Does my patient need an urinary catheter?.pptx

Asses the necesity of an urinary catheter in the perioperative setting.

1. Does my patient n eed a n urinary c atheter? Ovidiu Bedreag “Victor Babes” University of Medicine and Pharmacy Timisoara Anesthesiology and Intensive Care Department

2. INTRAOPERATIVE MONITORING

3. Monitoring Anaesthesia

4. Do we need to measure urine output? u rine output ~ kidney perfusion ~ cardiac output But not always…

5. Do we need to measure urine output? Low urinary output during and immediately after major surgery is to be expected and so, in isolation, this measure may not always be helpful.

6. Case scenario no. 1 53 years old woman Diagnosis: endometr y al cancer Surgery: abdominal hysterectomy Anesthesia: general anesthesia with desflurane

7. Case scenario no. 1 During 1 st hour of anesthesia urine output = 100 ml Switch to Trendelenburg position urine output = 0 ml in the next hour WHY?

8. Answers Increased central venous pressure ? Hypovolemia ? Increased antidiuretic hormone production due to intense surgical stimuli ? Pooling of urine into dome of the bladder?

9. Case scenario no. 2 A 75 year old gentleman was brought to the recovery room after a general anesthesia of about 1.5 hours duration. On arrival: agitated and not answering questions appropriately. high blood pressure heart rate was low (40 b/ min). He was assumed to be in pain given his agitation, but didn't improve much after opioid medication.

10. Case scenario no. 2 He started to have some irregular heart beats He was sweating

11. Case scenario no. 2 What if you previously know that: He had not emptied his bladder before surgery He has a history of prostate enlargement He received over a liter of IV fluids in the OR?

12. Case scenario no. 2 His bladder was emptied with a urinary catheter. Almost immediately: heart rate = 68. blood pressure corrected agitation disappeared. After a short nap, he “woke up” and was feeling "just fine" with no recollection of having the catheter placed. He had no further issues and was discharged to ward

13. Urinary Bladder Retention after Anesthesia? In recovery rooms all over the country.... "You can't go home until you pee."

14. POTENTIAL RISK FACTORS FOR POSTOPERATIVE URINARY RETENTION age > 50 male gender (preexisting enlarged prostate) prolonged surgery / anesthesia time pelvic surgery or hernia repair surgery increased administration of IV fluid (over-stretching the bladder makes it harder to empty after general anesthesia) medications during / after surgery (beta-blockers, opioids etc.).

15. POSTOPERATIVE URINARY RETENTION Bladder retention after general anesthesia one of the most common side effects true incidence is hard to pinpoint It is a problem for a significant number of people. Minor issues with delayed bladder emptying - up to 70% of patients in immediate postop period. Significant bladder retention problems – 1- 20% of patients after general anesthesia.

16. Potential complications related to bladder retention More than just an annoyance Urinary tract infections overfull bladder will be incompletely emptied = risk factor for infection if a catheter has to be used = risk factor for infection Longer-term issues with bladder emptying evidences that having an over-distended bladder can cause difficulty in emptying the bladder even after leaving the hospital.

17. Potential complications related to bladder retention A stretched bladder signals the nerves of the parasympathetic nervous system: slowed or irregular heartbeat low or high blood pressure nausea/vomiting cardiac arrest

18. This Patient Needs a n Urinary Catheter?

19. Appropriate Urinary Catheter Use Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB) Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and patients with impaired immunity .(Category IB) Use urinary catheters in operative patients only as necessary, rather than routinely. (Category IB) For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB) Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

20. Appropriate Indications for Indwelling Urethral Catheter Use Perioperative use for selected surgical procedures: patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract anticipated prolonged duration of surgery(>3 hours) (such catheters should be removed in PACU) patients anticipated to receive large-volume infusions or diuretics during surgery need for intraoperative monitoring of urinary output Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

21. Appropriate Indications for Indwelling Urethral Catheter Use Patient with acute urinary retention or bladder outlet obstruction Need for accurate measurements of urinary output in critically ill patients To assist in healing of open sacral or perineal wounds in incontinent patients Patient requires prolonged immobilization (e.g. pelvic fractures) To improve comfort for end of life care if needed Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

22. Inappropriate Use of Indwelling Catheters As a substitute for nursing care of patients with incontinence For obtaining urine for culture or other diagnostic tests when the patient can voluntarily void For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia etc.) Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

23. Appropriate Indwelling Urethral Catheter Use Proper Techniques for Urinary Catheter Insertion Proper Techniques for Urinary Catheter Maintenance If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension . Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

24. Appropriate Indwelling Urethral Catheter Use Consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. (Category II) Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II) Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

25. Appropriate Indwelling Urethral Catheter Use Maintain unobstructed urine flow. (Category IB) Keep the catheter and collecting tube free from kinking. (Category IB) Keep the collecting bag below the level of the bladder at all times Do not rest the bag on the floor. (Category IB) Gould CV, et al. Center for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

26. Assessment of common practice in perioperative services Do you insert an indwelling catheter for a specific procedures performed by a particular surgeon? Do you assess patients to determine if the insertion an indwelling catheter is medically indicated? Do you evaluate the need to keep the catheter in place at the end of the surgical procedure before transporting the patient to the post anesthesia care unit (PACU)? Do you date and time when the catheter was inserted? Saint S, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf . 2005; 31(8):455-462. Saint S, et al. Preventing hospital–acquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases. 2008; 46(2):243-250.

27. Inappropriately placed catheters are more often forgotten about 1 In 56% of hospitals there is no system to keep track of which patients have catheters, and 74% of hospitals do not keep track of how long the catheter is in place 2 Saint S, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf . 2005; 31(8):455-462. Saint S, et al. Preventing hospital–acquired urinary tract infection in the United States: a national study. Clinical Infectious Diseases. 2008; 46(2):243-250.

28. Complications related to urinary catheterization Catheter Associated Urinary Tract Infection (CAUTI) > 40% of all hospital-acquired infections (HAI) (most frequent HAI) Urethral Injury Bacteriuria Sepsis Difficulty in urinating after catheter removal Narrowing of the urethra Bladder injury Bladder stones

29. Inappropriate use of urinary catheterization One in four patients receives an indwelling urinary catheter at some point during their hospital stay Up to 86 % of patients undergoing surgery have urinary catheters 50 % of these catheters remain in place for more than two days Wald HL, et al. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143:551-557

30. Why is there no informed consent for urinary catheters? No informed consent is required for urinary catheterization. Many people feel that urinary catheterizations are an invasion of their bodily privacy even if they are done by a nurse or doctor of the same gender especially when they are not really necessary.

31. Different types of anesthesia and effects on bladder functions Local Anesthesia – no effect on bladder functio n General Anesthesia i n short surgeries that are not longer than 3 hours, there is usually no effect on the bladder. bladder will become distended in longer cases and the patient could become incontinent over time. Regional Anesthesia Patients lose the sensation to void about 1 minute after being injected with spinal anesthesia, but will continue to feel dull pressure as the bladder reaches full capacity the ability to contract the detrusor muscle is lost 2 to 5 minutes following the injection of local anesthetics and still persists even after bladder sensation is fully recovered. Spinal anesthesia with long-acting local anesthetic contributes more to Post Operative Urinary Retention than spinal anesthesia with short-acting local anesthetic Any bladder issues after surgery are most likely due to narcotics used for pain control.

32. Take home messages Too many catheters are inserted and catheters stay in too long ! Avoid large intravenous volumes of crystalloid administered intraoperative to restore blood pressure in the absence of surgical hemorrhage! Use urinary catheterization only in selected patients! Remove urinary catheters as soon as possible!

33. Tell Me Again Why This Patient Needs a n Urinary Catheter?