Diagnostic Peritoneal Lavage

Chapter 156 Diagnostic Peritoneal Lavage

Karl E. Jandrey, DVM, DACVECC

• Diagnostic peritoneal lavage (DPL) is performed when intraabdominal injury is suspected and when alternative diagnostic methods such as sonography are unavailable or the patient’s condition does not allow other diagnostic techniques or imaging to be performed.

• DPL is complementary to abdominocentesis.

• DPL does not reliably exclude significant injuries to retroperitoneal structures.

• Significant hemorrhage is present if the packed cell volume (PCV) of the peritoneal fluid exceeds 5%.

• Creatinine in the abdominal fluid more than twice that of peripheral blood is highly suggestive of free urine in the abdominal cavity.

INTRODUCTION

Abdominal disease can have life-threatening consequences, and in some cases surgical intervention is essential. Determining when surgery is indicated can be challenging, because abdominal clinical signs are commonly vague and nonspecific. Blunt trauma to the abdomen is a major component of traumatic injury and can be deadly. It can occur as a consequence of falls, motor vehicle accidents, or severe blows to the abdomen. Many other causes for an acute condition of the abdomen may warrant further diagnosis with the aid of abdominal fluid cytology.

When there is 5.2 to 6.6 ml of abdominal fluid per kg of body weight,¹ abdominocentesis is a valuable diagnostic procedure. When there is insufficient fluid for abdominocentesis, diagnostic peritoneal lavage DPL can provide a fluid sample for analysis. The cytologic and biochemical information obtained from a DPL helps determine whether an intraabdominal injury exists and whether surgery is required.

INDICATIONS

DPL should be considered when a diagnostic sample was not obtained by abdominocentesis. Specific indications for a diagnostic peritoneal lavage are (1) an acute condition of the abdomen, (2) penetrating or blunt abdominal trauma, (3) shock despite maximal fluid resuscitation, (4) central nervous system disease precluding reliable abdominal examination, (5) persistent abdominal pain of unknown cause, and (6) to assess postoperative dehiscence of an enterotomy or anastomotic site.^2,3 Contraindications include coagulopathy, organomegaly, and distention of an abdominal viscus. Complications include the introduction or spread of infection, laceration of a viscus, and hemorrhage from a punctured vessel, although the complication rate is quite low. DPL does not reliably exclude significant injuries to retroperitoneal structures.

Diagnostic peritoneal lavage is performed when alternative diagnostic methods such as sonography are unavailable or when the patient’s condition does not allow other diagnostic tests or imaging to be performed. The focused assessment with sonography for trauma (FAST) protocol was studied in dogs to prove that it is a rapid and simple technique to detect free abdominal fluid in the emergency room by veterinary clinicians with minimal ultrasonography experience.⁴ Using this technique, the operators scanned four regions in longitudinal and transverse planes of the abdomen with dogs in lateral recumbency. These regions are caudal to the xiphoid process, midline over the urinary bladder, and each flank. FAST was completed within a median time of 6 minutes. An accurate cytologic diagnosis was made in all dogs that received needle abdominocentesis. DPL was not performed on any of the dogs.

TECHNIQUE

Crowe and Crane described an open technique for DPL.⁵ A 1-cm incision is made carefully in the abdomen for direct visualization of catheter insertion into the peritoneal cavity. Careful hemostasis must be maintained to prevent false-positive results on fluid analysis. A closed technique has also been described using a catheter with an inner stylet that is rotated gently to penetrate the fascia and peritoneum.¹ A modification of the closed technique is presented.^6,7

Supplies

DPL is performed with a large-diameter catheter with multiple holes. Commercial peritoneal dialysis catheters work well, but over-the-needle catheters can be fenestrated and used with good results. Use of a peritoneal dialysis catheter for abdominocentesis alone, without lavage, has been shown to detect 1 to 4.4 ml/kg of free abdominal fluid.⁸ The larger diameter and multiple side holes of a peritoneal dialysis catheter make occlusion with omentum or bowel less likely. A 14-gauge or 16-gauge over-the-needle catheter with fenestrations placed manually using a No. 10 scalpel blade can increase the surface area for drainage (see Chapter 155, Abdominocentesis, and Color Plate 155-2, A). Fenestrations should be small and smooth. Fenestrations should not be too numerous or placed opposite each other on the catheter; this will weaken the integrity of the catheter (see Chapter 155, Abdominocentesis, and Color Plate 155-2, B). If the catheter is weakened or the fenestrations are not smooth, a portion of the catheter may break and remain in the subcutaneous tissue or intraabdominal space when removed from the abdomen.

Other supplies needed for a diagnostic peritoneal lavage include local anesthetic, a No. 11 scalpel blade, a fluid administration set, and sterile warm 0.9% sodium chloride for infusion (Box 156-1).

Tags: Small Animal Critical Care Medicine

Sep 10, 2016 | Posted by admin in SMALL ANIMAL | Comments Off

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