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How and When I Perform an Abdominocentesis in the Field
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Author’s Note: Please see the appendix on page 56 that list drugs, doses indications, and author's opinion.
Take Home Message
Evaluation of peritoneal fluid may rapidly provide invaluable information regarding the integrity of the gastrointestinal tract and health of the peritoneal cavity. More informed prognostic decisions are then possible in the horse displaying acute abdominal pain. However, peritoneal fluid analysis must be interpreted in conjunction with the clinical signs and physical examination findings and should not be used as the sole determining factor in case management decisions.
Introduction
In a field situation the ability to gain all the information contained in a sample of peritoneal fluid in a timely fashion is not possible, nor is it necessary to do so. The gross appearance is the most valuable indicator of the presence of devitalized intestine and is most likely to aid the clinician in the determination of the need for surgery. Serial evaluation of abdominal fluid color and specific gravity has a high positive predictive value for type of intestinal lesion,1,2 whereas patient age and abdominal fluid color has a high positive predictive value for clinical outcome.1 Progressive alterations in the peritoneal fluid parameters can be used to support the decision for surgical intervention.3
Materials
As a body cavity is being entered, sterile technique should be adhered to. To that end, sterile preparation supplies, examination gloves for surface preparation, and sterile gloves for the procedure should be used.
Clinician preference will determine the type of instrument used to penetrate the peritoneal cavity. An 18 gauge 1.5” needle allows a rapid collection of fluid, however, if the body wall is thick due to fat deposition of the size of the horse, an 18 gauge 3 1/2”spinal needle may be used, having the added advantage of flexibility and an indwelling stylet. Blunt ended teat cannulas or canine female urinary catheters decrease the chances of penetrating a viscus, however, they are more difficult to introduce into the peritoneal cavity, requiring a stab incision through the linea alba to gain entry to the peritoneal cavity.
The resultant peritoneal fluid should be collected in an EDTA tube (with bulk of the anticoagulant shaken out) for cytology, cell count and protein analysis. A clot tube may be collected for microbiological culture. A heparinized tube will allow assessment of peritoneal lactate.
Technique
An area caudal to the xiphoid and to the right of midline (minimize chances of a splenic sample) should be clipped and aseptically prepared. Local analgesia in the form of subcutaneous lidocaine is optional with the use of hypodermic needles but essential with the use of blunt ended cannulas to allow for an initial stab incision with a #15 scalpel blade (no handle) through the linea alba.
The needle or cannula is inserted through the body wall with sterile gloved hands. Two areas of resistance are likely to be felt, the first being the abdominal wall, and the second being the peritoneum. If fluid is not obtained, another attempt can be made adjacent to the first needle or cannula. Pain is likely to be elicited as the peritoneum is punctured.
The abdomen is under negative pressure and fluid may be difficult to obtain, especially in dehydrated horses. Ultrasonography may be used to identify ventral pocket of fluid and avoid enterocentesis increasing the likelihood of obtaining a representative peritoneal fluid sample in more difficult cases.
Indications
Peritoneal fluid is easily obtained in a field situation where operator and horse safety is considered. Light sedation may be necessary with fractious or painful horses. Prognostic decisions are improved in situations where systemic compromise of the horse is determined from aspects of the physical examination, presence of unrelenting pain, and progressive to sudden cardiovascular deterioration of the horse. Significant alteration in the peritoneal fluid may assist in the decision making process for referral or euthanasia.
Considerations
Even with considerable devitalization of the intestinal tract, it is possible to obtain a normal to near normal peritoneal fluid sample. The representative fluid may be trapped by the omentum, or protein and cellular components are diluted out by increased peritoneal fluid volume resulting from strangulating obstruction and increased hydrostatic pressure.
Blood contamination of the sample can readily occur confounding interpretation. Iatrogenic blood will be seen to swirl in the sample and be compacted by centrifugation. Splenic contamination will have a markedly elevated packed cell volume over the peripheral value. Internal hemorrhage will display hemolysis.
Enterocentesis will appear and smell like ingesta, however, the horse generally does not show signs of generalized cardiovascular collapse and debility as would be expected with a ruptured viscus. Additionally, there will be few to no cells present, as compared to fluid obtained following rupture where free and phagocytosed bacteria along with numerous inflammatory cells are most likely to be present. [...]
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