Catheter Management. Justine Andrew Urology Nurse Specialist

Transcription

1 Catheter Management Justine Andrew Urology Nurse Specialist

2 catheterisation to let or send down History of the catheter belongs to urology At the end of the 19 th C, patients carried catheters in the shafts of their cane and umbrellas

3 Purpose of talk Indications for catheterisation Methods Decision support Contraindications Management Patient comfort Frequency of changes Preventing managing infection Trouble shooting

4 Indications Complete bladder emptying prior to surgery or an investigative procedure Relief of acute and chronic urinary retention Postoperative drainage when intermittent catheterisation is inappropriate or stenting of the urethra is required Accurate urine output measurement in a critically ill patient To manage intractable urinary incontinence For instillation of drugs: BCG, mitomycin For patient comfort patient immobile, incontinent, confused or palliative When an epidural is insitu To empty the bladder either before or after child birth. Intractable skin breakdown caused or exacerbated by incontinence To facilitate irrigation of the bladder and management of haematuria/ clot retention Measure residual urine after a patient has voided in the absence of a bladder scanner Where a patient insists on this form of management after discussion and understands the risks

5 Long term >6 weeks Incontinence - stress or urge Retention due to poor contractility of bladder Obstruction ISC prevent over distension of bladder and detrusor muscle injury Patient preference

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7 Catheterisation methods Uritip -functional disabilities Urethral -intermittent or continuous Suprapubic catheter -lower incidence of UTI -increased risk of bladder and renal calculi

8 Intermittent self catheterisation Contraindications Priapism in male Previous false passage stricture or infection Injury or tumour in urethra or penis Precautions Patients with limited vision, dexterity Caution with Prostate surgery Bladder neck incision Urethral injury Complications Urethritis Urinary tract infection Prostatitis in men Urethral bleeding Strictures False passage

9 SPC long term complications Skin irritation Bladder shrinkage Bladder stones Higher incidence of squamous cell bladder cancer Chronic CAUTI Overgranulation at insertion site

10 Types of catheters Hydrogel coated catheter dwell time up to 12 weeks 100% silicone Silicone elastomer coated/latex silicone coated dwell up to 3 months Silver coated Antibiotic impregnated Silicone Elastomer coater/latex Silicone coated catheter 100% Silicone Hydrogel catheter

11 Flip-flow valves Suitable for a wide range of patients using either a urethral or suprapubic catheter Help maintain bladder tone Flushing action can help prevent infection Contraindications Change every two weeks variable

12 Catheter size Choose the smallest size that will provide adequate drainage Too large causes: Urethritis Bladder spasm Discomfort Trauma

13 Decision For uncomplicated urinary retention e.g. post-anaesthetic, medication side effects Size 14 To facilitate accurate urine measurements e.g. following major surgery, sepsis, trauma Size 14 For urinary incontinence e.g. severe CVA, medical condition Size 14 For patients with slight haematuria, turgid and/or mucous-laden urine e.g. augmented bladders Size For moderate to heavy haematuria with potential for clots e.g. post urological surgery, bladder and/or prostate cancer, renal trauma Size way

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15 Male urethra

16 Female urethra

17 Undergoing surgery for heart valve or orthopeadic surgery involving joint replacements Patients with existing heart valve/joint replacements may require antibiotic cover Distortion of the urethra due to recent urethral/prostate surgery or trauma Latex allergies Precautions

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19 Insertion of an indwelling IDC for Algorithm for male catheterisation Explanation Sterile Inflate balloon once urine evident in tube No less than 8mLs in balloon Documentation male

20 Potential complications during insertion Inability to advance catheter Urinary tract infection urosepsis Trauma to urethra or bladder Ureteral stricture formation Haemorrhage Paraphimosis phimosis pain Creation of a false passage Paraphimosis Introducer

21 Catheter associated UTI potentially leading to urosepsis Catheter encrustation/bladder calculi Bladder cancer (long term inflammation) Uretheral erosin Uretheral fistulas Psychological trauma Epididymororchitis in males complications

22 Spectrum of urinary infections in Asymptomatic bacteriuria (3-10% risk cumulative per day) Symptomatic CAUTI (dysuria, frequency, burning up to 48 hrs after catheter removal) Bacteremia /Urosepsis (includes asymptomatic bacteremia) catheterised patients

23 Etiology of CAUTI Enterobacteriaceae (e.g E.coli, Klebsiella) commonest causes Enterococci, Staph aureus, Pseudomonas, Candida sp also significant in certain cases. 80% infections associated with short term catheter (< 4wks) are monobacterial 80-95% long term catheter colonisation are polymicrobial

24 Source of microorganisms Pathogenesis of CAUTI Endogenous (meatal, rectal, or vaginal colonization) Exogenous (15%) usually via contaminated hands of HCW during catheter insertion or manipulation of collecting system Source of entry Extraluminal. Commonest cause (2/3 rd ). During insertion or migration of endogenous flora by capillary action in biofilms Intraluminal. Reflux of bacteria or collection bag contamination

25 Burden of CAUTI 40% of all infections in acute care hospitals worldwide. 25% of all hospitalised pts have indwelling catheters CAUTI rates/1000 cath days Rehab wards 17, Gen med wards 5-15, ICU's 3-8 Bacteremia occurs in 3-5% pts of CAUTI One of the leading causes of secondary bacteremia in acute care- 15% and in long term care facilities - 50%. Mortality in bacteremic patients is 10-15% Length of stay 2-4 days in uncomplicated CAUTI. Added issue of unnecessary antibiotic usage and adverse reactions. Cost of CAUTI (USD)- 600(uncomplicated), > $3000(urosepsis)

26 Collection of catheter urine spec To ensure sterile collection of urine sample from a catheter Aspirate 10 ml of urine with needle and syringe or Swab connection site Place a new bag Never sample from used drainage bag Remember to chase results to ensure optimal treatment

27 CAUTI diagnosis facts Infection that develops up to 48 hrs after removal of catheter should be categorised as CAUTI Quantitative cultures necessary to avoid over diagnosis due to bacterial growth from specimen contamination. About 30% significant pyuria not accompanied by bacteriuria Dipsticks for nitrates and leukocyte esterase non-specific Symptoms localised to urinary tract present in <15% pts. Non specific symptoms in certain groups- confusion in elderly or bladder spasms/ hyper reflexia in spinal cord injury Odorous or cloudy urine, even if new, should not be used as a diagnostic bedside test.

28 Trauma to urethra or bladder Exerting too much force during insertion Catheter folding on itself in the urethra Premature balloon inflation Urethral erosion

29 Haematuria Causes Urinary tract infection Stones within the urinary tract A bleeding disorder Urological cancer Radiation cystitis Investigations Cystoscopy Flexible vs rigid Urine cytology

30 TXT irrigation

31 Irritability of balloon Bladder stones Cystitis due to inflammatory response Incontinent despite catheter Bladder irritability

32 Plastic semi rigid, radio opaque hollow catheter, splints the ureter to provide internal support and maintains optimal drainage protecting renal function Ureteric stents

33 Indications for stent Malignancy Surgical procedures Renal stones

34 Reduce the Risk Technique Duration Microbial colonization of drainage bag Diabetes mellitus Female patient Periurethral colonization Co-morbidities

35 Proactive and Preventative Care Hand Hygiene Maintain closed system Early removal Promoting fluid intake Cranberry Juice Meatal cleansing Bladder Washouts/Instillations Constipation Catheter bags Catheter Valves Catheter Diary Gravity Urological review for further assessment and evaluation

36 Maintenance of Urethral Catheters Hygiene Wear gloves for catheter cares and emptying drainage bags. Empty the bag into a single-use collecting container ensuring there is no contact between the drainage port and the inside of the collecting container. This reduces the risk of cross-infection between in-patients. Change drainage bags every time bag leaks or becomes odorous. Educate patient about: Hand washing before and after catheter handling. Daily shower/wash and need for meatal, labial and perineal washing. Females should always wipe from front to back. Creams ointments or powders should not be applied to catheter site unless ordered by medical staff. Attaching night-bag to leg-bag without breaking connections or system as maintaining a closed drainage system reduces the risk of urinary tract infection. Bag to be kept on stand or in the approved carry bag, not on the floor. Keep drainage port off the floor. Provide patient with leg bag and educate re use where appropriate. General Irrigate catheter only when necessary (eg. lack of drainage, clot Maintain balloon at correct size by checking one to two weekly and re-inflating as necessary. retention, debris).

37 Cystotomy Hypergrannulation Debridement Medications Maxitrol Silver nitrate sticks

38 Potential problems during catheter removal Problem Cause Suggested Action Unable to deflate balloon Damaged or faulty valve on the inflation/ deflation arm of the catheter Channel obstruction Check the valve for evidence of damage. Try adding 2-3ml of sterile water into inflation channel to dislodge blockage. If unsuccessful use a syringe and needle to aspirate the fluid from the inflation arm (above the valve 1. Attach syringe to the inflation arm and leave in place for minutes. The effect of gravity will help with the deflation process 2. Squeeze the visible tubing to try and displace crystal formation in inflation channel 3. If above fails, refer to medical staff as the balloon will need to be punctured suprapubically using a needle under ultrasound visualization 4. Following catheter removal the balloon should be inspected to ensure it is intact and that there are no fragments left in the bladder

39 Potential problems post TROC Problem Cause Suggested Action 1. Frequency and Dysuria Inflammation of the urethral mucosa. Ensure a fluid intake of 2-3 liters per day. Urinary alkaliner. Advise the patient that frequency and dysuria is common but will usually be resolved once micturition ha occurred at least three times. Inform medical staff if the problem persists 2. Retention of urine Inability of the bladder to empty. Patient anxiety Encourage fluid intake. Encourage warm shower/bath to promote relaxation. Bladder scan, re-catheterization. 3. Urinary tract infection Bacteruria, resulting in frequency and dysuria Encourage a fluid intake of 2-3 L/day to promote flushing of the bladder. Urine sample if symptoms persist inform medics

40 Catheter changes Suprapubic catheter Can be left insitu for up to 12 weeks Or as per manufacturer's guidelines Indwelling catheters Can be left insitu for up to 12 weeks More frequently if blocking often

41 Fluid is medicinal when patients have indwelling catheters Aim for > 2L urine output per 24hr For recurrent infections, consider referral for an ultrasound to assess for bladder stones

42 contact Urology nurse specialist