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Peritoneal lavage in abdominal trauma: A prospective study comparing the peritoneal dialysis catheter with the intracatheter
ORIGINAL CONTRIBUTION
Peritoneal Lavage in Abdominal Trauma: A Prospective Study Comparing the Peritoneal Dialysis Catheter with the Intracatheter John B. Moore, MD* Ernest E. Moore, MD* Vince Markovchick, MDt Peter Rosen, MDt Denver, Colorado
The accuracy of peritoneal lavage in identifying significant intra-abdominal injury using a peritoneal dialysis catheter approaches 96%. The intracatheter, however, has frequently been substituted in the procedure with expectations of equal reliability. Our randomized prospective study compared the efficacy, accuracy, and safety of these two catheters. Although the complication rate was insignificant in both groups, the intracatheter was associated with technical difficulties in 46% of the patients compared to a rate of only 9% when the dialysis catheter was employed. Moore JB, Moore EE, Markovchick V, Rosen P: Peritoneal lavage in abdominal trauma: a prospective study comparing the peritoneal dialysis catheter with the intracatheter. Ann Emerg Med 9:190-192, April 1980.
catheter, peritoneal dialysis versus intracatheter; diagnostic techniques, peritoneal lavage; peritoneal lavage, dialysis catheter versus intracatheter; trauma, abdominal, peritoneal lavage INTRODUCTION The accuracy of peritoneal lavage in identifying significant intra-abdominal injury approaches 96%. The technique utilizing a peritoneal dialysis catheter or a similarly designed catheter has provided excellent diagnostic accuracy with minimal technical difficulties or complications. I-G In the Denver hospital community, however, a 16-gauge polyethylene catheter (intracatheter) has often been substituted in the procedure with expectations of equal reliability. This substitution is subject to potential inaccuracy.4, 5 The polyethylene catheter is flexible and short so that the tip does not sample the dependent portion of the peritoneal cavity, ie, the pelvis. The absence of side holes can also lead to inadequate lavage return. Our study was designed to prospectively compare the use of the peritoneal dialysis catheter to the polyethylene intracatheter. Particular attention was given to the efficiency, accuracy, and safety of the respective catheters. From the Departments of Surgery* and Emergency Medicine,t Denver General Hospital and the University of Colorado Health Sciences Center, Denver, Colorado. Address for reprints: Ernest E. Moore, MD, Department of Surgery, Denver General Hospital, Denver, Colorado 80204.
9:4 (April) 1980
Ann
Emerg Med
190/21
MATERIALS AND M E T H O D S F r o m S e p t e m b e r 1977 to J u n e 1978, 100 a d u l t p a t i e n t s s u s t a i n i n g trauma required diagnostic perit o n e a l l a v a g e in t h e emergency dep a r t m e n t a t D e n v e r G e n e r a l Hospital. Injuries included b l u n t abdomi n a l injuries and stab wounds with p e r i t o n e a l violation proven by local wound exploration. Excluded were those p a t i e n t s with overt gaseous intestinal distention and previous lower a b d o m i n a l s u r g e r y . P a t i e n t s w i t h i n t r a - a b d o m i n a l i n j u r i e s revealed by clinical e x a m i n a t i o n were t a k e n directly to the o p e r a t i n g room w i t h o u t p e r i t o n e a l lavage. P a t i e n t s u n d e r g o i n g p e r i t o n e a l l a v a g e were prospectively randomized for use of the peritoneal dialysis c a t h e t e r and t h e p o l y e t h y l e n e i n t r a c a t h e t e r according to odd or even days. Diagnostic p e r i t o n e a l l a v a g e was carried out using the method introduced by Root et al. 3 A F o l e y cathet e r was inserted to decompress the bladder. The lower abdomen was prepped with betadine solution and a p o i n t in the midline, one t h i r d the distance b e t w e e n t h e umbilicus and the pubic synthesis, was locally anest h e t i z e d w i t h 1% x y l o c a i n e w i t h 1:100,000 epinephrine. A 2 cm to 3 cm vertical skin incision was carried down to the midline fascia with careful hemostasis. The fascia was sharply opened for a p p r o x i m a t e l y a 1 cm length. The fascial edges were then g r a s p e d with towel clips to elevate the a n t e r i o r a b d o m i n a l wall and provide countertraction. As the peritoneal cavity was ent e r e d under direct vision the respective trocar or needle was w i t h d r a w n a n d the c a t h e t e r g e n t l y advanced in the direction of the pelvis. A syringe was a t t a c h e d to the c a t h e t e r and the p e r i t o n e a l c a v i t y was a s p i r a t e d for gross blood. If less t h a n 10 cc of freeflowing blood was aspirated, 1,000 cc of Ringer's lactate was infused into the peritoneal cavity. P a t i e n t s without s i g n i f i c a n t h y p o t e n s i o n or suspected spinal injuries were rolled from side to side to facilitate m i x i n g of t h e l a v a g e fluid a n d p e r i t o n e a l contents. The e m p t y i n f u s a t e c o n t a i n e r was lowered to the floor and a mini m u m of 350 cc was siphoned. A 50 cc a l i q u o t of t h e l a v a g e e f f l u e n t was s e n t to the l a b o r a t o r y for microscopic a n a l y s i s of red blood cell (RBC) and w h i t e blood cell (WBC) counts, det e r m i n a t i o n of a m y l a s e and bile, and G r a m ' s stain. Gross a n a l y s i s of t h e f l u i d by v i e w i n g t h r o u g h t h e in-
22/191
t r a v e n o u s t u b i n g was r e c o r d e d as s t r o n g l y positive if blood p r e v e n t e d t h e r e a d i n g of n e w s p r i n t , w e a k l y positive if blood was p r e s e n t b u t did not interfere with n e w s p r i n t reading, a n d n e g a t i v e if the l a v a g e was clear. P a t i e n t s a d m i t t e d on even days u n d e r w e n t p e r i t o n e a l lavage u s i n g a 16-gauge i n t r a c a t h e t e r [Intracath ®, 8-inch catheter, 16-gauge needle, Deseret]; those a d m i t t e d on odd days, the pediatric dialysis catheter [Trocath ~, peritoneal dialysis catheter, l l - i n c h , #V4901]. The procedure was considered a d e q u a t e for diagnostic i n t e r p r e t a t i o n if 10 cc of free-flowi n g gross blood were obtained on initial a s p i r a t i o n or if more t h a n 350 cc of a s p i r a t e were recovered. T h e p r e s e n c e of m o r e t h a n 100,000 RBC/cc, by microscopic analysis, was considered evidence for s i g n i f i c a n t visceral injury. G r e a t e r t h a n 500 WBC/cc or a n e l e v a t e d a m y l a s e level were considered relative indications for l a p a r o t o m y and used to corroborate physical finding.
toneal dialysis c a t h e t e r was successfully s u b s t i t u t e d in 15 of the 17 ina d e q u a t e l a v a g e r e t u r n s and in all four cases of a t h r e a d i n g problem. No complications occurred in this group. There were two (4%) false positives. The first included a multiple t r a u m a victim with severe head inj u r y t a k e n to the o p e r a t i n g room prior to microscopic analysis of the lavage a s p i r a t e . The RBC count was only 7,600 and a b d o m i n a l exploration was negative. The second p a t i e n t had an a b d o m i n a l stab wound with a lavage r e t u r n a p p e a r i n g s t r o n g l y positive a n d a m i c r o s c o p i c RBC c o u n t of 118,000. Despite advice to t h e cont r a r y , t h e p a t i e n t r e f u s e d surgery and h a d an uneventful recovery. One (2%) false n e g a t i v e r e s u l t involved a s t a b wound. The microscopic RBC c o u n t w a s 20,000, b u t a g r o s s l y bloody n a s o g a s t r i c r e t u r n led to subsequent exploration. The p a t i e n t had a p e n e t r a t i n g wound of the stomach r e q u i r i n g repair. DISCUSSION
RESULTS
Proponents of p e r i t o n e a l lavage r e p o r t excellent diagnostic accuracy w i t h m i n i m a l technical problems and complications. 1-s Strict adherence to a s t a n d a r d i z e d method is i m p o r t a n t in achieving the information sought by this diagnostic adjunct. Substitut i o n of t h e i n t r a c a t h e t e r for t h e p e r i t o n e a l d i a l y s i s c a t h e t e r would a p p e a r to be a m i n o r alteration, but h a s been f r a u g h t with unacceptable t e c h n i c a l p r o b l e m s (Table). T h e s e difficulties occurred in 46% of the int r a c a t h e t e r group and were remedied with the application of the peritoneal d i a l y s i s c a t h e t e r in t h e m a j o r i t y of cases. There does not a p p e a r to be a s i g n i f i c a n t difference, h o w e v e r , in t h e a c c u r a c y of t h e two c a t h e t e r s when a d e q u a t e l a v a g e r e t u r n is obtained. An incidental finding from this study was t h e inaccuracy of gross inspection in e s t i m a t i n g red blood cell count. Two of t h e t h r e e "false" positive lavages in this series Were opera t e d on b e f o r e m i c r o s c o p i c RBC count was confirmed. One h a d a RBC count of 20,000 a n d the o t h e r only 7,600. These do not meet the genera l l y a c c e p t e d c r i t e r i o n of a RBC count exceeding 100,000 for operative intervention.l,4, 5 The n a t u r e of a teaching institution, with a wide r a n g e of t r a i n i n g e x p e r t i s e , m i g h t a c c o u n t for t h e s e e r r o r s . We ha~e s i n c e r e l i e d on m i c r o s c o p i c RBC count prior to i m m e d i a t e o p e r a t i v e i n t e r v e n t i o n u n l e s s t h e a s p i r a t e is grossly positive.
Of t h e 100 p a t i e n t s , 54 w e r e r a n d o m i z e d into the p e r i t o n e a l dia l y s i s group. This c o n s i s t e d of 38 (70%) b l u n t abdominal injuries and • 16 (30%) a b d o m i n a l s t a b wounds. There were five (9%) technical probl e m s , a l l of w h i c h i n c l u d e d i n a d e q u a t e l a v a g e return. There was one (2%) c o m p l i c a t i o n of i n a d v e r t e n t s m a l l bowel laceration occurring duri n g cutdown which was p r i m a r i l y rep a i r e d w i t h o u t subsequent sequelae. One (2%) false positive occurred seco n d a r y to m i s i n t e r p r e t a t i o n of t h e l a v a g e return. This p a t i e n t had mult i p l e b l u n t injuries and was unstable. Before the microscopic analysis was known the p a t i e n t was t a k e n to the o p e r a t i n g room because gross inspection of the lavage was i n t e r p r e t e d as s t r o n g l y p o s i t i v e . The l a p a r o t o m y was n e g a t i v e and microscopic RBC count of the l a v a g e fluid was 20,000. In r e t r o s p e c t , t h e p a t i e n t ' s s e v e r e h e a d injury was responsible for the h e m o d y n a m i c instability. There were no f a l s e n e g a t i v e r e s u l t s in t h e p e r i t o n e a l dialysis group. Forty-six p a t i e n t s were included in t h e i n t r a c a t h e t e r group. T h e r e w e r e 32 (70%) b l u n t a b d o m i n a l inj u r i e s and 14 (30%) a b d o m i n a l stab wounds. Twenty-one (46%) technical p r o b l e m s o c c u r r e d , i n c l u d i n g 17 (37%) i n a d e q u a t e lavage r e t u r n s and four (9%) cases in which t h e r e was i n a b i l i t y to p a s s t h e i n t r a c a t h e t e r into the peritoneal cavity. The peri-
Ann
Emerg Med
9.4 (April) 1980
Table DIAGNOSTIC PERITONEAL LAVAGE FOR ABDOMINAL TRAUMA
Total No. Patients Dialysis Catheter Intracatheter
Inadequate Threading Return" Problem No. (%) No. (%)
54
5 (9)
0 (0)
0 (0)
0 (0)
46
17 (37)
4 (9)
1 (2)
1 (2)
CONCLUSION Based on the results of our prospective randomized study, we advocate the use of the peritoneal dialysis catheter rather t h a n the i n t r a c a t h e ter. We continue to prefer the cutdown technique w i t h direct visualization of peritoneal entry. Since the time of this study we h a v e modified
9:4 (April) 1980
True False True False Positive Negative No. (%) No. (%)
t h e site of t h e c u t - d o w n from t h e lower m i d l i n e to the infraumbilical l e v e l b e c a u s e of t h e p a u c i t y of p e r i t o n e a l fat. In our e x p e r i e n c e s,7 this approach has been most efficacious and reliable and has attended w i t h the l e ast morbidity.
REFERENCES 1. Fischer RP, Beverlin BC, Engrav LH,
Ann Emerg Med
et al: Diagnostic peritoneal lavage - - 14 years and 2,586 patients later. A m J Surg 136:701-704, 1978. 2. Olson WR, Redman HC, Hildreth DH: Quantitative peritoneal l avage in blunt abdominal trauma. Arch Surg 104:536542, 1972. 3. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal lavage. Surgery 57:633-637, 1965. 4. Thal ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. A m J Surg 125:64-69, 1973. 5. Thai ER: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 17:642-648, 1977. 6. Thompson JS, Moore EE, Van Duzer-Moore S, et al: The evolution of abdominal stab wound management. J Trauma, in press. 7. Markovchick VJ, Elerding SC, Moore EE, et al: Diagnostic peritoneal lavage. JACEP 8:326-328, 1979.
192/23
Peritoneal Lavage in Abdominal Trauma: A Prospective Study Comparing the Peritoneal Dialysis Catheter with the Intracatheter John B. Moore, MD* Ernest E. Moore, MD* Vince Markovchick, MDt Peter Rosen, MDt Denver, Colorado
The accuracy of peritoneal lavage in identifying significant intra-abdominal injury using a peritoneal dialysis catheter approaches 96%. The intracatheter, however, has frequently been substituted in the procedure with expectations of equal reliability. Our randomized prospective study compared the efficacy, accuracy, and safety of these two catheters. Although the complication rate was insignificant in both groups, the intracatheter was associated with technical difficulties in 46% of the patients compared to a rate of only 9% when the dialysis catheter was employed. Moore JB, Moore EE, Markovchick V, Rosen P: Peritoneal lavage in abdominal trauma: a prospective study comparing the peritoneal dialysis catheter with the intracatheter. Ann Emerg Med 9:190-192, April 1980.
catheter, peritoneal dialysis versus intracatheter; diagnostic techniques, peritoneal lavage; peritoneal lavage, dialysis catheter versus intracatheter; trauma, abdominal, peritoneal lavage INTRODUCTION The accuracy of peritoneal lavage in identifying significant intra-abdominal injury approaches 96%. The technique utilizing a peritoneal dialysis catheter or a similarly designed catheter has provided excellent diagnostic accuracy with minimal technical difficulties or complications. I-G In the Denver hospital community, however, a 16-gauge polyethylene catheter (intracatheter) has often been substituted in the procedure with expectations of equal reliability. This substitution is subject to potential inaccuracy.4, 5 The polyethylene catheter is flexible and short so that the tip does not sample the dependent portion of the peritoneal cavity, ie, the pelvis. The absence of side holes can also lead to inadequate lavage return. Our study was designed to prospectively compare the use of the peritoneal dialysis catheter to the polyethylene intracatheter. Particular attention was given to the efficiency, accuracy, and safety of the respective catheters. From the Departments of Surgery* and Emergency Medicine,t Denver General Hospital and the University of Colorado Health Sciences Center, Denver, Colorado. Address for reprints: Ernest E. Moore, MD, Department of Surgery, Denver General Hospital, Denver, Colorado 80204.
9:4 (April) 1980
Ann
Emerg Med
190/21
MATERIALS AND M E T H O D S F r o m S e p t e m b e r 1977 to J u n e 1978, 100 a d u l t p a t i e n t s s u s t a i n i n g trauma required diagnostic perit o n e a l l a v a g e in t h e emergency dep a r t m e n t a t D e n v e r G e n e r a l Hospital. Injuries included b l u n t abdomi n a l injuries and stab wounds with p e r i t o n e a l violation proven by local wound exploration. Excluded were those p a t i e n t s with overt gaseous intestinal distention and previous lower a b d o m i n a l s u r g e r y . P a t i e n t s w i t h i n t r a - a b d o m i n a l i n j u r i e s revealed by clinical e x a m i n a t i o n were t a k e n directly to the o p e r a t i n g room w i t h o u t p e r i t o n e a l lavage. P a t i e n t s u n d e r g o i n g p e r i t o n e a l l a v a g e were prospectively randomized for use of the peritoneal dialysis c a t h e t e r and t h e p o l y e t h y l e n e i n t r a c a t h e t e r according to odd or even days. Diagnostic p e r i t o n e a l l a v a g e was carried out using the method introduced by Root et al. 3 A F o l e y cathet e r was inserted to decompress the bladder. The lower abdomen was prepped with betadine solution and a p o i n t in the midline, one t h i r d the distance b e t w e e n t h e umbilicus and the pubic synthesis, was locally anest h e t i z e d w i t h 1% x y l o c a i n e w i t h 1:100,000 epinephrine. A 2 cm to 3 cm vertical skin incision was carried down to the midline fascia with careful hemostasis. The fascia was sharply opened for a p p r o x i m a t e l y a 1 cm length. The fascial edges were then g r a s p e d with towel clips to elevate the a n t e r i o r a b d o m i n a l wall and provide countertraction. As the peritoneal cavity was ent e r e d under direct vision the respective trocar or needle was w i t h d r a w n a n d the c a t h e t e r g e n t l y advanced in the direction of the pelvis. A syringe was a t t a c h e d to the c a t h e t e r and the p e r i t o n e a l c a v i t y was a s p i r a t e d for gross blood. If less t h a n 10 cc of freeflowing blood was aspirated, 1,000 cc of Ringer's lactate was infused into the peritoneal cavity. P a t i e n t s without s i g n i f i c a n t h y p o t e n s i o n or suspected spinal injuries were rolled from side to side to facilitate m i x i n g of t h e l a v a g e fluid a n d p e r i t o n e a l contents. The e m p t y i n f u s a t e c o n t a i n e r was lowered to the floor and a mini m u m of 350 cc was siphoned. A 50 cc a l i q u o t of t h e l a v a g e e f f l u e n t was s e n t to the l a b o r a t o r y for microscopic a n a l y s i s of red blood cell (RBC) and w h i t e blood cell (WBC) counts, det e r m i n a t i o n of a m y l a s e and bile, and G r a m ' s stain. Gross a n a l y s i s of t h e f l u i d by v i e w i n g t h r o u g h t h e in-
22/191
t r a v e n o u s t u b i n g was r e c o r d e d as s t r o n g l y positive if blood p r e v e n t e d t h e r e a d i n g of n e w s p r i n t , w e a k l y positive if blood was p r e s e n t b u t did not interfere with n e w s p r i n t reading, a n d n e g a t i v e if the l a v a g e was clear. P a t i e n t s a d m i t t e d on even days u n d e r w e n t p e r i t o n e a l lavage u s i n g a 16-gauge i n t r a c a t h e t e r [Intracath ®, 8-inch catheter, 16-gauge needle, Deseret]; those a d m i t t e d on odd days, the pediatric dialysis catheter [Trocath ~, peritoneal dialysis catheter, l l - i n c h , #V4901]. The procedure was considered a d e q u a t e for diagnostic i n t e r p r e t a t i o n if 10 cc of free-flowi n g gross blood were obtained on initial a s p i r a t i o n or if more t h a n 350 cc of a s p i r a t e were recovered. T h e p r e s e n c e of m o r e t h a n 100,000 RBC/cc, by microscopic analysis, was considered evidence for s i g n i f i c a n t visceral injury. G r e a t e r t h a n 500 WBC/cc or a n e l e v a t e d a m y l a s e level were considered relative indications for l a p a r o t o m y and used to corroborate physical finding.
toneal dialysis c a t h e t e r was successfully s u b s t i t u t e d in 15 of the 17 ina d e q u a t e l a v a g e r e t u r n s and in all four cases of a t h r e a d i n g problem. No complications occurred in this group. There were two (4%) false positives. The first included a multiple t r a u m a victim with severe head inj u r y t a k e n to the o p e r a t i n g room prior to microscopic analysis of the lavage a s p i r a t e . The RBC count was only 7,600 and a b d o m i n a l exploration was negative. The second p a t i e n t had an a b d o m i n a l stab wound with a lavage r e t u r n a p p e a r i n g s t r o n g l y positive a n d a m i c r o s c o p i c RBC c o u n t of 118,000. Despite advice to t h e cont r a r y , t h e p a t i e n t r e f u s e d surgery and h a d an uneventful recovery. One (2%) false n e g a t i v e r e s u l t involved a s t a b wound. The microscopic RBC c o u n t w a s 20,000, b u t a g r o s s l y bloody n a s o g a s t r i c r e t u r n led to subsequent exploration. The p a t i e n t had a p e n e t r a t i n g wound of the stomach r e q u i r i n g repair. DISCUSSION
RESULTS
Proponents of p e r i t o n e a l lavage r e p o r t excellent diagnostic accuracy w i t h m i n i m a l technical problems and complications. 1-s Strict adherence to a s t a n d a r d i z e d method is i m p o r t a n t in achieving the information sought by this diagnostic adjunct. Substitut i o n of t h e i n t r a c a t h e t e r for t h e p e r i t o n e a l d i a l y s i s c a t h e t e r would a p p e a r to be a m i n o r alteration, but h a s been f r a u g h t with unacceptable t e c h n i c a l p r o b l e m s (Table). T h e s e difficulties occurred in 46% of the int r a c a t h e t e r group and were remedied with the application of the peritoneal d i a l y s i s c a t h e t e r in t h e m a j o r i t y of cases. There does not a p p e a r to be a s i g n i f i c a n t difference, h o w e v e r , in t h e a c c u r a c y of t h e two c a t h e t e r s when a d e q u a t e l a v a g e r e t u r n is obtained. An incidental finding from this study was t h e inaccuracy of gross inspection in e s t i m a t i n g red blood cell count. Two of t h e t h r e e "false" positive lavages in this series Were opera t e d on b e f o r e m i c r o s c o p i c RBC count was confirmed. One h a d a RBC count of 20,000 a n d the o t h e r only 7,600. These do not meet the genera l l y a c c e p t e d c r i t e r i o n of a RBC count exceeding 100,000 for operative intervention.l,4, 5 The n a t u r e of a teaching institution, with a wide r a n g e of t r a i n i n g e x p e r t i s e , m i g h t a c c o u n t for t h e s e e r r o r s . We ha~e s i n c e r e l i e d on m i c r o s c o p i c RBC count prior to i m m e d i a t e o p e r a t i v e i n t e r v e n t i o n u n l e s s t h e a s p i r a t e is grossly positive.
Of t h e 100 p a t i e n t s , 54 w e r e r a n d o m i z e d into the p e r i t o n e a l dia l y s i s group. This c o n s i s t e d of 38 (70%) b l u n t abdominal injuries and • 16 (30%) a b d o m i n a l s t a b wounds. There were five (9%) technical probl e m s , a l l of w h i c h i n c l u d e d i n a d e q u a t e l a v a g e return. There was one (2%) c o m p l i c a t i o n of i n a d v e r t e n t s m a l l bowel laceration occurring duri n g cutdown which was p r i m a r i l y rep a i r e d w i t h o u t subsequent sequelae. One (2%) false positive occurred seco n d a r y to m i s i n t e r p r e t a t i o n of t h e l a v a g e return. This p a t i e n t had mult i p l e b l u n t injuries and was unstable. Before the microscopic analysis was known the p a t i e n t was t a k e n to the o p e r a t i n g room because gross inspection of the lavage was i n t e r p r e t e d as s t r o n g l y p o s i t i v e . The l a p a r o t o m y was n e g a t i v e and microscopic RBC count of the l a v a g e fluid was 20,000. In r e t r o s p e c t , t h e p a t i e n t ' s s e v e r e h e a d injury was responsible for the h e m o d y n a m i c instability. There were no f a l s e n e g a t i v e r e s u l t s in t h e p e r i t o n e a l dialysis group. Forty-six p a t i e n t s were included in t h e i n t r a c a t h e t e r group. T h e r e w e r e 32 (70%) b l u n t a b d o m i n a l inj u r i e s and 14 (30%) a b d o m i n a l stab wounds. Twenty-one (46%) technical p r o b l e m s o c c u r r e d , i n c l u d i n g 17 (37%) i n a d e q u a t e lavage r e t u r n s and four (9%) cases in which t h e r e was i n a b i l i t y to p a s s t h e i n t r a c a t h e t e r into the peritoneal cavity. The peri-
Ann
Emerg Med
9.4 (April) 1980
Table DIAGNOSTIC PERITONEAL LAVAGE FOR ABDOMINAL TRAUMA
Total No. Patients Dialysis Catheter Intracatheter
Inadequate Threading Return" Problem No. (%) No. (%)
54
5 (9)
0 (0)
0 (0)
0 (0)
46
17 (37)
4 (9)
1 (2)
1 (2)
CONCLUSION Based on the results of our prospective randomized study, we advocate the use of the peritoneal dialysis catheter rather t h a n the i n t r a c a t h e ter. We continue to prefer the cutdown technique w i t h direct visualization of peritoneal entry. Since the time of this study we h a v e modified
9:4 (April) 1980
True False True False Positive Negative No. (%) No. (%)
t h e site of t h e c u t - d o w n from t h e lower m i d l i n e to the infraumbilical l e v e l b e c a u s e of t h e p a u c i t y of p e r i t o n e a l fat. In our e x p e r i e n c e s,7 this approach has been most efficacious and reliable and has attended w i t h the l e ast morbidity.
REFERENCES 1. Fischer RP, Beverlin BC, Engrav LH,
Ann Emerg Med
et al: Diagnostic peritoneal lavage - - 14 years and 2,586 patients later. A m J Surg 136:701-704, 1978. 2. Olson WR, Redman HC, Hildreth DH: Quantitative peritoneal l avage in blunt abdominal trauma. Arch Surg 104:536542, 1972. 3. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal lavage. Surgery 57:633-637, 1965. 4. Thal ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. A m J Surg 125:64-69, 1973. 5. Thai ER: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 17:642-648, 1977. 6. Thompson JS, Moore EE, Van Duzer-Moore S, et al: The evolution of abdominal stab wound management. J Trauma, in press. 7. Markovchick VJ, Elerding SC, Moore EE, et al: Diagnostic peritoneal lavage. JACEP 8:326-328, 1979.
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