MANAGEMENT OF PATIENTS WITH INDETERMINATE DIAGNOSTIC PERITONEAL-LAVAGE RESULTS FOLLOWING BLUNT TRAUMA

The management of blunt trauma victims with indeterminate diagnostic peritoneal lavage (DPL) findings remains controversial. We reviewed 1,196 patients undergoing DPL to identify patients with indeterminate DPL (red cell counts of 20,000 to 99,999 rbc/mm3). Only 4% (48) had indeterminate DPL results. Repeat DPL (R-DPL) was performed in 31 patients. Six repeat DPLs produced positive results (> 100,000 rbc/mm3), 15 produced indeterminate results, and 10 produced negative results (< 20,000 rbc/mm3). A review of the nine laparotomies performed in this group revealed only two operations that were therapeutic. Twelve patients had abdominal CT scans following indeterminate DPL. Six patients had negative CT scans and were successfully managed without operation. The findings were positive on six other CT scans. Four patients with positive CT scans, including two splenic injuries, one liver injury, and one renal laceration, were managed successfully without surgery. The remaining two patients with positive CT scans underwent laparotomy. The first had a renovascular injury diagnosed from the CT scan after negative findings on repeat DPL. The second had a minor splenic injury diagnosed from the CT scan. A subsequent repeat DPL produced a positive result prompting a nontherapeutic operation. Eleven patients were observed without repeat DPL or CT scanning. Of these, four eventually underwent laparotomy on the basis of clinical suspicion alone. Only one of these patients required therapeutic intervention at the time of laparotomy. Intra-abdominal injury was common in patients with indeterminate DPL results, however only four (8%) of the patients required a therapeutic operation. Both negative repeat DPL results or negative findings on CT scans predicted successful nonoperative management. Positive or presistently indeterminate repeat DPL results led to two therapeutic operations for intraperitoneal injury in 21 cases. The data suggest that indeterminate DPL results correlate with injury that may be managed in the majority of cases without operation. Nontherapeutic laparotomy rates in this small but significant subgroup of patients with indeterminate DPL results may be decreased by CT scanning followed by observation in preference to repeated DPL.