Direct Peritoneal Resuscitation 

Updated: Dec 02, 2019
Author: Gretchen S Lent, MD; Chief Editor: Vincent Lopez Rowe, MD 

Overview

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]

Contraindications

Relative contraindications for DPR include the following:

  • Pregnancy
  • Operator inexperience
  • Previous abdominal surgery
  • Overlying skin infection
  • Skin infection
  • 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.[8]

Despite this traditional resuscitation, organs such as the liver and bowel continue to suffer vasoconstriction and hypoperfusion.[8, 9, 10, 11, 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.[9]

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.[12, 13]  The enhanced blood flow results from the vasoactive nature of the hyperosmolar dialysis solution.[14]  

When compared with traditional resuscitation, the addition of DPR has demonstrated increased blood flow to the liver, bowel, spleen, pancreas, lung, psoas, and diaphragm.[13, 12, 15, 16, 17]  Furthermore, DPR has been shown to reduce the inflammatory response and to reverse dysfunction of endothelial cells, improving the likelihood of survival.[12, 18]  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.[19, 20, 21, 22, 23]

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.[24]  Because of these shifts, the massive amounts of volume administered in hemorrhagic shock often far exceed the estimated blood loss.[25]  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.[26]

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 resuscitate the patient to a normal physiology. 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.[27, 28]

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.[28]

 

Periprocedural Care

Equipment

Direct peritoneal resuscitation (DPR) involves the following:

  • Silicone elastomer round Blake drain (Ethicon), 19 French
  • Hypertonic (2.5%) glucose-based peritoneal dialysis solution (eg, Delflex [Fresenius, Waltham, MA]; 25 g/L D-glucose, 0.567 g/L sodium chloride, 0.392 g/L sodium lactate, 0.0257 g/L calcium chloride, 0.0152 g/L magnesium chloride at a pH of 6, osmolality of 486 mOsm/L)

Patient Preparation

Anesthesia

DPR is generally performed during explorative surgery when the patient is under general anesthesia. Lidocaine (1%) with epinephrine can be used for local infiltration.

Positioning

The patient should be kept in a supine position.

 

Technique

Approach Considerations

Direct peritoneal resuscitation (DPR) is typically performed during a laparotomy, with sterile precautions.[29]

The stomach should be decompressed with a nasogastric or orogastric tube.

The urinary bladder should be decompressed with a Foley catheter.

The site is prepared with skin antiseptic (chlorhexidine or povidone-iodine) and then draped.

A Blake drain is placed in the left upper lateral quadrant and directed along the left pericolic gutter, around the root of the mesentery and down into the pelvis.

Direct Peritoneal Resuscitation During Damage-Control Surgery

A sterile cover is placed over the abdominal contents but under the fascia.

Next, a sterile operating room towel is placed over this cover, and another drain is put within this towel.

Next, the entire abdomen is covered with an occlusive dressing.

Next, DPR solution is instilled into the left-upper-quadrant drain, initially with a 500-mL bolus followed by 1.5 mL/kg/hr until definitive abdominal closure is achieved.

The towel drain is placed to low pressure suction, resulting in a continuous lavage within the abdomen.

Intravenous blood and crystalloid resuscitation is continued at the surgeon’s discretion.

Complications

The following are potential complications of DPR: