What is the procedure for performing a Diagnostic Peritoneal Lavage (DPL)?

From the Guidelines

The procedure for performing a Diagnostic Peritoneal Lavage (DPL) involves preparing the patient, making a small incision below the umbilicus, inserting a peritoneal dialysis catheter, and aspirating or infusing fluid to detect intra-abdominal bleeding, with a positive result indicated by the presence of frank blood, high RBC or WBC count, or other signs of injury, as outlined in the clinical policy by the ACEP Clinical Policies Committee 1. To perform a DPL, the following steps should be taken:

• Prepare the patient by placing them in a supine position and emptying their bladder with a Foley catheter
• Clean and drape the abdomen using sterile technique
• Administer local anesthesia, typically 1% lidocaine, and make a small 2-3 cm vertical incision below the umbilicus
• Carefully dissect through the subcutaneous tissue and fascia to expose the peritoneum
• Insert a peritoneal dialysis catheter into the peritoneal cavity, directing it toward the pelvis
• Aspirate with a syringe; if more than 10 mL of gross blood is obtained, this indicates a positive result
• If no blood is aspirated, infuse 1 liter of warm normal saline for adults (10-15 mL/kg for children) into the peritoneal cavity, gently agitate the abdomen, and then drain the fluid
• The fluid should be sent for analysis; a positive result includes RBC count >100,000/mm³, WBC >500/mm³, or presence of bile, bacteria, or food particles, as noted in the study by the ACEP Clinical Policies Committee 1. The sensitivity of DPL for hemoperitoneum approaches 98% 1, and it can detect as little as 20 mL of intra-peritoneal blood, making it a valuable tool in the evaluation of blunt abdominal trauma, although it has practical limitations in identifying certain types of injuries, such as retroperitoneal, diaphragmatic, and enteric injuries 1.

From the Research

Procedure for Performing a Diagnostic Peritoneal Lavage (DPL)

• The procedure for DPL can be performed through a surgical incision or a blind puncture, with the lavage catheter inserted into the peritoneal cavity 2.
• In cases of anterior abdominal stab wounds, DPL can be safely and effectively performed through the stab wound itself if penetration to the peritoneum is diagnosed 2.
• A modified combination technique for performing DPL uses a 10 mm umbilical incision, with open insertion of a 20 French peritoneal lavage catheter, and has been found to be cosmetically attractive and quicker than existing techniques 3.
• The DPL procedure involves infusing warmed saline via a cystoscopy infusion set, and the time required to perform the procedure has been studied, with a median total time of 7.6 +/- 4.2 min 3.
• Criteria for a positive DPL include initial aspiration of gross blood from the lavage catheter of more than 10 ml or red blood cell (RBC) count in the lavage fluid of more than 10,000/mm3, and these criteria have been found to be safe and practical for determining the need for exploratory laparotomy 4.

Techniques and Indications

• DPL is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but its use has decreased due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT) 5.
• DPL can be used to diagnose or exclude intestinal injury even in the presence of hemoperitoneum, with a diagnostic sensitivity of 96.6% and a specificity of 99.4% for intestinal injury 6.
• The role of DPL has been reduced since the development of ultrasonography and advanced computed tomographic scanners, but it may still be valuable in certain instances where radiologic diagnosis is unclear 6.