Abstract
Diagnostic peritoneal aspiration (DPA) involves the insertion of a needle or a catheter in the peritoneal cavity and aspiration of any blood or other fluid. Diagnostic peritoneal lavage (DPL) includes infusion of normal saline, lavage of the cavity, and macroscopic and microscopic evaluation of the returned fluid.
General Principles
Diagnostic peritoneal aspiration (DPA) involves the insertion of a needle or a catheter in the peritoneal cavity and aspiration of any blood or other fluid. Diagnostic peritoneal lavage (DPL) includes infusion of normal saline, lavage of the cavity, and macroscopic and microscopic evaluation of the returned fluid.
DPA and DPL have largely been replaced by the trauma ultrasound (FAST exam) and CT scan. However, DPA may have a useful role in the evaluation of the abdomen in a hemodynamically unstable patient, if the FAST exam is not definitive or not available.
The DPA is as sensitive as DPL in identifying clinically significant intraperitoneal bleeding. For this reason, DPL has largely been abandoned.
The procedure is most commonly performed with the percutaneous Seldinger technique. The open technique is preferred in patients with advanced pregnancy to avoid inadvertent injury.
DPA is contraindicated in patients with previous abdominal operations or coagulopathy. Morbid obesity is a relative contraindication.
Equipment
There are commercially available kits, which usually include:
5 ml syringe with 1% lidocaine with epinephrine
Chlorhexidine or betadine skin preparation
Scalpel
5 or 10 ml syringe with 18 G needle
Guidewire
Peritoneal catheter (Figure 22.1 A,B)
Figure 22.1 A,B Standard DPA kits generally include lidocaine 1%, scalpel, 18 g and 20 g needle with angiocatheter, 10 ml syringe, guidewire, and peritoneal catheter (A). Close up of peritoneal dialysis catheter showing the multiple side holes (B).
Percutaneous Seldinger Technique
A Foley catheter should be inserted before the procedure to decompress the bladder and avoid injury to the bladder.
Sterile preparation and draping of the anterior abdomen.
Make a 0.5 cm vertical skin incision about 1–2 fingerbreadths below the umbilicus. A supraumbilical incision is preferred in patients with severe pelvic fractures.
A needle attached to a 5 or 10 ml syringe is inserted into the peritoneum, with a slight angle, pointing towards the pelvis. Two “pops” should be felt during insertion through the fascia and the peritoneum.
If aspiration on the needle gives gross blood (10 ml or more), the investigation is positive and the procedure is terminated.
If the needle aspiration is negative, the syringe is disconnected from the needle and the guidewire is inserted through the needle, in a direction towards the pelvis. No resistance should be encountered during insertion of the guidewire.
o After insertion of the guidewire, the needle is removed taking precautions not to dislodge the wire.
o A peritoneal dialysis catheter is inserted over the guidewire, with a direction towards the pelvis. No excessive force should be exerted during insertion.
o The guidewire is removed while holding the catheter in place. A 10 ml syringe is connected to the catheter and aspiration is performed. If blood is aspirated (10 ml or more), the investigation is positive and the procedure is terminated (Figure 22.2 AD, Figure 22.3).
o After the procedure is completed, the catheter is removed and the skin is stapled or sutured.
