Peritoneal Lavage: Diagnostic Assisting

1.  Perform hand hygiene and don clean gloves, gown, and goggles.
2.  Place the patient in the supine position.
3.  Assess airway, breathing, and circulation (ABCs) and provide support (i.e., airway, intubation, intravenous lines) if the patient is hemodynamically unstable.
4.  Obtain vital signs, oxygen saturation, and pain status.
5.  Assess skin for color, temperature, and moisture.
6.  Assess neurologic status (i.e., pupils, GCS or PCS score, LOC using AVPU).
7.  Inspect and palpate the abdomen for signs and symptoms of injury.
8.  Insert a gastric tube to decompress the stomach and to prevent stomach perforation during catheter insertion.
9.  Insert an indwelling urinary catheter to decompress the bladder and assess urine output.
10. Assist the physician or advanced practice nurse in clipping the abdominal hair (if time permits) and cleansing the abdomen with antiseptic solution.
11. The physician or advanced practice nurse drapes the abdomen with sterile towels.
12. Assist the physician or advanced practice nurse, as necessary, with infiltration of the insertion site with lidocaine with epinephrine.
13. The physician or advanced practice nurse inserts the catheter into the peritoneal space via open or Seldinger (closed) technique.
  a.  If the open technique is used, an incision will be made through the abdominal skin and the subcutaneous tissue to the fascia, and the catheter will be inserted into the peritoneal cavity and advanced into the pelvis.
  b.  Alternatively, the catheter may be inserted over a guide wire (Seldinger, or closed, technique). The guide wire is passed through an 18-gauge needle inserted into the abdomen.

The next two steps in the procedure vary slightly based on the indication.

14. Diagnostic purposes: The physician or advanced practice nurse attaches a 20-ml syringe and aspirates. If 10 ml of blood is aspirated, the lavage is considered positive.
15. Core rewarming or cooling: Be prepared to assist in the placement of two catheters: one catheter is used to infuse fluid continuously; the other catheter is used to drain the lavage fluid.
16. Attach primed intravenous (IV) tubing or cystoscopy tubing to the catheter.
17. Ensure that the IV tubing does not contain a backcheck valve.
18. Consider the use of cystoscopy tubing, which allows much faster infusion and drainage.
  a.  To connect the catheter to the cytoscopy tubing, push the end of the connecting tubing into the sleeve of the cystoscopy tubing.
  b.  (Optional) Tie a suture around the distal end of the sleeve of the cystoscopy tubing to tighten the connection.
19. Infuse 1 L of sterile warmed normal saline solution or lactated Ringer's solution (10 to 20 ml/kg for a child).
20. Be prepared to end the infusion before the drip chamber is dry.
21. Monitor chest tube (if present) and urinary drainage for evidence of lavage fluid.
22. If the patient's condition permits, allow the lavage fluid to remain in the peritoneal space for 5 to 10 minutes. Palpate the abdomen, or gently rock the patient from side to side to distribute the fluid throughout the peritoneal cavity.
23. Lower the IV bag to the floor, and allow the fluid to siphon out of the abdomen.
24. If the fluid does not return, perform the following steps:
  a.  Confirm that the appropriate tubing has been used.
  b.  If necessary, cut off a backcheck valve, or vent and drain the fluid into a basin.
  c.  Try repositioning the patient.
  d.  Assist the physician or advanced practice nurse with repositioning the catheter or inserting another catheter if necessary.
  e.  Instill additional fluid to encourage fluid return. Adequate fluid return is 30% or more of the infused volume. Any fluid left in the abdomen is absorbed through the peritoneum and should be added to the patient's parenteral fluid intake.
25. Obtain laboratory specimens from the IV bag when the fluid return is finished. Commonly ordered tests and their positive findings include:
  a.  Red blood cell (RBC) count: 100,000/mm3 or greater (except in stab wounds to the lower chest or gunshot wounds, where 5,000 to 10,000/mm3 may be considered positive)
  b.  White blood cell (WBC) count: 500/mm3 or greater
  c.  Gram's stain (for bacteria): Bacteria or food fibers present
  d.  Amylase: Serum amylase elevated in the DPL fluid
26. Assist the physician or advanced practice nurse to remove the catheter and suture the wound.
27. If a laparotomy is indicated, the wound will not be sutured. Apply a dry sterile dressing for transport to the operating room.
28. Place a thin layer of antibiotic ointment and a dry sterile dressing over the wound.
29. Discard supplies, remove gloves, and perform hand hygiene.
30. Document the procedure in the patient's record.

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