What Is The Appropriate Size Of A Urinary Catheter Used For Infants?
Res Rep Urol. 2021; 13: 185–195.
Choosing the Correct Catheter for Pediatric Procedures: Patient Considerations and Preference
Chad Crigger
1Section of Urology, Division of Pediatric Urology, West Virginia Academy, Morgantown, WV, 26506, USA
Jake Kuzbel
1Department of Urology, Sectionalization of Pediatric Urology, West Virginia Academy, Morgantown, WV, 26506, United states of america
Osama Al-Omar
1Section of Urology, Partitioning of Pediatric Urology, West Virginia University, Morgantown, WV, 26506, USA
Received 2021 Jan 16; Accepted 2021 Mar 30.
Abstruse
Determining the need for float decompression and urinary diversion in the perioperative pediatric surgical patient tin crusade a clinical conundrum for the surgical team. Add in the several unlike types of urinary diversion devices possible, and the various materials associated therein and the procedure tin of a sudden seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, choice, and technique. We provide a wide overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attending can best be focused on the planned intervention at hand.
Keywords: pediatric surgery, pediatric urology, urinary diversion, quality improvement, CAUTI
Introduction
An average of 450,000 pediatric patients are admitted each year in the U.s.a. for surgery. Elective surgery admissions more often than not comprise 40% of the surgical hospitalizations with 55% of admissions classified as either gastrointestinal, orthopedic, or urological.1 Consider the high volume of additional outpatient surgical procedures, representing over threescore% of all surgeries in the United States in 2011, and the diligence to perioperative management in the pediatric patient is vital.2 While the firsthand pathology at hand and surgical technique dictated are the primary focus of the surgical team, one facet that receives considerably less attention, if any, is the part of urinary catheter placement.
The conclusion to identify a urinary catheter, or not, or another variant to decompress the bladder may seem trivial. Even so, a dive into the topic only farther complicates the thing. Consider that catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infection in the U.s., accounting for more than xxx% of infections reported past acute intendance hospitals.3 Equally this is associated with increased healthcare costs, hospital stays, morbidity and mortality rates, there has been a drive to determine when catheters should be utilized.iv In fact, national quality improvement measures to strictly determine safe catheter usage are seen in campaigns such as "Lose the Tube" of Choosing Wisely Canada.five
When the same dilemma is practical to the pediatric patient, the water is farther muddied. Pediatric patients, in fact, are not only pocket-sized adults. With incompletely developed and developing physiology, more delicate anatomy, in addition to the part urinary catheterization has historically played in the postoperative healing in sure procedures, selecting the proper catheter – and knowing when to use 1 – is no simple task.
In what follows, we hope to provide a footing for when catheterization should be employed in the pediatric patient by and large. Building on this, we will explore how the intended procedure, arroyo, and underlying pathology may all influence this pick process and then that clinicians may better arrive at a sound decision.
When Should a Catheter Be Used?
In 2018 Meddings and colleagues set up out to determine criteria for urinary catheter utilize in common general and orthopaedic surgeries using the RAND/UCLA appropriateness method.6 A bold undertaking, the panel, consisting of 2 multidisciplinary sub-panels totaling 24 members utilized a standard process to independently rate the clinical appropriateness for Foley catheter placement in 91 general surgical procedures and 36 orthopaedic surgeries. With the aim to limit unnecessary catheterization and prioritize removal when urinary drainage was needed, prompted three recommended categories: (a) procedures for which indwelling urinary catheter placement should be avoided, (b) procedures to consider removing indwelling urinary catheters before leaving the operating room, and (c) procedures in which urinary catheters should remain in use until postoperative day 1 (Figure 1). One obvious omission in this console review was the lack of review of urologic procedures.
Summary of perioperative urinary catheter use recommendations.
Notes: Adapted from Meddings J, Skolarus TA, Fowler KE, et al. Michigan Advisable Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Ceremoniousness Method. BMJ Quality & Safety. 2018;28(1):56–66. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC Past-NC. Published by BM© Writer(s) (or their employer(s)) 2019. Re-employ permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published past BMJ. With permission from BMJ Publishing Group Ltd.6
In the general surgical realm, Foley catheter use was highly appropriate for all colorectal surgeries with appropriate timing of get-go voiding trial occurring as early on as postoperative day 0 or postoperative day one. Routine catheter placement was accounted inappropriate for several procedures, including laparoscopic cholecystectomy, open appendectomy, laparoscopic appendectomy without a suprapubic port, open up repair of reducible hernias (inguinal, femoral, umbilical, epigastric), and well-nigh laparoscopic repairs provided the patient voided preoperatively.
One area where catheter placement was nearly highly dependent upon surgeon experience and training included whether or non suprapubic port placement in laparoscopic surgery impacted urinary drainage strategies. The panel discussed catheter placement may be avoided if the patient voided preoperatively with the option of bladder scanning, merely consensus appropriateness remained undecided regarding routine placement. As expected, many practices are determined by surgeon training and if any surgeon had experienced bladder or other urologic complications with suprapubic port placement. By convention, well-nigh urologists identify urinary catheters, at least intraoperatively, for most pelvic surgeries, including both open and laparoscopic approaches to minimize risk of inadvertent iatrogenic damage to the bladder.
For orthopaedic procedures, the competing interests were the need to subtract catheterization where infections are a real gamble to hardware and operative time. In general terms, about routine hip and human knee procedures can safely be performed without catheter placement if completed in nether two hours. In those that last longer than two hours, catheters could oft be removed before leaving the operative suite or on postoperative solar day 1 with no increase adventure in postoperative complications.
Postoperative Urinary Retention – What Is Information technology and What Mitigation Strategies Exist?
The overall take a chance of postoperative urinary memory (Cascade) in the general (non–urologic) surgical population is 3.eight%, though the cited incidence tin can vary widely from 5 to seventy% based on the type of surgery.7 In pediatric patients undergoing lower extremity orthopedic limb surgery, up to one–tertiary of patients may develop Pour.8
The alterations in physiology in the postoperative period can consequence from diverse types of anesthesia employed. The effects may exist due to anesthesia itself, the procedure performed and technique utilized, polypharmacy intraoperatively, and postoperative pain. Although in that location has been a recent push away from postoperative opiate pain management, opioids are commonly still used intraoperatively and are known to decrease the sensation of bladder filling past parasympathetic inhibition.ix Additionally, they increase sphincter tone. The event, and subsequent urinary retention, is greater with neuraxial opioids compared to intravenous administration. Full general anesthesia as well contributes to urinary retention by increasing shine muscle relaxation, and, conversely, decreasing float contractility. Finally, local neuraxial local anesthetics act at the immediate afferent and efferent junctions in the pathways pivotal to micturition. As such, longer acting agents carry a greater risk for postoperative bladder dysfunction.
While several distinct and competing criteria have been used to diagnose Cascade generally the condition tin be diagnosed based on history and physical examination, demand for bladder decompression, and, more recently, ultrasonography.10,11 Suprapubic hurting at rest and with at palpation also as a distended, palpable bladder can inkling the clinician into ongoing POUR, though this method does lack sensitivity. In developed patients, palpable dullness to the level of the belly button is a reliable surrogate in measuring bladder volumes of approximately 500 mL.12 Bladder catheterization offers both a diagnostic tool and therapeutic measure for POUR, as some criteria diagnose POUR if 100% of expected developed volume is drained (500–600 mL in adults) and more than the calculated bladder capacity at a certain age in a kid ([age in years + ii] x 30).thirteen Finally, ultrasonographic investigation has proven a useful offshoot in diagnosing POUR as information technology is not-invasive, painless and has a loftier sensitivity, with stiff correlation between volumes measured by bladder catheterization and ultrasound.xiv,15
Strategies to subtract the risk of Cascade have been heavily studied and resulted in alterations in operative management by the surgical squad and anesthesia management. Judicious intravenous fluid assistants based on calculated maintenance fluids, and accounting for insensible loss, is imperative. This arroyo should exist employed when possible, though there are instances when a surgeon may request hyperhydration, such as in urologic upper tract reconstruction, to induce a physiologic hydronephrosis.
Other approaches to decrease risk include existence cognizant of surgical duration. Keita et al demonstrated that surgical duration alone, specifically procedures lasting 80 minutes or longer, were independently associated with increased risk of POUR. This is likely multifactorial, due to the increased intravenous fluid administration and utilise of opiate pain command for general anesthesia. Nevertheless, pain control in the postoperative setting is crucial equally poor pain command can result in increased sympathetic discharge which further predisposes a patient to Cascade.sixteen
Catheter Size in Children – One Size Does Not Fit All
Catheterization in the pediatric patient, unlike the developed patient, is frequently performed in conjunction with diagnostic as well equally therapeutic procedures. Examples in which catheterization is diagnostic include contrast-enhanced imaging modalities such equally that seen in cystourethrography. Though the process is normally performed and relatively safe, there are relative contraindications to immediate catheterization including pelvic fractures, known trauma to the urethra, or claret at the meatus.17 Complications are rare considering how ofttimes catheterization is performed, however, they exercise arise. Examples include false passage cosmos, urethral perforation, hematuria secondary to traumatic placement, infection and subsequent delayed complication of urethral stricture formation.
Fundamental to avoiding, or at to the lowest degree minimizing, complications is appropriate catheter size selection. The method for doing so varies widely and traditional selection processes rely on the child's age, body weight, or both.18–21 Verbal formulas have even been derived to provide an platonic and custom approach to proper catheter sizing in children. One relies on a patient'southward age to gauge torso weight (in kg) up to 10-years:22 Weight may not always exist the most accurate, nonetheless, as in that location can be dandy variance of expected weight for a given age. To address this, Kopac devised a formula based entirely on body weight (up to thirty kg) and correlated this with catheter size:
This formula was verified to help those clinicians speedily make up one's mind the advisable catheter size who may not have readily available access to published nomograms for height and weight or who may not frequently care for pediatric populations. Equally the formula is based on published relations between urinary catheter size and a child's age and trunk weight, the formula holds strong correlation up to 30 kg.23
Special Considerations
Hypospadias Repair
Management of urine postoperatively post-obit surgical repair of hypospadias is, in itself, a highly debated topic in the realm of pediatric urology. Classic reasons for placing a urethral stent or other urinary drainage device such as a Foley include the conventionalities that voiding postoperatively may prove painful or cause discomfort that may predispose a kid to develop urinary retention – by leaving a urethral stent, the risk for re-cannulating a fresh hypospadias repair is avoided. Additionally, others believe urethral stenting provides a physical framework around which a repair may heal, particularly if the urethral plate is reconstructed and tubularized every bit in the tubularized incised plate repair (TIP procedure).24 To address this exact question, El-Sherbiny prospectively randomized boys undergoing a TIP procedure to either stented (n=35) or unstented (n=29) groups for postoperative management. Findings from this study demonstrated painful voiding in the first calendar week was seen in 14% and 45% of stented and unstented patients, respectively. Additionally, none of the stented patients developed urinary retention or extravasation compared to 24% and 17% in unstented patients. In regards to postoperative meatal stricture, meatal dilatation was required in six% of stented patients versus 17% of unstented patients. Finally, the re-operative rate trended lower in the urethral stented group (nine% vs 20%), though the divergence was not statistically significant.25 Based on these findings, his conclusion was that urethral stenting after TIP repair for hypospadias is advantageous.
Yet, several studies have evaluated healing in unstented hypospadias repair procedures. Hafez and colleagues utilized a rabbit model to written report the temporal healing after TIP urethroplasty. They used a combination of retrograde urethrograms and microscopic examination at varying intervals and found no instances of fistulae or stricture in 13 performed procedures. Additionally, consummate healing of the peri-urethral connective tissue with minimal fibrosis was seen.26 This has since been replicated numerous times in boys with several studies demonstrating that successful hypospadias repair is independent of the use of a urethral stent.27
Now the use of urethral stenting and urinary diversion after hypospadias repair rests mostly on surgeon preference and grooming, or in the case of re–do repairs. Most options for transurethral drainage include a modified catheter of acceptable size, typically 6 Fr or 8 Fr, or a feeding tube ranging 5–8 Fr placed atraumatically with verified drainage and secured via a glans stay suture (Figure 2). Fourth dimension to removal varies as well, with a traditional dwell time of seven days, though recent studies have shown that removal postoperative day 1 (overnight urethral stenting), is not associated with any significant increment in adverse outcomes.28
Urinary diversions – urethral stents and urinary catheters. Left half of motion-picture show represents feeding tubes which may exist fashioned into urethral stents, ranging 3.five–8 Fr. On the right one-half of the picture are various catheters, 6–12 Fr.
Urinary Retention
De-novo urinary retention outside the setting of postoperative urinary retentivity, known neurological disorder and neonates is a rare entity. In their comprehensive review of pediatric presentation of acute urinary retention in the emergency setting betwixt 2000 and 2012, Nevo et al plant an overall incidence of urinary retentivity of 8.48 cases per 100,000 children. Additionally, 75% of children presenting were male. Underlying causes included mechanical obstruction (25%), infection or inflammation (18%), astringent fecal constipation (thirteen%), and previously unknown neurologic disorders (11%). Interestingly, upwards to 21% were idiopathic. Of note, all patients with mechanical obstruction were boys and five of fourteen patients had a pelvic tumor.29
Historic period was also a factor – a bimodal distribution was noted with 29% of events occurring betwixt three and 5 years of age, and 32% between the ages of x and 13. Based on the alarming charge per unit of apropos underlying pathology, astute onset urinary retention in a previously salubrious child – excluding the postoperative period, known neurological disorder, and neonate age – should prompt swift and comprehensive evaluation.
In another study, adverse drug furnishings (particularly with antihistamines and neuroleptics such as haloperidol and carbamazepine) and behavioral dysfunctional voiding were vi times more common in boys.xiii
Neurogenic Float
Neurogenic float or neurogenic detrusor-sphincter dysfunction encompasses abnormalities in the voiding arc that may develop due to a lesion at whatever level in the nervous system. This condition contributes to various forms of lower urinary tract dysfunction and can contribute to urinary tract infections, incontinence, and vesicoureteral reflux. In the long term, it tin lead to renal scarring and compromised upper tracts, portending to chronic renal failure.30
The main goals of therapy are aimed to foreclose deterioration of the urinary tract and to assist the child achieve continence at an appropriate age. Management of neurogenic bladder, and its associated sequelae, has seen enormous gains, in big part to the introduction of make clean intermittent catheterization (CIC). This has increased adherence to conservative management principles, which has allowed deferment of surgical intervention, if needed, until an age where success is virtually probable.
European Association of Urology (EAU) emphasizes and celebrates the overwhelming success CIC has had on early management of neurogenic bladder, and how, if started soon after nativity, children do not develop upper tract deterioration.thirty Kochakarn et al detailed the basis for early CIC and its effect by randomizing children with neurogenic bladder secondary to myelomeningocele to early on intervention (i year of age or less, n = 36) or late intervention (CIC >3 years old, n = 31). Children who were started on CIC after had earlier renal deterioration and worse renal office (measured by increases in blood urea nitrogen and serum creatinine). Hydronephrosis was observed in 10 patients who received early intervention and eighteen patients who were in the later treatment group. Patients in the afterwards treatment group also had before and more than severe hydronephrosis. Interestingly, in cases where surgery was performed, in either group, results of surgery were meliorate in those who received early CIC, though surgery was required earlier in the late CIC group. Of notation, no deviation in urinary tract infection was seen between the 2 groups.31 A major barrier to the success of CIC, however, relies on complete back up and credence past the patient, parents, and schools to ensure timely drainage.32
In those requiring CIC, hydrophilic, cocky-lubricating catheters are preferred and are associated with decreased hazard of symptomatic urinary tract infection, bacteriuria, hematuria and pain, and increased patient satisfaction.33
For patients who have progressively worsening renal function despite CIC, definitive interventions include Mitrofanoff, Monti, or bladder augmentation. In such cases, a carefully selected, age-advisable, urethral catheter is left indwelling for three to four weeks typically. For redundancy, a minimum of a 12 Fr catheter is too placed suprapubically to maximize drainage and as well irrigate mucus debris as needed. This is typically removed i to two weeks after the urethral catheter is removed and the patient is able to reliably demonstrate appropriate manipulation of the reconstructed diversion.
Posterior Urethral Valves
With an estimated incidence of 1 in 5000–12,500 live-births, posterior urethral valves (PUV) are 1 of the few life-threatening congenital anomalies of the urinary tract.34,35 Often diagnosed antenatally on routine ultrasonography, proper management is imperative to avoid continued, and typically irreversible, kidney damage. Antenatal management is a rather recent treatment option afforded by incredible achievements in maternal-fetal management, technology, and bold surgical sense. A detailed discussion of such treatment is beyond the scope of this text, only antenatal handling is reserved for only the well-nigh severe cases and consists of percutaneous vesicoamniotic shunt placement.36 This intervention is simply offered at the about specialized of institutions that are able to offer jointly the obstetric, pediatric urologic, and potential pediatric care necessary to best maximize success.
Postnatally, if PUV is suspected in a newborn male, prompt drainage of the bladder is necessary, followed by voiding cystourethrogram (VCUG), if possible, which will demonstrate the archetype "keyhole" sign (Figure 3). A neonate may be decompressed with a feeding tube ranging from 3.5 to 8 Fr, though 5 Fr is typically performed. 6 Fr balloon catheters may also exist utilized, and in rarer instances, iv.viii or 6 Fr ureteral double j-coiled stents tin can be used. Of note, the utmost care must be taken to non inflate the balloon within the urethra, inevitably causing more trauma. It is our recommendation that a 5 Fr feeding tube or double-j stent over a guidewire be placed if possible and confirmed with bedside fluoroscopy or ultrasound. All the same, a 6 Fr urethral catheter may also be used without inflating the balloon and appropriately secured with tegaderm or tape.thirty Alternative methods, if the transurethral arroyo fails, include suprapubic catheter insertion or cutaneous vesicostomy. Once the urinary organisation is decompressed, valve ablation typically is the definitive intervention and is performed once the child is safe to undergo anesthesia. A urethral catheter is placed during definitive treatment and left in place until the creatinine nadirs, which typically occurs 24 to 48 hours later on repair.
Voiding Cystourethrogram (VCUG) of male person infant demonstrating dilated prostatic urethra with archetype "cardinal hole" sign secondary to posterior urethral valve. Some upper tract deterioration is already noted on the right given the significant dilatation from increased intravesical pressures.
Urinary Decompression Afterward Urologic Reconstruction
The role of urinary drainage via trans-anastomotic ureteral stenting or percutaneous drainage remains heavily debated with the emergence of "stent-less" ureteral reconstruction, specifically in pyeloplasty.37 While this contend continues for upper tract urinary decompression, urethral catheterization is seemingly ubiquitous to drain the lower urinary tract. Conventionally, the bladder is decompressed for at least 24 hours, or overnight, in instances where extravesical ureteral reimplantation is utilized unless the patient has a history of voiding or bowel dysfunction, or both. More than variability is seen in intravesical ureteral reimplant every bit the bladder wall and mucosa are violated. Urethral catheter dwell time in these instances is based on surgeon preference.
Catheter Placement in the Pediatric Trauma Patient
As previously mentioned, relative indications for immediate urethral catheter placement in the setting of pediatric trauma include unstable pelvic fractures, known trauma to the urethra, or blood at the meatus.
The bladder is the 2d most common genitourinary (GU) injury in children, attributable to the proportionately larger aspect in children and lack of protection from the pubic symphysis due to incomplete lie within the pelvis from immature skeletal development.38,39 Bladder injuries tin by and large be categorized equally either intraperitoneal or extraperitoneal. Cystography or computed tomography (CT) are preferred to plain film, with CT imaging the modality of choice in evaluating a suspected float injury. Prompt surgical exploration is required for intraperitoneal ruptures to avoid intraperitoneal infection, peritonitis and expiry. Adequate urethral catheter drainage – by ensuring continuous drainage free of clots or debris – is typically sufficient for uncomplicated extraperitoneal rupture. Adequate drainage is ensured by appropriate size option, as previously mentioned, and gentle irrigation with normal saline as needed to guarantee patency.
Rarely, urethral catheter drainage is also used in conjunction with ureteral stenting for upper tract (ureter and/or renal) injuries to guarantee a depression-pressure arrangement with continued drainage in instances where urinary extravasation is noted from the proximal ureter or renal pelvis.39
Blood at the meatus in a presenting pediatric trauma patient warrants careful consideration. Current American Urological Association (AUA) guidelines on Urotrauma provide a stepwise approach for such a patient. Guideline statement 19 recommends clinicians should perform retrograde urethrography later pelvic or genital trauma resulting in claret beingness seen at the meatus. If partial disruption is noted with some dissimilarity passing to the bladder, then the guidelines emphasize that a single effort with a well-lubricated catheter may exist attempted by an experienced provider, in this instance, a urologist. If complete distraction is noted, suprapubic tube placement is warranted; additionally, in most cases of pelvic fracture associated with urethral injury (PFUI), suprapubic drainage is preferred.40,41
Catheter Preference in Female and Male Patients
Cather preference is less an issue when considering gender difference than ensuring strict sterile technique. Bated from an obvious abnormality (such equally hypospadias or stricture) the anatomy of a male infant is similar to that of an adult male, though smaller and lacking secondary sexual characteristics. A physiologic phimosis is oftentimes encountered during childhood, only the foreskin should non be forced to be retracted. Care should exist taken to avoid forceful catheter placement as the tissue of a male baby is much less resilient compared to an adult male.18
Again, the well-nigh important factor when it comes to Foley placement in male versus female patients, is technique. In females, exposure is of import and may require additional personnel to ensure contamination is minimized. This increased risk of infection in females results from their significantly shorter urethra (4 cm in adult female vs xx cm in developed male). Anatomic differences are reflected in the difference in size of male and female person catheters used in CIC (Effigy four).
Urinary catheters for intermittent catheterization, 12 Fr female catheter (acme) vs 12 Fr male person catheter (bottom) representing anatomic difference in overall urethral length (Magic3GO Hydrophilic catheters, BARD).
Two mutual scenarios in male pediatric urologic patients cause swell anxiety amongst guardians and providers unfamiliar with their presentation – uncorrected hypospadias and uncircumcised boys with physiologic phimosis. Anecdotally, the urethral opening and plate in uncorrected hypospadias often is able to accommodate normal, age-appropriate, catheterization in the absence of a concomitant urethral stricture, which is exceedingly rare in uncorrected hypospadias. In the setting of physiologic phimosis in the male infant, spatial awareness of the expected location of the meatus can often time let passage of the urethral catheter. Another, well-documented arroyo, is the application of steroid cream with gentle retraction to manual release whatever adhesions. If the acuity necessitates more immediate attending, dorsal slit may always exist performed. Knowledge of these common conditions, and how to address each, can greatly reduce many phone calls the pediatric provider experiences.
Office of Antibiotics and Catheter Materials
Antibiotic Prophylaxis – Is There a Role?
Much like the role of urethral stenting in hypospadias repair, there is substantial variation in exercise methods amidst pediatric urologists with regards to antibiotic prophylaxis with urinary catheterization and minor lower urinary tract procedures. Although guidelines exist, these are geared toward the adult urologic patient.
To accost this chasm, in 2017, Glaser and associates surveyed members of the Society for Pediatric Urology regarding antibody employ with catheterization. A significant bulk, 78%, prescribed daily prophylaxis with a hypospadias stent in place, merely disagreement abound thereafter. Interestingly, urologists over 50 years and fellowship-trained pediatric urologists were more likely to prescribe prophylaxis for hypospadias stents. All-encompassing variation existed with prophylaxis for Foley catheters, percutaneous nephrostomy tubes, suprapubic tubes and internal double–j ureteral stents, with 30–50% of respondents not prescribing prophylaxis for these drainage systems. Additionally, the majority of respondents do not routinely prescribe a dose of prophylaxis prior to tube removal aside from removal of a ureteral stent.42
The utilise of urine cultures and culture data differed widely, as well. The bulk do not routinely obtain urine culture prior to removal of a hypospadias stent (90%), Foley catheter (75%), nephrostomy tube (59%), suprapubic tube (69%) or ureteral stent (67%). A void for consensus regarding prophylaxis in the pediatric-patient exists with such wide variation in actual practice, coupled with the potential toll of handling and morbidity for urinary tract infection. This topic remains heavily debated, and researched.
In 2018 Canon and colleagues shed lite on this debate in their evaluation of the incidence of symptomatic urinary tract infection (UTI) following stented, distal hypospadias repair. Additionally, they evaluated the impact of prophylactic antibiotic therapy on UTI incidence. Urinalysis and/or urine cultures were obtained intraoperatively from 48 patients aged 0 to 5 years who did not receive preoperative antibiotic regimens. These patients were randomized to prophylaxis vs no prophylaxis groups in equal numbers. While the incidence of symptomatic UTI was low in this small-scale pilot report, information technology did not vary between groups and prophylactic antibiotic therapy did not appear to lower the incidence of symptomatic UTI.43
Catheter Coatings
Biofilm formation and encrustation are two dreaded natural progressions with repeated and chronic catheter utilise. Both tin develop despite advisable oral or intravenous antimicrobial therapy. With the increased morbidity associated, many have considered special catheter materials to reduce formation. Johnson and others sought to answer how coated catheters faired confronting traditional silicone or latex foleys. In a meta-analysis totaling over thirteen,000 patients, they plant there was low-quality evidence favoring nitrofurazone-impregnated catheters in patients catheterized for short durations, less than 1 calendar week. The benefit was observed in an overall decreased chance of bacteriuria without any increased run a risk of antimicrobial resistance.44
Other catheter coatings have too shown some modest do good. Silvery-coated catheters accept been heavily studied and low-quality evidence suggests a benefit over traditional latex catheters. Endpoints demonstrated a decreased chance of bacteriuria and no evidence of urethral irritation or antimicrobial resistance. Differences were pregnant only with silver alloy-coated catheters simply non silver oxide-coated catheters. Specifically, silver alloy-coated catheters reduced the risk of asymptomatic bacteriuria compared to standard latex catheters, but this significance was lost when compared to standard, all-silicone catheters.45
Traditional latex catheters have fallen out of favor due to concerns over latex allergy. Silicone is a ubiquitous catheter material at present and is preferred in patients with long-term catheterization due to decreased likelihood of catheter encrustation. For those patients prone to catheter blockage secondary to encrustation, silicone catheters should be utilized.
Catheter Dwell Time
But every bit significant consideration afforded to determining appropriateness of urinary catheter placement, equal consideration should exist given to urinary catheter dwell time. To assess the take chances of catheter dwell time, Letica-Kriegel et al studied a large retrospective cohort of 61,047 patients from six unlike hospitals to appraise how the run a risk for CAUTI changes over time. Their results demonstrated that each boosted day of catheterization increases the hazard of CAUTI, even when controlling for sex activity, age, and patient comorbidities. Additionally, they likewise identified female sex activity, pediatric age, and underlying neurologic problems as independent run a risk factors for CAUTIs.46 These findings confirmed the long-held do and drive amongst surgical teams to remove urinary catheters as before long equally possible (when safely and feasible). Information technology also served as a modern update to the classic finding that adult patients with urinary catheters develop bacteriuria at a rate of 8% per day during the offset week.47
Conclusion
In the larger context of perioperative management, urinary catheter selection in the pediatric is often an afterthought. In cases where urinary diversion is utilized, existing noesis regarding catheter selection often complicates the process. A pace-wise process should be employed and begins with determining the need for catheter placement in the first identify.
If warranted, either due to predictable operative time, immobility, or pelvic laparoscopic surgery, amidst other reasons, careful attention to technique must be emphasized. The correct size for the pediatric patient, based on height and weight, aids in proper catheterization. Silicone-based catheters predominate currently and should be utilized when available. Once placed, a push should be made to remove the catheter as presently as medically necessary, with a keen focus on antibiotic prophylaxis only if necessary, to maintain antimicrobial stewardship. In cases where postoperative urinary retention, or underlying disease states (such as neurogenic float) may predispose to re-catheterization, CIC should always be employed first until no longer feasible– due to trauma or patient condition. Taken together, these mental checkpoints tin can ensure catheter usage remains judicious to subtract the use of CAUTI and whatsoever subsequent sequelae in the pediatric surgical patient.
Disclosure
The authors reported no conflicts of interest for this work.
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What Is The Appropriate Size Of A Urinary Catheter Used For Infants?,
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