Technic for Peritoneal Dialysis and Diagnostic Peritoneal Lavage Charles R. Sachatello, MD, Lexington, Kentucky Brack Bivins, MD, Lexington, Kentucky
Peritoneal dialysis has a well established but limited role in the management of renal failure. Diagnostic peritoneal lavage is an unappreciated but distinctly valuable adjunct to the clinical assessment of the severely injured patient [l-3]. Both procedures share the common technical requirement of intraperitoneal insertion of a catheter. The equipment specifically designed for peritoneal dialysis for renal failure is easily adaptable for diagnostic peritoneal lavage. This technic of intraperitoneal catheter insertion is based on the experience gained from the use of diagnostic peritoneal lavage in more than 100 severely injured patients and review of catheter complications in four patients with renal failure. Technic Peritoneal Dialysis for Renal Failure
Preferably, the catheter is inserted after the patient has ingested nothing by mouth for 12 hours. A cathartic, enema, or predialysis use of sorbital and Kayexalatem is indicated to empty the colon. Diagnostic Peritoneal Lavage In the Severely Injured Patient
Diagnostic peritoneal lavage can be safely performed very early in the initial phase of management of the severely injured patient. (Figure 1.) The patient should first have an adequate airway or endotracheal tube, intravenous lines, nasogastric tube, and indwelling urinary catheter. Preliminary lateral x-ray examination of the cervical spine is advisable if possible. Likewise a plane abdominal film is indicated; although this x-ray film is rarely helpful, it should be obtained to exclude the initial presence of free intraperitoneal air. Small amounts of air invariably enter the peritoneal cavity during the course of catheter insertion. This air is often seen on fol-
From the Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky. Reprints requests should be addressed to Charles R. Sachateiio, MD, Department of Surgery, University of Kentucky Medical Center, 600 Rose Street, Lexington, Kentucky 40506.
vohalm 131. Mey 1976
low-up chest x-ray films of patients who have had negative diagnostic lavage and can be misdiagnosed as representing a perforated viscus. lntraperitoneal Fluid Admlnlstratlon
When obtainable, a history of previous operations should be noted. Even with a negative history, the abdomen should be inspected for the scars of previous incisions. Women should be especially examined for the low transverse incision (Pfannenstiel) which frequently results in an almost unnoticeable scar hidden within the pubic hair. One need be aware that with this particular incision the opening into the fascia is often made vertically through the linea alba despite the fact that the skin incision is transverse. In general, it is inadvisable to insert the catheter through or immediately adjacent to an abdominal incision. The preferred site for catheter insertion is the midline, midway between the umbilicus and symphysis pubis. This area is avascular and provides less fascial resistance than other sites. The lower abdomen should be shaved and prepped carefully. The subcutaneous tissue and superficial skin is injected with 1 per cent lidocaine with epinephrine and a 5 to 6 mm incision is made in the skin. Epinephrine reduces the skin and subcutaneous bleeding which can easily confuse the interpretation of the amount of blood in the dialysat.e of the severely injured patient. The catheter should not be inserted until there is meticulous skin and subcutaneous hemostasis. It is not necessary to use an epinephrinecontaining local anesthetic in patients with renal failure who are undergoing peritoneal dialysis. A 14 or 16 gauge plastic-sheathed needle is connected to the dialysis tubing filled with isosmotic Ringer’s lactate solution. The needle is directed into the subcutaneous tissue through the previous skin incision. The physician should have fingertip control of the needle while advancing it. He should simultaneously observe the drip chamber of the dialysis fluid. Penetration of the peritoneum will be recognized tactically by a distinct “give ” and visibly by the immediate free flow of dialysis fluid in the drip
637
Sacbatello and Bivins
Figure 1. Schematic representation of diagnostic peritoneal iavage. A, small amount of free intraperitoneai fluid gravitates toward cui de sac as tt is the most dependent portion of the peritom?al cavfty in tfte supine position. B and C, intraperitoneat adminktration of Ringer’s lactate-the fluid has a tendency to colfect’posteriorly as the air-containing viscera move anteriorly. The intraperftoneal fluid gives the intestines more mobifity, D, catheter directed toward cul de sac. Nearly fjuantitative return is possible because of d siphoning effect. In theory the amount of blood In the fast 50 cc of dialysate removed is most apt to represent the “true” amoqnt of blood in the peritoneal cavity. initial recovery of a blood-tinged dialysate followed by clear dlalysate is very suggestive of catheter-related abdominal wall bleeding in a patient who would otherwise have had a negative lavage.
chamber. The plastic-sheathed needle should be inserted another 0.5 to 1 cm and then the needle withdrawn from the catheter an equal amount, leaving the tip of the plastic catheter in the peritoneal cavity. This maneuver will permit the free flow of fluid into the peritoneal cavity while it reduces the likelihood of needle perforation of a viscus. Alternatively, the needle can be removed completely and the dialysis tubing connected directly to the plastic catheter. One liter of dialysis fluid will run into the peritoneal cavity through a 14 gauge catheter in 10 to 15 minutes. Patients who are having diagnostic peritoneal lavage should be encouraged or assisted to roll from side to side once or twice while the fluid is running into the peritoneal cavity. This motion aids to insure in mixing the lavage fluid with any blood in the peritoneal cavity.
636
In the hurried activity of an emergency room setting, it is especially important that the physician performing diagnostic lavage personally verify the nature of the dialysate solution. Under no circumstances should a 5 per cent glucose solution be administered intraperitoneally. Failure to recover this fluid from the peritoneal cavity may lead to major fluid and electrolyte problems. Catheter Insertion
The morbidity of peritoneal dialysis for renal failure and the reliability of diagnostic peritoneal lavage is dependent on the technical expertise used to insert the dialysis catheter. The surgeon should grasp the catheter in such a way as to have total control of it while advancing it through the abdominal wall. (Figure 2.) The hand should act as a guard, predetermining the depth of
The American Journal of Surgery
Peritoneal Dialysis
penetration, and precluding inadvertent over-penetration. A distinct “give” is noted as the peritoneal cavity is entered. It is safer to direct the catheter obliquely toward the patient’s pelvis than either vertically or cephalad. The catheter is connected to the dialysate tubing and an additional 100 cc of dialysis fluid is allowed to run into the peritoneal cavity to check both the patency of the system and flow dynamics. If the system is functioning properly, infusion should continue until 1,000 cc has been administered. The dialysate is then recovered by gravity drainage. In some patients the fluid return is nearly quantitative; in others only an aliquot is recovered. External abdominal pressure, slight withdrawal of the catheter, and a 360’ twisting rotation are all helpful maneuvers and may facilitate fluid recovery in individual patients. With diagnostic lavage, an aliquot of as little as 200 to 300 cc of recovered dialysate is informative. Crystal clear dialysate is indicative of the absence of intraperitoneal blood. A hematocrit value on the dialysate of 1 per cent or more is indicative of intraperitoneal blood and may warrant laparotomy. The significance of salmon-colored dialysate, or dialysate hematocrit of 0.5 per cent or less must be interpreted in light of the total clinical picture. The mere presence of blood-tinged dialysate fluid is not an indication for exploratory laparotomy. Catheter-RelatedComplications Diagnostic Peritotieal Lavage. We have had two complications in which the obturator transversed the mesentery, leading to intraperitoneal blood loss and a false-positive dialysate. In both patients the obturator was advanced in a cephalad direction. It appears likely that directing the catheter toward the pelvis will result in fewer such complications. Peritoneal Dialysis. The records of four patients known to liave technical complications of peritoneal dialysis for renal failure were reviewed. These complications were: (1) retroperitoneal hematoma leading to death; (2) perforation of transverse colon; (3) perforation of cecuti; and (4) injury to iliac vein. The patient with the retroperitoneal hematoma had peritoneal dialysis instituted at another major university hospital and then transferred to the University of Kentucky Medical Center. He was noted to have a large retroperitoneal hematoma but clear peritoneal dialysate on admission. Several days later the retroperitoneal hematoma expanded tapidly, leading to hypotension and death. In the patient with perforation of the transverse colon, the peritoneal dialysis catheter was inserted
Volume 131, May 1979
Figure 2. The obturator should be grasped as shown to preclude uncontrolled dr lhadvertent excessively deep penetration. With &oke eqdptnent, the me&/ obturator will
recede wtthtntheptastk cdheter, necemttathg a two hand iechntc.Chehandaf7tsasthegrardwhtt8theottmfa~ the force necesskry to push the trocar through the abdominel wall.
without prior intraperitoneal instillation of fluid or the use of enemas or cathartics. Feculent material was noted in the catheter prior to the initiation of dialysis. A hole in the tfansverse colon was closed at laparotomy. In the third patient, elective peritoneal dialysis was initiated late in the evehing. No cathartics or enemas were used, and the patient had only recently eaten. The specially designed trocar in the Travenol set was used for intraperitoneal fluid administration. The needle was inserted at McBurney’s point and 2 L of saline instilled. The patient complained of abdominal pain and passed 1,800 cc of dialysate fluid per rectum. A hole in the cecum was noted and closed at laparotomy. The fourth patient was a small child with renal failure. The obturator injured the iliac vein, requiring operative intervention. The complications of intraperitoneal catheter insertion potentially threaten life but are fortunately relatively uncommon. They are basically related to the uncontrolled or excessively deep penetration of the obturator within the peritoneal cavity or to the failure to evacuate the gastrointestinal tract.
639
Sachatello
and Bivins
There are three groups of patients in whom this percutineous method of catheter insertion is contraindicated. The first is the patient known to have extensive intraperitoneal adhesions or multiple prior laparotomies. in these patients the likelihood is that one or more loops of bowel are adherent to the abdominal wall. Childreli represent the second group of patients in whom percutaneous catheter insertion is inadvisable. There simply is too small a margin of error in that there is so little distance between the abdominal wall and iliac vessels. The third group are patients with multiple distended loops of bowel, ileus, or bowel obstruction. It is much safer in each of these three groups of patients to cut down to the peritoneal cavity and insert the cathetejr under direct vision. Hemostasis must be meticulous so as not to confuse the interpretation of the dialysate. In time, the extraordinary advantage and utility of diagnostic peritoneal lavage in the initial assess-
640
ment and management of the severely injured patient will be widely recognized. Its widespread use, however, wiil depend on the surgeon’s confidence in the relative safety of this procedure and the accumulated experience that its use will not lead to an excessive rate of negative laparotomies. The intraperitoneal instillation of Ringer’s lactate and the use of epinephrine-containing local anesthesia prior to insertion of the dialysis catheter, may reduce the incidence of catheter-related complications or false-positive lavages.
References 1. Perry JF, DeMeules JE, Root HD: Diagnostic peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstst 131: 742, 1970. 2. Thal ‘ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. Am J Surg 125: 64, 1973. 3. Olsen WR. Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104: 536, 1972.
The American Journal of Surgery
Peritoneal dialysis has a well established but limited role in the management of renal failure. Diagnostic peritoneal lavage is an unappreciated but distinctly valuable adjunct to the clinical assessment of the severely injured patient [l-3]. Both procedures share the common technical requirement of intraperitoneal insertion of a catheter. The equipment specifically designed for peritoneal dialysis for renal failure is easily adaptable for diagnostic peritoneal lavage. This technic of intraperitoneal catheter insertion is based on the experience gained from the use of diagnostic peritoneal lavage in more than 100 severely injured patients and review of catheter complications in four patients with renal failure. Technic Peritoneal Dialysis for Renal Failure
Preferably, the catheter is inserted after the patient has ingested nothing by mouth for 12 hours. A cathartic, enema, or predialysis use of sorbital and Kayexalatem is indicated to empty the colon. Diagnostic Peritoneal Lavage In the Severely Injured Patient
Diagnostic peritoneal lavage can be safely performed very early in the initial phase of management of the severely injured patient. (Figure 1.) The patient should first have an adequate airway or endotracheal tube, intravenous lines, nasogastric tube, and indwelling urinary catheter. Preliminary lateral x-ray examination of the cervical spine is advisable if possible. Likewise a plane abdominal film is indicated; although this x-ray film is rarely helpful, it should be obtained to exclude the initial presence of free intraperitoneal air. Small amounts of air invariably enter the peritoneal cavity during the course of catheter insertion. This air is often seen on fol-
From the Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky. Reprints requests should be addressed to Charles R. Sachateiio, MD, Department of Surgery, University of Kentucky Medical Center, 600 Rose Street, Lexington, Kentucky 40506.
vohalm 131. Mey 1976
low-up chest x-ray films of patients who have had negative diagnostic lavage and can be misdiagnosed as representing a perforated viscus. lntraperitoneal Fluid Admlnlstratlon
When obtainable, a history of previous operations should be noted. Even with a negative history, the abdomen should be inspected for the scars of previous incisions. Women should be especially examined for the low transverse incision (Pfannenstiel) which frequently results in an almost unnoticeable scar hidden within the pubic hair. One need be aware that with this particular incision the opening into the fascia is often made vertically through the linea alba despite the fact that the skin incision is transverse. In general, it is inadvisable to insert the catheter through or immediately adjacent to an abdominal incision. The preferred site for catheter insertion is the midline, midway between the umbilicus and symphysis pubis. This area is avascular and provides less fascial resistance than other sites. The lower abdomen should be shaved and prepped carefully. The subcutaneous tissue and superficial skin is injected with 1 per cent lidocaine with epinephrine and a 5 to 6 mm incision is made in the skin. Epinephrine reduces the skin and subcutaneous bleeding which can easily confuse the interpretation of the amount of blood in the dialysat.e of the severely injured patient. The catheter should not be inserted until there is meticulous skin and subcutaneous hemostasis. It is not necessary to use an epinephrinecontaining local anesthetic in patients with renal failure who are undergoing peritoneal dialysis. A 14 or 16 gauge plastic-sheathed needle is connected to the dialysis tubing filled with isosmotic Ringer’s lactate solution. The needle is directed into the subcutaneous tissue through the previous skin incision. The physician should have fingertip control of the needle while advancing it. He should simultaneously observe the drip chamber of the dialysis fluid. Penetration of the peritoneum will be recognized tactically by a distinct “give ” and visibly by the immediate free flow of dialysis fluid in the drip
637
Sacbatello and Bivins
Figure 1. Schematic representation of diagnostic peritoneal iavage. A, small amount of free intraperitoneai fluid gravitates toward cui de sac as tt is the most dependent portion of the peritom?al cavfty in tfte supine position. B and C, intraperitoneat adminktration of Ringer’s lactate-the fluid has a tendency to colfect’posteriorly as the air-containing viscera move anteriorly. The intraperftoneal fluid gives the intestines more mobifity, D, catheter directed toward cul de sac. Nearly fjuantitative return is possible because of d siphoning effect. In theory the amount of blood In the fast 50 cc of dialysate removed is most apt to represent the “true” amoqnt of blood in the peritoneal cavity. initial recovery of a blood-tinged dialysate followed by clear dlalysate is very suggestive of catheter-related abdominal wall bleeding in a patient who would otherwise have had a negative lavage.
chamber. The plastic-sheathed needle should be inserted another 0.5 to 1 cm and then the needle withdrawn from the catheter an equal amount, leaving the tip of the plastic catheter in the peritoneal cavity. This maneuver will permit the free flow of fluid into the peritoneal cavity while it reduces the likelihood of needle perforation of a viscus. Alternatively, the needle can be removed completely and the dialysis tubing connected directly to the plastic catheter. One liter of dialysis fluid will run into the peritoneal cavity through a 14 gauge catheter in 10 to 15 minutes. Patients who are having diagnostic peritoneal lavage should be encouraged or assisted to roll from side to side once or twice while the fluid is running into the peritoneal cavity. This motion aids to insure in mixing the lavage fluid with any blood in the peritoneal cavity.
636
In the hurried activity of an emergency room setting, it is especially important that the physician performing diagnostic lavage personally verify the nature of the dialysate solution. Under no circumstances should a 5 per cent glucose solution be administered intraperitoneally. Failure to recover this fluid from the peritoneal cavity may lead to major fluid and electrolyte problems. Catheter Insertion
The morbidity of peritoneal dialysis for renal failure and the reliability of diagnostic peritoneal lavage is dependent on the technical expertise used to insert the dialysis catheter. The surgeon should grasp the catheter in such a way as to have total control of it while advancing it through the abdominal wall. (Figure 2.) The hand should act as a guard, predetermining the depth of
The American Journal of Surgery
Peritoneal Dialysis
penetration, and precluding inadvertent over-penetration. A distinct “give” is noted as the peritoneal cavity is entered. It is safer to direct the catheter obliquely toward the patient’s pelvis than either vertically or cephalad. The catheter is connected to the dialysate tubing and an additional 100 cc of dialysis fluid is allowed to run into the peritoneal cavity to check both the patency of the system and flow dynamics. If the system is functioning properly, infusion should continue until 1,000 cc has been administered. The dialysate is then recovered by gravity drainage. In some patients the fluid return is nearly quantitative; in others only an aliquot is recovered. External abdominal pressure, slight withdrawal of the catheter, and a 360’ twisting rotation are all helpful maneuvers and may facilitate fluid recovery in individual patients. With diagnostic lavage, an aliquot of as little as 200 to 300 cc of recovered dialysate is informative. Crystal clear dialysate is indicative of the absence of intraperitoneal blood. A hematocrit value on the dialysate of 1 per cent or more is indicative of intraperitoneal blood and may warrant laparotomy. The significance of salmon-colored dialysate, or dialysate hematocrit of 0.5 per cent or less must be interpreted in light of the total clinical picture. The mere presence of blood-tinged dialysate fluid is not an indication for exploratory laparotomy. Catheter-RelatedComplications Diagnostic Peritotieal Lavage. We have had two complications in which the obturator transversed the mesentery, leading to intraperitoneal blood loss and a false-positive dialysate. In both patients the obturator was advanced in a cephalad direction. It appears likely that directing the catheter toward the pelvis will result in fewer such complications. Peritoneal Dialysis. The records of four patients known to liave technical complications of peritoneal dialysis for renal failure were reviewed. These complications were: (1) retroperitoneal hematoma leading to death; (2) perforation of transverse colon; (3) perforation of cecuti; and (4) injury to iliac vein. The patient with the retroperitoneal hematoma had peritoneal dialysis instituted at another major university hospital and then transferred to the University of Kentucky Medical Center. He was noted to have a large retroperitoneal hematoma but clear peritoneal dialysate on admission. Several days later the retroperitoneal hematoma expanded tapidly, leading to hypotension and death. In the patient with perforation of the transverse colon, the peritoneal dialysis catheter was inserted
Volume 131, May 1979
Figure 2. The obturator should be grasped as shown to preclude uncontrolled dr lhadvertent excessively deep penetration. With &oke eqdptnent, the me&/ obturator will
recede wtthtntheptastk cdheter, necemttathg a two hand iechntc.Chehandaf7tsasthegrardwhtt8theottmfa~ the force necesskry to push the trocar through the abdominel wall.
without prior intraperitoneal instillation of fluid or the use of enemas or cathartics. Feculent material was noted in the catheter prior to the initiation of dialysis. A hole in the tfansverse colon was closed at laparotomy. In the third patient, elective peritoneal dialysis was initiated late in the evehing. No cathartics or enemas were used, and the patient had only recently eaten. The specially designed trocar in the Travenol set was used for intraperitoneal fluid administration. The needle was inserted at McBurney’s point and 2 L of saline instilled. The patient complained of abdominal pain and passed 1,800 cc of dialysate fluid per rectum. A hole in the cecum was noted and closed at laparotomy. The fourth patient was a small child with renal failure. The obturator injured the iliac vein, requiring operative intervention. The complications of intraperitoneal catheter insertion potentially threaten life but are fortunately relatively uncommon. They are basically related to the uncontrolled or excessively deep penetration of the obturator within the peritoneal cavity or to the failure to evacuate the gastrointestinal tract.
639
Sachatello
and Bivins
There are three groups of patients in whom this percutineous method of catheter insertion is contraindicated. The first is the patient known to have extensive intraperitoneal adhesions or multiple prior laparotomies. in these patients the likelihood is that one or more loops of bowel are adherent to the abdominal wall. Childreli represent the second group of patients in whom percutaneous catheter insertion is inadvisable. There simply is too small a margin of error in that there is so little distance between the abdominal wall and iliac vessels. The third group are patients with multiple distended loops of bowel, ileus, or bowel obstruction. It is much safer in each of these three groups of patients to cut down to the peritoneal cavity and insert the cathetejr under direct vision. Hemostasis must be meticulous so as not to confuse the interpretation of the dialysate. In time, the extraordinary advantage and utility of diagnostic peritoneal lavage in the initial assess-
640
ment and management of the severely injured patient will be widely recognized. Its widespread use, however, wiil depend on the surgeon’s confidence in the relative safety of this procedure and the accumulated experience that its use will not lead to an excessive rate of negative laparotomies. The intraperitoneal instillation of Ringer’s lactate and the use of epinephrine-containing local anesthesia prior to insertion of the dialysis catheter, may reduce the incidence of catheter-related complications or false-positive lavages.
References 1. Perry JF, DeMeules JE, Root HD: Diagnostic peritoneal lavage in blunt abdominal trauma. Surg Gynecol Obstst 131: 742, 1970. 2. Thal ‘ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. Am J Surg 125: 64, 1973. 3. Olsen WR. Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104: 536, 1972.
The American Journal of Surgery
