|
Selivanov V; Chi HS; Alverdy JC; Morris
JA Jr; Sheldon GF, 'Mortality in retroperitoneal hematoma.'
J Trauma 1984 24(12):1022-7
'Because of the high incidence
of hemoperitoneum associated with retroperitoneal hematoma,
peritoneal lavage is less useful in the setting of of pelvic
fracture than in other settings of suspected intra-abdominal
trauma.'
'Nine of 27 patients initially stable
patients underwent laparotomy on the day of admission because
of the development of hemodynamic instability, and all had
retroperitoneal hematoma as the source of the increasing
transfusion requirements.'
'It is likely that CT scanning of
patients with pelvic fractures and suspected intra-abdominal
injuries to solid organs will result in the lowering of
the negative laparotomy rate and morbidity in that group.'
| Study |
DPL
False positive
|
| Mendez C, 'Diagnostic accuracy
of peritoneal lavage in patients with pelvic fractures.'
1994 |
2.5% |
| Hubbard S, 'Diagnostic errors with
peritoneal lavage in patients with pelvic fractures'
1979 |
29% |
| McMurty R, 'Pelvic disruption in
the polytraumatized patient: a management protocol.'
1980 |
18% |
| Selivanov V, 'Mortality in retroperitoneal
hematoma.' 1984 |
33% |
Evidence
Mendez C; Gubler KD; Maier RV 'Diagnostic
accuracy of peritoneal lavage in patients with pelvic fractures.'
Arch Surg, 1994 May, 129:5, 477-81; discussion 481-2
OBJECTIVE: To determine the accuracy of
diagnostic peritoneal lavage (DPL) for the evaluation of
intraabdominal injury in patients with a pelvic fracture
as a result of blunt trauma. DESIGN: Retrospective cohort
analysis. SETTING: Level I trauma center in metropolitan
Seattle, Wash. PATIENTS: Four hundred ninety-seven consecutive
patients admitted with pelvic fractures following blunt
trauma during a 60-month period. OUTCOME MEASURES: Positive
results of DPL, defined by one of the following: an immediate
aspiration of more than 10 mL of gross blood; a red blood
cell count of more than 0.0001 x 10(12)/L; a white blood
cell count greater than 0.0005 x 10(9)/L; an elevated amylase,
bilirubin, or creatinine level; or organic particles or
bacteria in the effluent returned after installation of
1 L of crystalloid fluid lavaged in the peritoneal cavity.
RESULTS: Two hundred eighty-six patients underwent DPL.
For 80 patients (28.0%), results of DPL were positive and
for 194 patients (67.8%) the results of DPL were negative.
For two patients (0.7%), results of DPL were false positive
for a sensitivity of 94%. For another two patients (0.7%),
the results of DPL were false negative for a specificity
of 99%. As a diagnostic modality, DPL has a positive predictive
value of 98% and a negative predictive value of 97%. CONCLUSIONS:
Diagnostic peritoneal lavage is a reliable method for the
evaluation of intra-abdominal injury and should remain a
standard component in the evaluation of patients following
blunt injury with or without pelvic fractures.
Nallathambi MN, Ferreiro J, Ivatury
RR, Rohman M, et al. (1987). “The use of peritoneal lavage
and urological studies in major fractures of the pelvis--a
reassessment.” Injury 18(6): 379-383.
Fifty patients with major fractures of
the pelvis (Trunkey' s classification types I and II) treated
in an urban Level I Trauma Center were analysed to assess
the role of peritoneal lavage and urological studies in
the initial evaluation. The mechanisms of injury were automobile
v. pedestrian (44 per cent), falls from heights (44 per
cent), and motor vehicular accidents (12 per cent). Important
hypotension was present in 46 per cent of patients on arrival.
Peritoneal tap or lavage was selectively used in 11 patients
(22 per cent). Four patients in refractory hypotension despite
vigorous resuscitation had positive results. There were
no false-positive results or missed intra-abdominal injuries
in any of the 50 patients. Laparotomy was carried out in
10 of 50 patients. IVP or cystography was performed in 25
of 50 patients. However, injuries of the urinary tract requiring
operative correction (eight injuries in six patients) were
all associated with gross haematuria. Urological studies
were negative in patients with 1 to 3+ microscopic haematuria.
Peritoneal lavage is recommended on a selective basis in
patients with pelvic fractures. Microscopic haematuria does
not warrant contrast studies of the urinary tract.
Hubbard SG; Bivins BA; Sachatello CR;
Griffen WO Jr "Diagnostic errors with peritoneal lavage
in patients with pelvic fractures" Arch Surg, 1979
Jul, 114:7, 844-6
Diagnostic peritoneal lavage, considered
to be a highly accurate, technique for detecting intraperitoneal
blood in the trauma patient, may be less reliable in the
presence of a pelvic fracture. In a retrospective review
of 222 patients with pelvic fractures, 61 patients were
found who had had a diagnostic peritoneal lavage performed
as part of the initial evaluation of their condition. Twenty-six
of these patients had had a negative lavage result negative
lavage result. There had been no false-negative results
in this group, although six patients required operations
for extraperitoneal injuries. Of the 35 patients with a
positive lavage results, 10 (29%) were found to have false-positive
lavage results with no intraperitoneal source of bleeding.
The only deaths in this series occurred in the group requiring
operations, eight of 41 (20%). Four of the eight detahs
were due to uncontrollable bleeding that resulted from exploration
of the retroperitoneal hematoma. These data suggest that
a negative lavage result is highly reliable in the patient
with a pelvic fracture and should allow management with
confidence that there is no severe intraperitoneal injury.
Positive lavage results, however, must be interpreted with
caution.
Cochran W; Sobat WS "Open versus
closed diagnostic peritoneal lavage. A multiphasic prospective
randomized comparison. " Ann Surg, 1984 Jul, 200:1,
24-8
A total of 118 trauma patients were prospectively
randomized to receive either open or closed peritoneal lavage.
In addition, comparisons were made between using an infraumbilical
versus a supraumbilical approach in patients with pelvic
fractures. No statistical difference was noted between the
open and closed groups, despite the overall accuracy rate
of 96.6%. The supraumbilical approach was vastly superior
to the infraumbilical approach in patients with pelvic fracture
with an accuracy rate of 90.9% versus 57%. In this regard,
use of the infraumbilical approach in this setting is to
be highly discouraged. Finally, patient body habitus, technique,
and physician experience all play a role in the outcome
of the lavage.
Guide to Evidence Appraisals
The definitions of the types of evidence
and the grading of recommendations used originate from the
US Agency for Health Care Policy and Research
| Evidence
obtained from meta-analysis of randomised controlled
trials |
| Evidence
obtained from at least one randomised controlled trial |
| Evidence
obtained from at least one well-designed controlled
study without randomisation |
| Evidence
obtained from at least one other type of well-designed
quasi-experimental study |
| Evidence
obtained from well-designed non-experimental descriptive
studies, such as comparative studies, correlation studies
and case control studies |
| Evidence
obtained from expert committee reports or opinions and/or
clinical experience of respected authorities |
|
|
