		==Diagnostic Criteria==

SLuckettG: /* Diagnostic peritoneal aspiration (DPA) */

2019-05-15T22:15:52Z

Diagnostic peritoneal aspiration (DPA)

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	===Diagnostic peritoneal aspiration (DPA)===		===Diagnostic peritoneal aspiration (DPA)===
	*Aspiration of >~~10mL of~~ blood or enteric ~~contest~~ is ~~considered grossly~~ positive~~, instillation of the lavage fluid~~ is not necessary		#Aspirate fluid from peritoneal cavity
			#If >10 mL blood or enteric contents, test is positive and it is not necessary to instil lavage fluid

	===Diagnostic peritoneal lavage (DPL)===		===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		*If no fluid or <10mL fluid is aspirated, instill 1L of warm NS into abdomen, then immediately allow to drain passively

SLuckettG: /* Abdominal access */

2019-05-15T22:14:37Z

Abdominal access

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	==Procedure==		==Procedure==
	===Abdominal access===		===Abdominal access===
	*~~Insertion sites~~		#Mark insertion site
	**~~Infraumbilical (~~2 cm below~~) location is the standard~~ site		#*Three possibilities:
	**~~Supraumbilical insertion site is preferred~~ in pregnant trauma ~~patient or~~ in ~~the~~ presence of a pelvic ~~fracture~~		#**Infra-umbilical
	**Periumbilical site		#***2 cm below umbilicus
	*Open ~~method~~		#***Standard site
	**All three layers (skin, fascia, peritoneum~~) are opened~~ under direct ~~vision~~		#**Supra-umbilical
	**Method of choice when precise insertion of ~~the~~ catheter is critical		#***Preferred in pregnant trauma patients
	***Patient with pelvic ~~fracture, to avoid~~ large hematoma ~~that may be tracking anteriorly~~		#***Preferred in presence of pelvic facture
	***Pregnant patient		#Prep site with antiseptic
	*Semi-~~open method~~
	**Fascia is opened under direct ~~vision~~		====Open Technique====
	**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.		#Use scalpel to incise skin
	*Closed ~~method~~		#Dissect through skin, fascia, and peritoneum under direct visualization
	**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		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)
	**The wire and catheter ~~are then inserted following~~ the ~~same method as above.~~
	**Faster, but ~~greater~~ risk of complications and ~~catheter malposition~~		====Semi-Open Technique====
	**Avoid this method in ~~the~~ presence of a pelvic fracture or prior midline incision		#Open skin and fascia under direct visualisation
			#Insert needle through peritoneum
			#Use Seldinger technique to pass wire through needle
			#Pass catheter over wire and remove wire
			#Secure catheter

			====Closed Technique====
			#Make small nick through skin
			#Blindly pass needle through linea alba and into peritoneum
			#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)===		===Diagnostic peritoneal aspiration (DPA)===

SLuckettG: /* Equipment Needed */

2019-05-15T22:01:09Z

Equipment Needed

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	==Equipment Needed==		==Equipment Needed==
	*Foley catheter and nasogastric tube ~~must be placed~~ prior to ~~performing~~ DPL to ~~avoid injuring the~~ bladder or stomach		*Foley catheter and nasogastric tube
	*Local ~~anesthesia with~~ 1% [[lidocaine]] with epinephrine ~~generally provides adequate anesthesia~~		**Place prior to DPL to decrease risk of injury to bladder or stomach
	*~~Several kits are commercially available~~		*Local anesthetic
	**~~If not~~, ~~may use tray for~~ abdominal access for laparoscopy ~~with a~~ rigid peritoneal dialysis catheter		**1% [[lidocaine]] with epinephrine
			*Commercial DPL kit
			**Alternately, abdominal access kit for laparoscopy and rigid peritoneal dialysis catheter

	==Procedure==		==Procedure==

SLuckettG: /* Contraindications */

2019-05-15T21:59:49Z

Contraindications

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	==Contraindications==		==Contraindications==
	===Absolute===		===Absolute===
	*~~Presence of a clear~~ indication for immediate laparotomy		*Clear indication for immediate laparotomy

	===Relative===		===Relative===

SLuckettG: /* Indications */

2019-05-15T21:59:15Z

Indications

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	==Indications==		==Indications==
	*Evaluation ~~to detect or rule out intraabdominal~~ hemorrhage in a hemodynamically unstable ~~blunt trauma~~ patient ~~who is 1) unable to go to CT AND 2)~~ when [[FAST~~]] is~~ not available or ~~technically inadequate~~		*Evaluation for intra-peritoneal hemorrhage in hemodynamically unstable patient when FAST and CT are not available or appropriate
	*Aid in ~~the~~ diagnosis of diaphragmatic injury ~~in select patients.~~		**Blunt abdominal trauma
	**Lavage fluid exiting from a chest tube is pathognomic for ~~diaphragmatic injury~~		**Tangential gunshot wounds
	*Anterior or flank stab wounds ~~with inconclusive~~ local wound exploration		*Aid in diagnosis of diaphragmatic injury
	*Hemodynamically stable patient with tangential gunshot wounds		*Evaluation for peritoneal penetration of flank and anterior abdominal stab wounds when local wound exploration inconclusive

	==Contraindications==		==Contraindications==

SLuckettG: /* Overview */

2019-05-15T21:56:53Z

Overview

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	==Overview==		==Overview==
	*~~This invasive bedside procedure was once the gold standard for the evaluation of abdominal trauma~~		*Largely historical significance
	*~~DPL is highly sensitive for detecting the presence of intraperitoneal blood and organ injury in blunt abdominal trauma~~		**Supplanted by [[FAST]] and CT<ref>Pryor JP. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-53.</ref>
	*[[FAST]] ~~scan (~~and CT~~), has led to a diminishing role for this procedure primarily because of low specificity and high rates of unnecessary laparotomy~~<ref>Pryor JP. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43(3):344-53.</ref>		**Can be done at bedside, but is invasive
			**Historical gold standard for evaluation of intra-peritoneal bleed in abdominal trauma

	===Two part procedure===		===Two part procedure===
	#Diagnostic peritoneal ~~tap or aspirate~~ (DPA)		#Diagnostic peritoneal aspiration (DPA)
	#*~~A catheter is inserted into the~~ peritoneal cavity~~, initially to aspirate blood or fluid.~~		#*Fluid aspirated from peritoneal cavity for analysis
	#Diagnostic peritoneal lavage (DPL)		#Diagnostic peritoneal lavage (DPL)
	#*Fluid ~~is infused for a~~ peritoneal ~~lavage~~, ~~if necessary.~~		#*Fluid instilled into peritoneal cavity, then drained for analysis

	==Indications==		==Indications==

Mholtz: Text replacement - "* " to "*"

2017-07-24T01:13:25Z

Text replacement - "* " to "*"

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	#*A catheter is inserted into the peritoneal cavity, initially to aspirate blood or fluid.		#*A catheter is inserted into the peritoneal cavity, initially to aspirate blood or fluid.
	#Diagnostic peritoneal lavage (DPL)		#Diagnostic peritoneal lavage (DPL)
	#* Fluid is infused for a peritoneal lavage, if necessary.		#*Fluid is infused for a peritoneal lavage, if necessary.

	==Indications==		==Indications==