Download Working as One for Optimal Perioperative Urinary Retention

Working as One for
Optimal Perioperative
Urinary Retention
Management for
Orthopedic Patients
Conflict of Interest
I hereby certify that, to the best of my
knowledge, no aspect of my current
personal or professional situation might
reasonably be expected to affect
significantly my views on the subject on
which I am presenting.
Helen Copenheaver, BSN, RN, ONC
Jenny Fowler, BSN, RN, ONC
Learner Outcome
As a result of this webinar, the learner
will implement quality-focused,
evidence-based changes in the care of
the Orthopaedic Surgery patient that
improve clinical outcomes, patient
satisfaction and shorten LOS.
WellSpan Surgery and
Rehabilitation Hospital
York, Pennsylvania
www.wellspan.org
•The WellSpan Surgery and Rehabilitation Hospital (WSRH) is a modern, patient-centered
facility for advanced orthopedic, spine, and neurosurgical treatment and inpatient
rehabilitation. Opening in April 2012, it is one of six hospitals within the integrated health
care delivery system of WellSpan Health in central Pennsylvania.
• The WSRH supports the journey to optimal independence by providing superior quality
care, delivered by a compassionate team, in a patient-centered, healing environment.
•WellSpan’s Mission: Working as one to improve health through exceptional care for all,
lifelong wellness and healthy communities.
1
Objectives
• Recognize effects of post-operative urinary
retention during the perioperative period
• Identify urinary health management
practices to reduce the adverse outcomes of
urinary retention in the surgical orthopaedic,
spinal anesthesia patient
Post-Operative Urinary Retention
(POUR)
• Definition of POUR may vary between medical
institutions or clinician preferences
• Most basic description of POUR is the inability
to void with an occurrence of a full bladder
after a surgical procedure
Urinary Retention
• Common after surgery
• Incidence in surgical cases can vary based on
the type of surgery, anesthesia, medications,
and patient demographics
• Any patient population may be effected
Anatomy and Physiology
• The bladder is funnel or balloon shaped
– Body: Detrusor muscle
– Neck: Urethra and sphincters
• A normal bladder responds to urge to void at
300cc, with ability to hold up to 400-500cc
2
Bladder Reflex
Bladder Filling
• Detrusor relaxes
•Sphincters contract
• Bladder begins to fill
Micturition
• Contraction of
detrusor muscle and
relaxation of pelvic
floor allows for
emptying
Bladder
and Spinal Cord
Communication
Bladder Over-Distension
• If lack of ability to completely empty occurs,
over-distension of the bladder may transpire
150cc
• Bladder wall tension
• First urge to void
around 150cc
300cc
• Tension receptors
notify spinal cord that
bladder is full around
300cc
Bladder Over-Distension
• One episode of bladder distension can cause
life-long impairment of the bladder
• Bladder levels at or exceeding greater than
500cc for periods longer than 1-3 hours placed
patients at most risk for genitourinary damage
– This may cause detrusor muscle damage, leading
to reduced ability to sense fullness and experience
proper bladder contraction
• Over-distension can occur at any time during
the perioperative period
Urinary Retention
in Orthopaedic Patients
• Orthopaedic patients are at increased risk for
urinary retention in the perioperative period
– National rates vary, with retention rates being
reported in up to 75% of lower-limb surgical
orthopaedic patients
– Reduced mobility, pain and preoperative opioid
use, and existing bladder dysfunction may
contribute to increased risk
3
Urinary Retention
and Spinal Anesthesia
Spinal Anesthesia Effects
• Spinal anesthesia is commonly utilized in lowerlimb orthopaedic surgery patients
• Patients may have decreased ability to sense a
full bladder, void, or empty completely, placing
them at increased risk for POUR
– Improves clinical outcomes while achieving
adequate sensory and motor blocks
– Spinal analgesia, such as bupivacaine, act on the
spinal cord neurons that also effect the control of
the bladder
• Unilateral spinal anesthesia has lower incidence of POUR
• The timing of spinal anesthesia wear-off may
vary between patients, but effects of spinal
injection on the bladder may last for hours
– Intrathecal opioids can enhance this sensory deficit
Abdominal
pain or
pressure
Polling
Question
Polling Question
What may contribute to an orthopaedic surgical patient
being at greater risk for POUR?
A. Opioid usage
B. Reduced mobility
C. Long holding times while hospitalized
D. All of the above
Life-long
issues
Anxiety or
embarrassment
Chills or
sweating
Confusion
Urinary
Retention:
Adverse
Patient Effects
Urinary tract
infections
Incontinence
Cardiac
dysrhythmias
Nausea and
vomiting
Hypertension
or
hypotension
4
Increased
Urine and Bone Connection
length-of-stay
Outpatient
follow-up or
consultation
• Orthopaedic surgical patients with UTIs are at
risk for the spread of bacteria from the urine
to the blood stream, increasing the risk for
bacterial infection around the prosthesis and
septic arthritis
Patients
discharged home
with foley
catheters
Prolonged
discharge time
Urinary
Retention:
Health System
Adverse Effects
Decreased
patient
satisfaction
Increased
nursing cost
related to time
Nosocomial
infections
Nonreimbursement
Polling Question
True or False
Autonomic presentations due to bladder overdistension can include cardiac dysrhythmias or
asystole.
Early Diagnosis and Intervention
• Orthopaedic surgical recovery times are
shortening, requiring prompt diagnosis of
urinary retention in the surgical period
– Early prevention and treatment of urinary
retention during the perioperative period is key to
preventing damages of over-distension, while also
increasing patient satisfaction and recovery rates
5
Perioperative Bladder
Management
A comprehensive
perioperative
bladder
management
protocol is
recommended
Preoperative
Intraoperative
General Perioperative
Recommendations
Recovery
Postoperative
Patient Education
• Patient involvement
– Encourage input regarding urinary history
– Educate on:
•
•
•
•
Purpose of bladder management protocol
Risks associated with urinary retention
Strategies to assist with optimal voiding
Prevention of urinary tract infections
– Education on signs and symptoms of infection
Identifying Retention
– Clinical assessment, such as palpation, does not
provide an accurate portrayal of bladder volume
• This can be especially true in spinal anesthesia cases
– A bladder scanner can be used throughout the
perioperative period to accurately monitor bladder
volumes and need for bladder decompression
6
Bladder Scanner
• Provides a reliable indicator of bladder volumes
– May slightly underestimate amounts +/- 50cc
– Quick and non-invasive
• Staff performing the bladder scan should be educated on
the device prior to use for optimal accuracy
Post-Void Residual (PVR)
• Measurement of urine in bladder after a
spontaneous void
– Useful in urodynamic assessment
• A normal PVR is considered <200cc
– Can be used throughout the perioperative period
• Usually via bladder scanner
• Helps identify distension levels in the bladder
– High PVRs are linked to increased UTI risk
– Justify need for catheterization intervention
Catheterization Guidelines
• Indwelling foley catheters are NOT
recommended for surgical orthopaedic, spinal
anesthesia patients
– Indwelling foley catheters ideal in surgical cases
lasting 3 hours or longer, or based on physician
preference for patients at high-risk for POUR
• If used, indwelling catheters recommended to be
removed within 24 hours of insertion to reduce
infection risk
Intermittent Catheterization
• Intermittent catheterizations are preferable
– Cost-effective benefits
– Less risk of UTI than an indwelling catheter
• Invasive procedure should be justified by identifying
patient bladder volumes
• No increase in risk for UTIs with recatheterization using
the intermittent method if employing aseptic technique
• Antibiotic prophylaxis also assists in UTI prevention
7
Identify Risk Factors
• Assess patients at high risk for POUR
Preoperative
Recommendations
International
Prostate Screening Score (I-PSS)
• Standardized questionnaire
– Validated by American Urological Association (AUA)
– Simple and effective way to recognize urinary
issues that may contribute to urinary retention
– Takes approximately 5 minutes to complete
individually or by oral proctor
– Age and gender may not accurately represent
POUR risk factors, although patients with
genitourinary histories, such as benign prostatic
hypertrophy (BPH) may be at greater risk
– Identifying at-risk patients allows for close
monitoring and possible preoperative
intervention, such as initiation of medication or
consultation preoperatively
Not at
all
Less
than 5
Less
than
half the
time
About
half the
time
More
than
half the
time
Almost
always
..had the feeling of not emptying your
bladder?
0
1
2
3
4
5
..had to urinate less than every two hours?
0
1
2
3
4
5
..found you stopped and started again
several times while urinating?
0
1
2
3
4
5
..found it difficult to postpone urination?
0
1
2
3
4
5
..had a weak urinary stream?
0
1
2
3
4
5
..had to strain to start urination?
0
1
2
3
4
5
..gotten up at night to urinate?
0
1
2
3
4
5
In the past month how often
have you..
Mild: Score 1-7
Moderate: Score 8-19
High: Score 20-35
http://www.urospec.com/uro/Forms/ipss.pdf
8
High-Risk Patients
• Awareness assists in prevention
– Additional monitoring
Preoperative Void
• Patients should void preoperatively
– Documentation of time of void and amount of void
• Allows for consistent monitoring of urine output
• Medication intervention
– Some high-risk patients may benefit
– Common class is alpha-blockers
– Assists in intervention needs in later operative stages
• Identify possible preoperative distension levels or
voiding problems
• Example: Tamsulosin
Pre-Op Post-Void Residuals
• High-risk patients for urinary retention can benefit
from preoperative post-void residuals (PVR) to
avoid a full bladder in the operative suite
– May require early intervention catheterization
• The earlier the intervention, the less likely for adverse effects
or subsequent bladder over-filling
• PVR pre-op greater than 200cc can place patient at risk
Polling Question
What class of medication may benefit the patient in
the perioperative treatment of urinary retention?
A. Mineralocorticoids
B. Alpha-blockers
C. Thioxanthenes
D. Antianginal agents
9
General
Intraoperative
Recommendations
• Indwelling catheters recommended for
surgeries that will last longer than 3 hours
– Indwelling catheters may also be recommended
by clinicians for very high-risk patients, or patients
with a known history of POUR complications
Bladder Scan
• Bladder scan at end-of-case
– Catheterize in the operating room for bladder levels
greater than 300cc at the end of surgical case
• >300cc at completion of case is a high POUR risk
• Operating room catheterization benefits:
Recovery
Recommendations
– Sterile environment decreases infection risk
– Focus on patient comfort and privacy
– Increases patient satisfaction levels
10
Bladder Scan
• Continue close bladder scan monitoring
– Straight catheterization for volumes greater than 400cc
– Patient satisfaction focus
• Focus on privacy and comfort due to close quarters
• Patient may be in pain or experiencing post-surgery effects
Post-Surgical
Recommendations
– Education and purpose of scanning and any need for intervention
Post-Surgical Interventions
•
•
•
•
•
•
•
•
•
•
Bedside commode
Privacy (if applicable)
Running water
Positioning
Early ambulation
Multi-modal pain management
Timed voiding for cognitively impaired individuals
Warm compresses to lower abdomen
Medication considerations
Urology consultation
Bladder Monitoring
• Monitor patient for urinary distension symptoms
– Lower abdominal pressure or bloating, incontinence,
nausea or vomiting, cardiac dysrhythmias
• Close bladder scan monitoring
– Scan on arrival and every 3 hours until patient voiding
– Continue documentation of bladder levels
11
Post-Surgical Catheterization
• For bladder scan levels >400cc
– Have patient attempt to void if applicable
• Provide safety, privacy, and comfort
• Initiate interventions to assist in void attempt if needed
– If unable to void or to attempt to void, straight
catheterization for >400cc levels
• >500cc requires a critical response
Catheterization Considerations
• Educate patient on bladder health
– Catheterized patients should be monitored for and
educated on signs and symptoms of infection
– Special considerations for orthopaedic patients
• Consider indwelling catheter with physician
after two straight catheterizations
– Urology consultation may also benefit patient
Post-Operative Patient Void
Polling Question
Question
Polling
• Post-void residuals should be obtained after a
patient void for at least two readings <200cc
How does using post-void residuals as a bladder management tool
in the postoperative period benefit the spinal anesthesia,
orthopaedic patient?
Post-Void Residual
<200cc
Post-Void Residual
200cc-399cc
• Stop PVR after two readings
<200cc
• Continue post-void residuals
and bladder scan monitoring
until two PVR levels <200cc
• Reassess as needed
A. PVRs identify volumes that may require intervention.
B. PVRs are an accurate record of intake versus output.
C. PVRs are not necessary as palpation is a reliable tool.
D. PVRs help diagnose urinary tract infections.
• Straight catheterization for PVR >400cc
12
Perioperative and Operative:
Spinal Bladder Management Algorithm
Working As One
Working as One
I-PSS Questionnaire
Mild: Score </=7
Moderate: Score 8-19
High-Risk: Score 20-35
Preoperative Suite:
Mild to Moderate Risk Patients
•Encouragement of patient to void
•Documentation of time of void
Preoperative Suite:
High-Risk Patients
•Encouragement of patient to void
•Post-void residual scan
•Consult with physician for PVR >200cc
Operating Room
•Indwelling foley catheter for
procedure >3 hours
•Bladder scan patient end of case
Bladder Scan >300cc
•Straight catheterization
in operating room
•Document intervention
Recovery:
Spinal Bladder Management Algorithm
Bladder Scan <300cc
•Document findings
•Continue to monitor
Communicate
interventions or
bladder volumes to
recovery room nurse
Post-Surgical:
Spinal Bladder Management Algorithm
Badder scan on admission to unit
Scan bladder before
leaving recovery
and as needed
No Spontaneous Void:
Bladder Scan
For scan <400cc
•Document scan amount
•Report scan volumes, times,
and IV intake volumes to nurse
receiving transfer
For scan =/> 400cc
•Straight catheterization
•Document amount
•Report urine, scan, and IV
intake volumes to nurse
receiving transfer
<100
Scan in
3 hours
Patient transferred to
post-surgical area
100-399
• 100-300
Scan in 3
hours
• 300-399
Scan in 1
hour
Spontaneous Void:
Post-Void Residual (PVR)
•Measure urine output
•PVR within 30 minutes of void
•Document all findings
>400
•Offer interventions
•Attempt to void
•Straight cath if no
void within 30
minutes of scan time
•Consult with
physician after second
straight cath
PVR
>400
For PVR 200-399
•Scan until
voiding
spontaneously
with PVR <200cc
for two readings
For PVR
<200cc
•Stop PVRs
after two
readings
<200cc
•Reassess PRN
13
Patient Experience
Early
engagement
Education
Early
intervention
Respect
Comfort
Thank you!
Questions?
Contact Information:
Helen Copenheaver, BSN, RN, ONC
717-812-6311
[email protected]
References
References
(1) Afazel, M. R., Jalali, E., Sadat, Z., & Mahmoodi, H. (2014). Comparing the effects of hot pack and lukewarmwater-soaked gauze on postoperative urinary retention: A randomized controlled clinical trial. Nursing and Midwifery
Studies, 3(4), 1-5.
(2) Balderi, T., & Carli, F. (2010). Urinary retention after total hip and knee arthroplasty. Minerva
Anestesiologica, 76(2), 120-130.
(3) Balderi, T., Mistraletti, G., D'Angelo, E., & Carli, F. (2011). Incidence of postoperative urinary retention
(POUR) after joint arthoplasty and management using ultrasound-guided bladder catheterization. Minerva
Anestesiologica, 77(11), 1050-1056.
(4) Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention: Anesthetic and
perioperative considerations. Anesthesiology, 110(5), 1139-1157. doi:10.1097/ALN.06013e31819f7aea
(5) Bjerregaard, L. S., Bogo, S., Raaschou, S., Troldborg, C., Hornum, U., Poulsen, A. M., . . . Kehlet, H. (2015).
Incidence of and risk factors for postoperative urinary retention in fast-track hip and knee arthroplasty. Acta
Orthopaedica, 86(1), 1-6. doi:10.3109/17453674.2014.972262
(6) Brouwer, T., Rosier, P. F., Moons, K. G., Zuithoff, N. P., van Roon, E. N., & Kalkman, C. J. (2015). Postoperative
bladder catheterization based on individual bladder capacity. Anesthesiology, 122(1), 46-54.
doi:10.1097/ALN.0000000000000507
(7) Feliciano, T., Montero, J., McCarthy, M., & Priester, M. (2008). A retrospective, descriptive, exploratory study
evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge.
Journal of PeriAnesthesia Nursing, 23(6), 394-400. doi:10.1016/j.jopan.2008.09.006
(8) Joelsson-Alm, E., Nyman, C. R., Lindholm, C., Ulfvarson, J., & Svensen, C. (2009). Perioperative bladder
distension: A prospective study. Scandinavian Journal of Urology and Nephrology, 43(1), 58-62.
doi:10.1080/0036559080229912
(9) Joelsson-Alm, E., Ulfvarson, J., Nyman, C. R., Divander, M.-B., & Svensen, C. (2012). Preoperative ultrasound
monitoring can reduce postoperative bladder distension: A randomized study. Scandinavian Journal of Urology and
Nephrology, 46, 84-90. doi:10.3109/00365599.20111.637959
(10) Johansson, R.-M., Malmvall, B.-E., Andersson-Gare, B., Larsson, B., Erlandsson, I., Sund-Levander, M., . . .
Christensson, L. (2012). Guidelines for preventing urinary retention and bladder damage during hospital care. Journal of
Clinical Nursing, 22, 347-355. doi:10.1111/j.1365-2702.2012.04229.x
(11) Karason, S., & Olafsson, T. A. (2013). Avoiding bladder catheterisation in total knee arthroplasty: Patient
selection criteria and low-dose spinal anesthesia. Act Anaesthesiologica Scandinavica, 57, 639-645.
doi:10.1111/aas.12089
(12) Kieffer, W., & Kane, T. (2012). Predicting postoperative urinary retention after lower limb arthroplasty.
Orthopaedic Sugery, 94, 356-358. doi:10.1308/003588412X131712215911691
(13) Lau, H., & Lam, B. (2004). Management of postoperative urinary retention: A randomized trial of in-out versus
overnight catheterization. ANZ Journal of Surgery, 74(8), 658-661. doi:10.1111/j.1445-1433.2004.03116.x
(14) Luger, T. J., Garoscio, I., Rehder, P., Oberladstatter, J., & Voelckel, W. (2008). Management of temporary urinary
retention after arthroscopic knee surgery in low-dose spinal anesthesia: development of a simple algorithm. Archives of
Orthopaedic and Trauma Surgery, 128(6), 607-612. doi:10.1007/s00402-007-0481
(15) Miller, A. G., McKenzie, J., Greenky, M., Shaw, E., Gandhi, K., Hozack, W. J., & Parvizi, J. (2013). Spinal
anesthesia: Should everyone receive a urinary catheter? The Journal of Bone and Joint Surgery, Incorporated, 95(16),
1498-1503. doi:10.2106/JBJS.K.01671
(16) Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th
ed.). Philadelphia: Lippincott Willians & Wilkins.
(17) Sarasin, S. M., Walton, M. J., Singh, H. P., & Clark, D. I. (2006). Can a urinary tract symptom score predict the
development of postoperative urinary retention in patients undergoing lower limb arthoplasty under spinal anaesthesia?
A prospective study. The Royal College of Surgeons of England, 88, 394-398. doi:10.1308/003588406X106531
(18) Shadle, B., Barbaro, C., Waxman, K., Connor, S., & Von Dollen, K. (2009). Predictors of postoperative urinary
retention. The American Surgeon, 75(10), 922-924.
(19) Sung, K. H., Lee, K. M., Chung, C. Y., Soon-Sun, K., lee, S. Y., Ban, Y. S., & Park, M. S. (2015). What are the risk
factors associated with urinary retention after orthopaedic surgery? BioMed Research International, 2015, 1-5.
doi:10.1155/2015/613216
14