Open versus closed peritoneal lavage with particular attention to time, accuracy, and cost

Evaluation of the abdomen in the critically ill patient: opening the black box

PURPOSE OF REVIEW

Evaluation of the abdomen in critically ill patients can be challenging. This article reviews the available data and proposes evidence-based guidelines for evaluation of the abdomen in the critically ill patient.

RECENT FINDINGS

The critically ill are often clinically unevaluable due to distracting injuries, respiratory failure, obtundation, or other conditions. Even when patients can be examined, the clinical exam can be unreliable and misleading. Critically ill patients who are sufficiently stable to undergo imaging benefit from computerized tomography unless biliary sepsis is suspected, when ultrasound is preferred. There is an important role for endoscopy and angiography in the setting of gastrointestinal hemorrhage, as well as magnetic resonance imaging for mesenteric ischemia. Critically ill patients who are too unstable for imaging may require bedside laparoscopy or diagnostic peritoneal lavage. Abdominal compartment syndrome should be considered in the differential diagnosis of the unstable critically ill patient. Empiric laparotomy may still need to be employed in diagnosis and management of unstable patients.

SUMMARY

Timely and accurate diagnosis of life-threatening intraabdominal pathology is essential to care for critically ill patients. A multitude of laboratory, radiologic, and interventional modalities are available to evaluate the abdomen in the critically ill.

Open or closed diagnostic peritoneal lavage for abdominal trauma? A meta-analysis

OBJECTIVES

To perform a meta-analysis of prospective, randomized controlled trials comparing the closed and open technique of diagnostic peritoneal lavage (DPL) in trauma patients to determine whether there are any difference in outcomes.

METHODS

A search of MEDLINE database of English language articles published from 1977 to 1999 was conducted by using the terms diagnostic peritoneal lavage, trauma, and randomized controlled trials. A manual search and Cochrane Library database search was also conducted. Seven randomized controlled trials, including a total of 1,126 patients were identified that compared closed versus open technique. Two reviewers assessed the trials independently. Trial quality was critically appraised by using the Jadad Instrument, a validated published quality scale. Data extraction of major complications, technical difficulties, procedure times, and false-negative and false-positive rates was carried out. The fixed effects model was used for statistical analysis. The Peto odds ratio (OR), weighted mean differences and 95% confidence intervals (95% CI) were calculated.

RESULTS

The overall quality of studies was poor (mean, 2.4/7). Major complications did not differ significantly between closed versus open technique (OR, 0.65; 95% CI, 0.15 to 2.92. Technical failures and difficulties were significantly higher in the closed group, i.e., OR 4.33 (95% CI, 1.96 to 9.56) and OR 4.19 (95% CI, 2.842 to 6.19), respectively. Accuracy of closed and open DPL was comparable with no difference in false-negative or false-positive rates between the two techniques. Procedure time was consistently lower in the closed technique.

CONCLUSIONS

The closed DPL technique is comparable to the standard open DPL technique in terms of accuracy and major complications. The advantage of reduced time to perform the closed DPL is offset by the increased technical difficulties and failures of this group. Therefore, any significant benefit of routine closed DPL in improving outcomes can be excluded with more confidence based on pooled data than by the individual trials alone.

Percutaneous diagnostic peritoneal lavage using a Veress needle versus an open technique: a prospective randomized trial

OBJECTIVE

To prospectively compare the speed, sensitivity, complications, and technical failures of percutaneous diagnostic peritoneal lavage (DPL) using a Veress needle versus open DPL.

METHODS

One hundred seventy-six blunt trauma patients requiring DPL were prospectively randomized to undergo either open DPL using a standard technique or percutaneous DPL using an 18-gauge Veress needle to penetrate the peritoneal cavity, with the lavage catheter then being inserted over a guide wire.

RESULTS

Mean time to successful placement of the lavage catheter for the percutaneous Veress needle technique was 2.73 minutes versus 7.28 minutes for the open DPL technique (p < 0.001). Sixteen percent of open lavage procedures took more than 11 minutes; the majority (60%) of Veress needle lavage procedures took less than 2 minutes. There were no false-negative findings in either group, and there was one false-positive result in each group. A wound infection after an open DPL was the only complication. Poor return of lavage fluid (<200 mL) accounted for most technical failures; this was more prevalent with the percutaneous method (11.2%) than with the open technique (3.8%) (p < 0.05).

CONCLUSION

The percutaneous DPL method using a Veress needle is significantly faster than the open DPL method. The Veress needle lavage was as safe and as sensitive as the open lavage; however, technical failure occurred more frequently with the Veress needle lavage than with the open DPL.

Incremental analysis of diagnostic peritoneal lavage fluid in adult abdominal trauma

It is uncertain how much diagnostic peritoneal lavage (DPL) fluid must be recovered from abdominal trauma patients to avoid falsely low red blood cell (RBC) counts. A study was carried out to investigate this controversy. A convenience sample of adult abdominal trauma patients in a Level 1 university trauma center who were undergoing DPL with 1 L crystalloid was enrolled. Subjects with grossly positive or colorless effluent were excluded. A blinded prospective experimental design was used. Differences were evaluated among RBC counts collected at 200, 400, 600, and 800 mL of returned fluid using repeated-measures analysis of variance. In 11 patients, mean RBC counts collected at 200 and 400 mL were 24,600 (95% confidence interval [CI], 20,700 to 29,100) and 39,700 (95% CI, 33,200 to 47,100) cells/microL. These were substantially lower than the final mean count of 95,800 (95% CI, 80,000 to 115,800), measured at 800 mL (F = 23.7, P < .0001). Mean counts at 600 mL were less than those obtained at 800 mL but were not statistically different (P = .08). Two of the 11 subjects would have been misclassified (as not requiring surgery) had "early" sampling been used. In abdominal trauma patients, the RBC count of DPL fluid regularly increases as more fluid is recovered. It is important to collect >600 mL of effluent to avoid misleading, low RBC counts and misclassification of patients.

Is closed diagnostic peritoneal lavage contraindicated in patients with previous abdominal surgery?

OBJECTIVE

To compare the accuracies and complication rates of diagnostic peritoneal lavage (DPL) in trauma patients with and without previous abdominal surgery.

METHODS

A retrospective review of DPL accuracy and complication rate was performed using all ED trauma patients who underwent DPL during 1993 as identified by the trauma registry. Care was provided at a Level-1 trauma center, a 1,100-bed, central-city teaching hospital with an annual ED census of 84,000. Records were reviewed for a history of previous surgery, DPL results, complications, mechanism of injury, and location of abdominal scars. DPL was performed using the Seldinger technique with a standard Arrow Diagnostic Peritoneal Lavage Kit using an 8-Fr catheter. Rates for patient groups with and without previous abdominal surgery were compared using Fisher's exact test. A "misclassified" DPL was defined as either a positive DPL with negative laparotomy or a negative DPL with subsequent need for laparotomy. "Complications" were defined as iatrogenic injury during the procedure or inability to obtain return of fluid during the lavage.

RESULTS

A total of 372 DPLs were performed; 42 in patients with previous surgery and 330 in patients without prior surgery. The groups were similar with respect to proportion with blunt trauma (95% vs 97%), positive DPL (19% vs 19%), misclassified rate (2.4% vs 1.8%), and complication rate (2.4% vs 0.9%); no significant difference was found between groups. The previous abdominal surgeries were appendectomy (n = 20), tubal ligation (n = 5), abdominal hysterectomy (n = 4), cholecystectomy (nonlaparoscopic) (n = 4), pyloric stenosis (n = 1), uterine prolapse (n = 1), undescended testis (n = 1), partial gastrectomy (n = 1), and unknown (n = 5). The analysis had a 90% power of detecting a 10% difference between the 2 groups.

CONCLUSION

The complication rate and accuracy of closed DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients without previous abdominal surgery.

A modified combination technique for performing diagnostic peritoneal lavage

Existing open diagnostic peritoneal lavage techniques (DPL) use small bore catheters, through a small lower midline incision or infra-umbilical incision. This study evaluated a modified DPL technique using a 10 mm umbilical incision, with open insertion of a 20 French peritoneal lavage catheter. The catheter has 27 radial side holes in the terminal distal 13 cm, and a female Leur lock connector. Warmed saline is infused via a cystoscopy infusion set. The time required to perform a new technique was studied in 10 patients. The median time to catheter insertion was 2.4 +/- 3.8 min, infusion time 0.75 +/- 0.3 min, effusion time 0.3 +/- 1.7 min, and a median total time of 7.6 +/- 4.2 min (median +/- s.d.). There was no complications. This technique of DPL is cosmetically attractive, much quicker than existing techniques and we have found its initial use encouraging.

Open versus closed diagnostic peritoneal lavage in the evaluation of abdominal trauma

Two hundred forty-two patients underwent diagnostic peritoneal lavage (DPL) over a 12-month period. One hundred sixteen patients (48%) were randomized to an open lavage technique and 126 (52%) to a percutaneous (closed) guide wire procedure. The closed procedure required an average of 16 minutes to complete with one operator, whereas the open method required two operators and an average time of 26 minutes (p less than 0.001). Technical complications occurred in 31 patients undergoing closed lavage (25%) and 4 patients undergoing open lavage (3%) (p less than 0.01). Fifty-eight percent of the closed lavage complications were related to fluid return and 42% to guide wire placement. All the open lavage complications were caused by inadequate fluid return. These data do not support the initial use of percutaneous lavage. The open technique is favored and certainly used when the closed method fails or when direct visualization of the peritoneal cavity is indicated. Physicians involved in the management of abdominal trauma must be familiar with both methods of DPL.