You want to put what in where? Direct Peritoneal Resuscitation (DPR) for intra-abdominal injuries.

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Kevin Yeh
Critical Care Pharmacist with special interests in trauma and surgery.

The Pre-brief

A 30-year-old female arrives at the emergency department with three gunshot wounds to the back.  CT abdomen showing liver laceration involving >50% of the in the right hepatic lobe with active extravasation, Inferior Vena Cava (IVC) laceration, a kidney laceration, and multiple small bowel lacerations with significant hemoperitoneum.  Massive transfusion protocol was activated and the patient was taken urgently to the operating room for exploratory laparotomy and damage control surgery (DCS). At the conclusion of her operation, her abdomen was temporarily closed and drains were placed for direct peritoneal resuscitation (DPR) therapy.

What is DPR?

Intra-abdominal catastrophes with hemorrhagic shock requiring DCS usually yield wounds that are difficult to manage. Intestinal and abdominal wall edema from aggressive intravenous resuscitation also delays wound closure immediately after surgery. DPR is a method in which the peritoneal cavity is continuously irrigated with hypertonic peritoneal dialysis solution. During hemorrhagic shock, blood is shunted away from the intestines, which increases the risk of mesenteric ischemia.  Animal studies have shown the use of DPR increases splanchnic blood flow, decreases edema, and mediates the inflammatory response. (24952444)

In humans, Smith and colleagues demonstrated that the use of DPR decreased time to abdominal closure, decreased intra-abdominal complications, and decreased ICU length of stay (LOS).  However, these studies are limited to being retrospective and included patients with non-traumatic injuries. (20421025) (25159241).

Subcapsular hematoma. Contrast-enhanced CT scan shows multiple subcapsular hematomas in the right and left hepatic lobes (arrows). Multifocal intraparenchymal hematomas are also seen (arrowheads). Source is linked to the image.

What does the literature say?

J Am Coll Surg. 2017 Apr;224(4):396-404. doi: 10.1016/j.jamcollsurg.2016.12.047. Epub 2017 Jan 27. PMID: 28137537.

The Debrief

  • Utilization of DPR decreases time to definitive abdominal closure while decreasing morbidity and mortality 
  • Larger, multi-center trials should be performed for better generalizability

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