ORIGINAL CONTRIBUTION peritoneal lavage; trauma, abdominal

Randomized, Prospective Comparison of Open and Closed Peritoneal Lavage for Abdominal Trauma Study objective: The study was designed to determine if open peritoneal lavage is superior to closed peritoneal lavage. Design and participants: Patients who were admitted to a trauma center and needed peritoneal lavage were assigned to alternate trauma teams. Team I performed only open lavages one month and then switched to closed lavages; team 2 did only closed lavages and then switched to open lavages. Measurements: The incidences of positive lavages and iavage complication were noted. Also measured were the length of time for catheter insertion, length of time of fluid retrieval, volume of effluent, technical diffL culty of lavage, training level of the operator, effluent RBC count, and material cost. Results: Two hundred twenty patients were randomized. No differences were noted in complication rate, volume of effluent, or length of time for fluid retrieval. Significant differences were noted ,for catheter insertion time (3.6 minutes for closed lavage and 6.9 minutes for open), ease of catho eter insertion (closed technique is favored), and material cost ($96.26 for open lavage and $69,70 for closed lavage). Conclusion: Closed peritoneal lavage is superior to open peritoneal lao cage in abdominal trauma; it is faster, easier to use, cheaper, and as safe as open lavage. /Troop B, Fabian T, Alsup B, Kudsk K: Randomized, prospective comparison of open and closed peritoneal lavage for abdominal trauma. Ann Emerg Med December I991;20:1290o1292.]

Bryan Troop, MD, FACS Timothy Fabian, MD Betty Alsup, RN Kenneth Kudsk, MD Memphis, Tennessee From the Department of Surgery, University of Tennessee, Memphis. Received for publication January 25, 1991, Revision received June 8, 1991. Accepted for publication August 14, 1991. Address for reprints: Bryan R Troop, MD, FACS, 621 South New Ballas Road, Suite 1017, St Louis, Missouri 63141.

INTRODUCTION The introduction of diagnostic peritoneal lavage to the treatment of blunt abdominal trauma has improved the probability of finding intra-abdominal hemorrhage before the effects of hemorrhagic shock are obvious. The virtues of peritoneal lavage are that it can be performed quickly, accurately, and with the use of minimal equipment and is known to have a low complication rate.~ 4 We undertook a study to determine the advantages and disadvantages of open versus closed peritoneal lavage in patients with acute blunt abdominal trauma. MATERIALS A N D METHODS Adult victims of blunt trauma who were admitted to the trauma center and had an indication for peritoneal lavage were included in this study. Excluded were those with obvious indications for celiotomy and patients who had a previous midline or subcostal abdominal scar; those patients were evaluated by the open technique or by abdominal computed tomography scan. Patients with pelvic fractures were not excluded from the study; however, the lavage was done in the supraumbilical site in those patients. The trauma service consists of two trauma teams, team 1 and team 2, who alternate 24 periods of work. These teams are composed of surgery residents in the first through fifth postgraduate years of training. Each team has at least four residents, and each team serves exclusively on the trauma service for two months. Team 1 performed all peritoneal lavages using the open technique, as described elsewhere, s and team 2 used the closed technique, as described by Lazarus et al. a At the end of their month, team 1 switched to the closed technique of peritoneal lavage, and team 2

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20:12 December 1991

PERITONEAL LAVAG E Troop et al

began using the open technique. The closed technique of Lazarus et al is done by perforating the peritoneum w i t h a needle, passing a guide wire through the needle into the abdomen, and then passing the lavage catheter over the guide wire after removing the needle. The catheters were supplied in kits obtained from Cook Critical Care (CPLSYI00). A lavage was considered positive if more than 10 mL of blood was aspirated after catheter introduction or if the RBC count on the lavage effluent was more than 100,000 voL-1. All patients without a grossly positive lavage (more than 10 mL of aspirated blood) had 1 L of lactated Ringer's instilled into the abdomen and the effluent collected by a gravity siphon. All patients with a positive lavage underwent celiotomy. An admitting area nurse measured the time it took to introduce the lavage catheter and for lavage fluid to infuse and drain out. Patient preparation for both open and closed lavages was identical, and the time taken to prepare the abdomen was not measure& The volume of effluent was recorded, and an aliquot of it was measure for RBC count. The experience level of each resident also was recorded, and his perception of the degree of difficulty of the lavage was recorded as easy, moderately difficult, or difficult to perform. Patient characteristics, including age, sex, mechanism of injury, and injuries, were recorded. Each patient and/or each patient's chart was reviewed after at least 48 hours for possible complications.

RESULTS During the eight-month study period, 220 patients qualified for the study. The average age was 31 years old (Table 1). The male:female ratio was the same in both groups. There were 19 positive peritoneal lavages in the open group and 18 in the closed group. The volume of effluent was 538 mL for open lavage and 574 mL for closed lavage; the difference was not statistically significant. Catheter insertion took 6.9 - 3.4 minutes in the open group but only 3.6 _ 1.6 minutes in the closed peritoneal larage group (P < .05). The time for larage effluent was the same in the two groups. In the closed p e r i t o n e a l lavage 20:12 December 1991

TABLE 1. Patient data Open Lavage No, of patients Age (yrs ± SD) Female Motor vehicleaccidents Grossly bioody taps Positive lavages Volume return (mL ± SD) Length of time for catheter insertion (minutes ± SD) RBC count (p.L-1) Material cost

Closed Lavage

P

109 31,5 ± 14.4 21 91 (83%) 14 4 574 ± 204 3,6 ± 1.6

NS NS NS NS NS NS NS < ,05

5,944 ± 15,095

3,289 ± 11,581

< .05

$96,26

$69,70

111 30.4 ± 12,1 21 87 (78%) 14 5 538 ± 203 6,9 _+ 3,4

group, there was one false-positive lavagel no f a l s e - n e g a t i v e lavages were found in this study. One patient in the closed group had perforation of his undrained urinary bladder that was treated by simple Foley drainage for five days. There was a m i n o r wound infection in the open lavage group. The cost of materials averaged $96.26 for the open group and $69.70 for the closed lavage patients, a difference of $26.56 per patient. In this study, the most likely resident to perform the peritoneal lavage was in the third year of training, although residents in all training years participated (Table 2). There were only t h r e e lavages in the closed group that were perceived to be difficult but 12 such lavages in the open group (P < .05) (Table 3). DISCUSSION Hemorrhagic shock continues to be the most common cause of death from motor vehicle accident trauma and blunt trauma. Effective control of this hemorrhage depends on rapid identification of the bleeding location. The widespread use of peritoneal lavage has improved the diagnostic accuracy of the multiply injured patient. 2 Although computed t o m o g r a p h y of the a b d o m e n has s h o w n p r o m i s e in diagnosing abdominal injury, it is not only limited in its ability but also more time consuming. 7"9 Therefore, peritoneal larage is expected to continue to be a useful technique in evaluating multiply injured patients. 1o It is important to identify the optimum technique of peritoneal lavage. Three studies have demonstrated no statistical difference in the cornAnnals of Emergency Medicine

plication rates of open and closed lavage. T M In this study, additional factors were examined. The closed technique of lavage was superior in the amount of time that it took to perform the procedure. Although the saving of approximately three and one-half m i n u t e s m a y seem small, this did not include the time that it took to close the open incision. Some of the incisions were left open temporarily while attention was diverted to such other life-threatening problems as head injuries. In this study, large-bore tubing (8.51:, minimal ID) was used for all lavages and probably decreased lavage time in both the open and closed groups. 14 The volume of lavage effluent favored the closed lavage method, but this was not statistically significant. The RBC counts of the nonpositive lavage patients were compared. The open group had an average count of 6,101 RBCs/IxL, whereas the closed g r o u p had an a v e r a g e of 3,367 RBCs/~L. Although this is sta'tistically significant, it is probably not clinically important. It m a y imply that closed lavage is less traumatic. The procedure was considered easy to perform by the majority of operators in both groups, but the technically difficult procedures were most often encountered in the open group (Table 2). At our institution, it is not uncommon for the open lavage to be done with an assistant, either a more junior resident or a medical student, primarily to provide exposure by retraction. This not only requires more personnel but also decreases the access to the patient by other care providers. It is interesting to note that the more training the resident had, 1291/33

PERITONEAL LAVAGE Troop et al

TABLE 2.

Percentages of lavages done by level of training

Resident Postgraduate Year

% Open Lavage

% Closed Lavage % Total

1

11.4

13.0

12.2

2 3

28.6 45.7

20.7 44.6

24.9 45.2

4 5

10.9 8.6

10.9 10.9

8.1 9.6

TABLE 3.

Difficult open ]avages

Resident No. of Postgraduate No. of Difficult % Difficult Year Lavages Lavages Lavages 1

9

0

0.0

2 3

30 48

2 6

6.7 12.7

4

6

1

16.7

5

9

3

33.3

the more difficult an open lavage was considered {Table 3). This may be because the more experienced residents selected the patients who were more likely to be difficult in the first place. Data from Walter et al suggested that open peritoneal lavage can be done safely by surgery residents, is Our study supports this and also demonstrates that the closed lavage is equally safe. In this study, there was a savings of $26.44 per patient. This is in large part because less equipment was needed for the closed lavage procedure. Since the completion of our prospective study, we have had two additional lavage complications. The iliac vein was aspirated in a patient having a closed lavage. The iliac vein did not require repair but resulted in

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a false-positive lavage. The second complication was a perforation of the small intestine in a patient undergoing an open lavage. The bowel was repaired, and the patient developed no complications. Although the closed-lavage techniques appear to be better in terms of technical ease, time of performance, and cost, the open technique still has some advantages. We encountered one morbidly obese patient in whom the closed lavage catheter was not long enough to penetrate the abdominal wall. The patient was then lavaged by the open technique. Patients who have had a previous celiatomy may not be good candidates for closed lavage, but the procedure may be done carefully by the open method. Although the closed technique as described in this study appears superior to open peritoneal lavage, we continue to teach and use both methods at our trauma center. Also of note is that 28 of the 37 peritoneal lavages (76%) that were positive were grossly positive. CONCLUSION Peritoneal lavage continues to be an essential technique for managing patients with blunt abdominal trauma. Previous studies have compared open with closed peritoneal lavage in terms of complication rates. This study examined not only complication rates but also time for catheter insertion, time for fluid retrieval, and the technical difficulty experienced in performance of the peritoneal lavage. We found that the closed peritoneal lavage technique, as described by Lazarus et al, had several advantages, including less time for catheter insertion, being technically easier to perform, and less cost. There were no differences

Annals of Emergency Medicine

in complication rates. Because not all patients are suitable for closed peritoneal lavage, we continue to advocate training in the open or semiopen technique of peritoneal lavage.

REFERENCES 1. Bivins BA, Sachatello CR, Daugherty ME, et al: Diagnostic peritoneal lavage is superior to clinical evaluation in blunt abdominal trauma. A m Surg 1978;44: 6,37-641. 2. Fischer RP, Beverlin BC, Engrav LH, et al: Diagnostic peritoneal lavage: Fourteen years and 2,586 patients later. A m [ Snrg 1978~136:701-704. 3. Root HD, Hauser CW, McKinley CR, et ah Diagnostic peritoneal lavage. Surgery 1965;57:633-637. 4. Sherman JC, Dellaurier GA, Hawkins M G et al: Percutaneous peritoneal lavage in blunt trauma patients. J Trauma 1989;29:806804. 5. DuPriest RW, Khaneja SC, Rodrigues A, et ah A technique for open diagnostic peritoneal lavage. Surg Gynecol Obstet 1978;147:241-243. 6. Lazarus HM, Nelson JA: Peritoneal lavage with low morbidity. Am7 Emerg Med 1979;8:316-319. 7. Davis RA, Shayne )P, Max MH, et ah Tlle use of computerized axial tomography versus peritoneal lavage in the evaluation of blunt abdominal trauma: A prospective study. Sury,ery 1985;98:848-849. 8. Fabian TC, Mangiante EC, White TJ, et al: A prospective study of 9I patients undergoing both computed tomography and peritoneal iavage following blunt abdominal trauma. J Trauma 1986;26:602-608. 9. Marx JA, Murre EE, Jorden RC, et al: Limitations of computed tomography in the evaluation of acute abdominal trauma: A prospective comparison with diagnostic peritoneal lavage. J Trauma 1985;25:933-946. 10. Sorkey AJ, Farnell MB, Williams HJ, et aI: The complimentary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma. Surgery 1989;106:794-801. 11. Hernandez EH, Stein JM: Comparison of the Lazarus-Nelson peritoneal lavage catheter with the standard peritoneal dialysis catheter in abdominal trauma. J Trauma 1982;22:153-I54. 12. Patehter HL, Hofstetter SR: Open and percutaneous and lavage for abdominal trauma: A randomized prospective study. Arch Sur,g 1981;116:318-319. 13. Wilson WR, Schwarcz TH, PiIcher DB: A prospective randomized trial of tire Lazarus-Nelson vs the standard peritoneal dialysis catheter for peritoneal lavage in bhmt abdominal trauma. J Trauma 1987;27:1177-1180. 14. Cotter CP, Hawkins MD, Kent RB, et ah Ultrarapid c c diagnostic peritoneal lavage. J Trauma 1989;29:615416. 15. Wakers HL, Hupp J, McCabe CJ, et ai: Peritoneal lavage and the surgical resident. Surg Gyneco] Obstet 1987;165:496-502.

20:12 D e c e m b e r 1991

Randomized, prospective comparison of open and closed peritoneal lavage for abdominal trauma.

The study was designed to determine if open peritoneal lavage is superior to closed peritoneal lavage...
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