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

1. Does my patient
need an urinary catheter?
Ovidiu Bedreag
“Victor Babes” University of Medicine and Pharmacy Timisoara
Anesthesiology and Intensive Care Department

2. INTRAOPERATIVE
MONITORING

3. Monitoring
Anaesthesia

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

8. 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.

9. Case scenario no. 1
• 53 years old woman
• Diagnosis: endometryal cancer
• Surgery: abdominal hysterectomy
• Anesthesia: general anesthesia with
desflurane

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

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

12. 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.

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

14. 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?

15. 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

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

17. 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.).

18. 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.

19. 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.

20. 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

21. This Patient
Needs an Urinary Catheter?

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Assessment of common practice in
perioperative services
1. Do you insert an indwelling catheter for a specific
procedures performed by a particular surgeon?
2. Do you assess patients to determine if the insertion an
indwelling catheter is medically indicated?
3. 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)?
4. Do you date and time when the catheter was inserted?
1. Saint S, et al. A reminder reduces urinary catheterization in hospitalized
patients. Jt Comm J Qual Patient Saf. 2005; 31(8):455-462.
2. 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.

31. Inappropriately placed catheters are more often
forgotten about1
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 place2
1. Saint S, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J
Qual Patient Saf. 2005; 31(8):455-462.
2. 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.

32. 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

33. 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

34. 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.

35. Different types of anesthesia and
effects on bladder functions
• Local Anesthesia – no effect on bladder function
• General Anesthesia
– in 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.

36. 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!

37. Tell Me Again Why This Patient
Needs an Urinary Catheter?