Background
Direct peritoneal resuscitation (DPR), also known as intraperitoneal fluid resuscitation, is an adjunct in the treatment of hemorrhagic shock. [1] It consists of saturating the peritoneal cavity with a hypertonic peritoneal dialysis solution. The goal is to restore microvascular function, tissue perfusion and to increase the chance of survival. [2, 3]
DPR has been shown to result in rapid and sustained splanchnic vasodilation, regardless of when it is initiated (eg, immediate vs 4-hour delay). [4, 5]
Indications
DPR is indicated (1) in patients with trauma who are in extremis from hemorrhagic shock and (2) in patients who are undergoing damage-control surgery. [6, 7, 8, 9, 10]
Contraindications
Relative contraindications for DPR include the following:
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Pregnancy
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Operator inexperience
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Previous abdominal surgery
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Overlying skin infection
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Skin infection
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Coagulopathy
Technical Considerations
Splanchnic hypoperfusion
Traditional resuscitation in an individual with hemorrhagic shock using intravenous fluid and blood has been shown to restore central hemodynamics; however, splanchnic and end-organ perfusion remains inadequate. [11]
Despite this traditional resuscitation, organs such as the liver and bowel continue to suffer vasoconstriction and hypoperfusion. [11, 12, 13, 14, 1] This inadequate perfusion fails to meet local metabolic demands and results in a cascade of problems, including tissue hypoxia, endothelial cell dysfunction, cytokine release, oxygen radicals, inflammatory response syndrome, and eventual multiorgan dysfunction and respiratory distress syndrome. [12]
Studies show that when the small intestine is topically exposed to a commercially available dialysis solution, it exhibits rapid and sustained vasodilation and actual hyperperfusion. [15, 16] The enhanced blood flow results from the vasoactive nature of the hyperosmolar dialysis solution. [17]
When compared with traditional resuscitation, the addition of DPR has demonstrated increased blood flow to the liver, bowel, spleen, pancreas, lung, psoas, and diaphragm. [16, 15, 18, 19, 20] Furthermore, DPR has been shown to reduce the inflammatory response and to reverse dysfunction of endothelial cells, improving the likelihood of survival. [15, 21] For these reasons, there is also experimental evidence that DPR can be used to reverse the causal microvascular vasoconstriction in necrotizing enterocolitis and even septic shock. [22, 23, 24, 25, 26]
Tissue edema
During the resuscitation of a patient with hemorrhagic shock, fluid shifts result from perturbed Starling forces on capillaries, vascular endothelium activation of Na+/H+ exchanger, and osmotic solvent drag. [27] Because of these shifts, the massive amounts of volume administered in hemorrhagic shock often far exceed the estimated blood loss. [28] In intra-abdominal hemorrhage, this edema can result in abdominal compartment syndrome, delays in abdominal closure, and several complications of the abdominal wall.
DPR has been shown to decrease overall edema and to normalize body water ratios. In intra-abdominal hemorrhage, DPR reduces time to definitive fascial closure, minimizes intra-abdominal complications, and results in better patient outcomes. [29]
Damage-control surgery
Damage-control surgery, or temporary abdominal closure, is the rapid initial surgical control of contamination and hemorrhage followed by a temporary closure to allow resuscitation the patient to a normal physiologic state. Once stabilized, the patient undergoes reexploration and definitive repair of injuries. Damage-control surgery can reduce the risk of mortality by 50% by preventing coagulopathy, acidosis, and hypothermia. [30, 31]
The addition of DPR to damage-control surgery has been shown to decrease the time to definitive fascial closure, mitigate complications, and provide better patient outcomes. [31]
