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Encouraging Independence and Promoting Confidence Through Improved Bowel and Bladder management. 30 January 2012 Update Peristeen US About the presentation The following materials are presented for general information purposes only. They do not constitute medical advice and should not be a substitute for consultation with a trained medical professional. 30 January 2012 Update Peristeen US Disclosure: Amy Dannels-McClure RN, ND Amy Dannels-McClure is currently a Clinical Consultant for Coloplast Corporation. Amy has worked with patients with neurogenic bowel and bladders since graduating from University of Colorado Health Sciences Center in 2004 and continues her passion for this area of healthcare. DISCLOSURE Amy Dannels-McClure discloses that she is a full time employee of Coloplast Corp. 30 January 2012 Update Peristeen US Page 3 What will we cover in this presentation? The focus of the presentation is to give you tools to better understand bowel and bladder function and provide you with the latest in management options: BLADDER BOWEL • Bowel function-how exactly do we evacuate stool? • Bowel health-preventing constipation and bowel accidents • Bladder management options • Bowel management options- absorptive products, male external catheters, intermittent catheters, determining which product will help Diet, medications, digital removal, enemas, gaining independence and confidence in your bowels • Bladder function-how does the bladder work? • Bladder health and hygiene- preventing UTIs gain the most independence What’s new in the world of bladder management! 30 January 2012 Update Peristeen US Page 4 What’s new for bowel management! How does SB affect the bladder? Nerves below affected lesion do not work properly • Neurogenic bowel: disruption of intrinsic nervous system control • Neurogenic bladder: disruption of nervous system control on the bladder 30 January 2012 Update Peristeen US Page 5 Neurogenic Bladder-a disconnect between the brain and the bladder Failure to Store: Incontinence – Because of Bladder – Because of Outlet – Combined Bladder and Outlet Failure to Empty: Retention – Because of Bladder – Because of Outlet – Combined Bladder and Outlet • • • • • 30 January 2012 Update Peristeen US Can lead to: High pressure bladder Secondary vesicoureteral reflux Hydronephrosis Renal Failure Bladder Health: Preventing urinary tract infections • Use proper hand washing techniques-clean your hands to help prevent germs from entering the bladder when you cath. • Discard the catheter after each use- single use catheters are accessible to most now. • Regularly empty your bladder- • Drink adequate fluids-you want to keep the urine clear and the bladder flushed. • Use good hygiene when cleaning area-wipe from front to back. 30 January 2012 Update Peristeen US Page 7 empty the number of times prescribed by your provider in order keep the volume of fluid in your bladder low. The Centers for Medicare and Medicaid Services expanded catheters allowed per month for single use on April 1, 2008 Many other insurers have expanded policies • CMS issued a change in policy for Medicare, following initiatives already initiated for Medicaid and the VA system • Increased allowable number of catheters per month to follow catheter labels for single use • Medicare now allows a new catheter for each time you catheterize, up to 200/month; other insurance may have different numbers they allow per month, but most have expanded coverage • You may need to get a new prescription from your doctor for insurance to cover single use • Hydrophilic and uncoated catheters were both included and covered the same 30 January 2012 Update Peristeen US Page 8 Selecting a bladder management option best for the patient GOAL: Protect the kidneys! Option based on patient condition and individualized needs Behavioral Management Catheterization • Prompted toileting • Indwelling (Foley) catheters • Biofeedback • Supra pubic catheters • Devices (bedpans, urinals) • Intermittent catheters Containment • Absorbent products (underpads, briefs) • Male external catheters Pharma/ Surgical Options • Medications • Mitrofanoff procedure • Bladder augmentation • Bladder neck procedures • Urinary diversion 30 January 2012 Update Peristeen US INTERMITTENT CATHETERS IN 30 January 2012 Update Peristeen US Page 10 OUT Intermittent Catheters: Alternative to indwelling catheter for long term management A catheter is inserted into the bladder through the urethra or Mitofanoff channel After the bladder is emptied, the catheter is removed and discarded. Regular bladder emptying prevents the bladder from overfilling and losing muscle tone. avoids urinary retention avoids overflow incontinence. preserves kidney function Regular bladder emptying eliminates residual urine ♦ decreases bacterial growth ♦ avoids urinary leakage between episodes 30 January 2012 Update Peristeen US Regular emptying? Which catheter will encourage this practice best? Child Adolescence Adult Your needs may change over time Speak with your healthcare provider if you experience any the following or want to know about new products: Problems Possible Experiences Possible Solutions Dexterity Difficulty handling the catheter or opening the packaging An easier to handle package or a catheter that is pre-lubricated (hydrophilic) to encourage independence and successful transition to self cathing. Sensation Catheterization uncomfortable or painful Hydrophilic catheter (pre-lubricated) Mobility Challenges transferring to a toilet vs. cathing in a wheelchair or while outside the home Closed system / set (catheter w/bag) extension tubing Insertion More difficulty passing the catheter Hydrophilic catheter (pre-lubricated) or a Coudé tip catheter Infection Experiencing more frequent UTI’s Closed system / set (catheter w/bag) Coverage or other insurance issues Dealers are experts in insurance billing. Manufacturers of catheters know which suppliers carry their catheters. Insurance 30 January 2012 Update Peristeen US Page 12 Why were hydrophilic catheters developed? Hydrophilic coated catheters developed to: Minimize risk of complications • Reduce friction on insertion and withdrawal • Minimize risk of urethral trauma • Prevent catheter sticking to urethral mucosa • Easier to do catheterization • Improve compliance Offer comfort and security • Allow for ease of use • Promote quality of life Stensballe, et al, 2005 and Chartier-Kastler et. Al, 2011 30 January 2012 Update Peristeen US Page 13 Convenience very important to consider Convenience and ease-of-use includes many characteristics • Packaging easy to open • Quiet to open and use • Catheter easy to hold • Catheter easy to insert • Less friction—in and out • Fewer steps to catheterize • Portability of catheters • Don’t have to wash catheters 30 January 2012 Update Peristeen US Page 14 “Catheters that are more convenient and easy to use may result in better long-term compliance.” Chartier-Kastler E and Denys P, Neurourol and Urodyn 2011; 30:21-31 Patient Considerations Benefits of Intermittent Catheterization for bladder management include: • Continence • No need for a urine collection (drainage) bag • The need for absorbent products is minimized • Less moisture associated skin care issues • Promotes control, confidence and self esteem 30 January 2012 Update Peristeen US Page 15 Be your own best advocate Do you take my insurance/ Medicare/Medicaid plan? Are there other/new catheter options that might work better for me? 30 January 2012 Update Peristeen US Page 16 Do you accept assignment for my preferred brand of catheter? How does SB affect the bowel? Nerves below affected lesion do not work properly • Neurogenic bowel: disruption of intrinsic nervous system control 30 January 2012 Update Peristeen US Page 17 When the bowel and brain disconnect • Rectum and Sigmoid colon contract to push feces into anal canal • Full anal canal causes internal sphincter to relax • Voluntary external sphincter is relaxed AND pelvic floor relaxes 30 January 2012 Update Peristeen US Neurogenic Bowel Disruption of normal intrinsic nervous systemloss of control of bowel emptying: Increased colonic transit time • Constipation Relaxation of anal sphincter • Fecal Incontinence 30 January 2012 Update Peristeen US Page 19 Patients with neurogenic bowel have limited or no anal sphincter control Intact control 30 January 2012 Update Peristeen US Page 20 No/limited control Bowels…MAJOR impact on Quality of life! 66% of children over age 6 with fecal incontinence report major influence on social activities Pediatric patients with neurogenic bowel dysfunction have lower quality of life expression • emotional, physical, psychological distress • school absences • social discrimination • low self-esteem 30 January 2012 Update Peristeen US Page 21 When do we start bowel program? Medical deicisions: KUB to assess fullness of stool in the colon, stool diary to develop pattern, history of bowel management treatments. • Are they struggling with frequent UTIs? • Is skin breakdown an issue from either continence products or accidents? • Are they having GI complaints (such as abdominal pain, anorexia or poor weight gain)? Usually a social concern rather than medical • Each child will have a different tolerance to when they want to begin a program • Child should lead the initiative for intervention 30 January 2012 Update Peristeen US Page 22 Factors to be considered when selecting a bowel regime Development • Has child met other developmental milestones appropriately? • Has a toileting process been taught by the family? • Is the child continent of urine? • Any confounding learning disabilities? 30 January 2012 Update Peristeen US Page 23 Psychosocial • Self-esteem • What is child’s peer support group like? Bullies? • Are peers/school aware of medical needs? • Are their extracurricular events and social activities that a child isn’t doing because of bowel concerns? • Are peers detecting odor from diapers or fecal incontinence? Management options 30 January 2012 Update Peristeen US Page 24 Conservative Measures (After a good clean-out!) • Diet (fiber) and water intake • Toileting 2-3 times per day after meals • Proper positioning • Supported feet • Biofeedback • Inconclusive success but creates an awareness of defecation process • If child has strength of external sphincter this may increase • Digital stimulation is an inexpensive way of eliciting rectal emptying but works only if the reflex arc is intact. 30 January 2012 Update Peristeen US Page 25 Transanal Irrigations • Cone Enema and Peristeen® Enema systems • More of the colon is washed out • Decreases fecal incontinence episodes over use of conservative measures alone • Less invasive than surgical intervention • Often used in conjunction with laxative/ softeners to keep good stool consistency 30 January 2012 Update Peristeen US Peristeen vs. traditional large volume enemas Peristeen Anal Irrigation System Large volume Enema1 Class II Class I Yes No Device used to hold water in rectum Catheter with built in retention balloon designed for the rectal vault Cone shaped device (indicated for stoma irrigation) or catheter without rectal retention balloon Documented level of colon cleansed Complete descending colon, sigmoid and rectum2 Rectum & sigmoid colon Expected outcomes Free of feces/flatus for up to 2 days2 Rectum will be free of feces/flatus-stool may be still present and expelled at any time Method of delivery Manual control pump-encourages independence and allows for control of the flow of water Lubricate required No- catheter has a hydrophilic coating yes Dwell time of fluid in colon None Most recommendations state 1030 minutes or as long as one can retain the fluid Volume of fluid to instill 1-1000mL customized per patient 500-1000mL Position of user during procedure Sitting on toilet Preferrably on their side FDA classification Prescription required 1 Christensen Gravity only P, et al. Scientigraphic Assessment of retrograde Colonic Washout in 30 January 2012 Fecal Incontinenece Update Peristeen US and Constipation. Diseases of the Colon & Rectum 2003: 46: 2 Foundations 27 68-76.Page of Nursing Third Edition, Lois White RN, PhD delmar Cengage Learning 2011, Nursing Procedures Chapter 29; procedure 29-29: pages 762-766. Peristeen® System 30 January 2012 Update Peristeen US Page 28 How....... does Peristeen work? • Peristeen assists the evacuation of feces from the bowel by introducing water into the rectum via a catheter (with retention balloon) inserted in the rectum. Other characteristics: • Only requires tap water • May be used daily or every other day • May be used by people with limited manual dexterity • Self-administered or with assistance from a caregiver 30 January 2012 Update Peristeen US Page 29 Transanal irrigation difference Works to empty contents of rectum, sigmoid and descending colon Feces present in descending colon and rectum before TAI Descending colon and rectum empty Christensen P, et al. Dis Colon Rectum. 2003 Jan;46(1):68-76. Scientific assessment of retrograde colonic washout in fecal after TAI Incontinence & constipation. K.Krogh, N.Olsen et al Colorectal transport in normal defaecation Colorectal desease 2003 5, 185 - 192 30 January 2012 Update Peristeen US First patient’s feedback US.... The best part is we are able to skip some nights which is a huge help on those busy weekends! “We started a bowel management routine with Brianna when she was 2 ½ years old. The main reason why we started was to reduce urinary tract infections. Before the bowel management routine, we were using Miralax and Brianna always had something in her diaper. We thought it was the cause of the UTI’s. We started with the cone enema. It was working; however, we had to do the enema nightly and it took about an hour and a half to administer and sit on the toilet. In December 2012, we went to Cincinnati Children’s to fine tune the cone enema. They had us try a balloon enema. This balloon enema did not work because the balloon would not stay during the transfer from the floor to the toilet. We had a mess all over! This routine also took about an hour and a half to perform. In April 2013, we started using the Peristeen product for bowel management. I am able to perform this on the toilet. The best part is we are able to skip some nights which is a huge help on those busy weekends! We are even thinking about going camping for a weekend! With the other products, Brianna would need to be near a toilet every day. The other benefit is the whole routine takes less time. We are able to complete it in about an hour. I have noticed that I am able to clean her out better more often. Before I would have a successful clean out about 70% of the time. With the Peristeen, we have a successful cleanout about 95% of the time. This product has eliminated accidents.” Thanks Angela 30 January 2012 Update Peristeen US Page 31 Where do we go from here… University of Iowa Children’s Hospital and Clinics Iowa City, Iowa • Kris Bonnett NP Josh Petersen NP • Dr. Eyed M. Hanna Division of Gastroenterology • Dr. Chris Cooper Dr. Doug Storm Omaha Children’s Hospital Omaha, Neb (Peds only and current pt) • Jill Bell NP Dr. Steven Raynor • Kristin Madden NP Megan Enebach NP Genesis Rehab Hospital Davenport, Iowa (Adults only) • Shani Marland RN • Dr. Conway Chin Madonna Rehab Hospital Lincoln, Nebraska (Peds and Adults) • Dr. Krabbenhoft • Dr. Kafka 30 January 2012 Update Peristeen US Page 32 THANK YOU!! Questions? How much Longer!? 30 January 2012 Update Peristeen US