The number of in-out catheterisations is reduced by mobilising the postoperative patient with bladder needs to the toilet in the recovery room: A randomised clinical trial

Risk Factors for Postoperative Urinary Retention After Lumbar Fusion Surgery: Anesthetics and Surgical Approach

INTRODUCTION

Postoperative urinary retention (POUR) after lumbar fusion surgery can lead to longer hospital stays and thus increased risk of developing other postoperative complications. Therefore, we aimed to determine the relationship between POUR and (1) surgical approach and (2) anesthetic agents, including sugammadex and glycopyrrolate.

METHODS

After institutional review board approval, L4-S1 single-level lumbar fusion surgeries between 2018 and 2021 were identified. A 3:1 propensity match of patients with POUR to those without was conducted, controlling for patient age, sex, diabetes status, body mass index, smoking status, history of benign prostatic hyperplasia, and the number of levels decompressed. POUR was defined as documented straight catheterization yielding >400 mL. We compared patient demographic, surgical, anesthetic, and postoperative characteristics. A bivariant analysis and backward multivariable stepwise logistic regression analysis ( P -value < 0.200) were performed. Significance was set to P < 0.05.

RESULTS

Of the 899 patients identified, 51 met the criteria for POUR and were matched to 153 patients. No notable differences were observed between groups based on demographic or surgical characteristics. On bivariant analysis, patients who developed POUR were more likely to have been given succinylcholine (13.7% vs. 3.92%, P = 0.020) as an induction agent. The independent predictors of POUR identified by multivariable analysis included the use of succinylcholine {odds ratio (OR), 4.37 (confidence interval [CI], 1.26 to 16.46), P = 0.022} and reduced postoperative activity (OR, 0.99 [CI, 0.993 to 0.999], P = 0.049). Factors protective against POUR included using sugammadex as a reversal agent (OR, 0.38 [CI, 0.17 to 0.82], P = 0.017). The stepwise regression did not identify an anterior surgical approach as a notable predictor of POUR.

CONCLUSION

We demonstrate that sugammadex for anesthesia reversal was protective against POUR while succinylcholine and reduced postoperative activity were associated with the development of POUR. In addition, we found no difference between the anterior or posterior approach to spinal fusion in the development of POUR.

Micturition in the toilet compared with bedpan in laboring Nulliparas: a randomized controlled trial

Background

Bladder overdistension in labor may lead to prolonged postpartum urinary retention. We hypothesized that nulliparas mobilizing to toilet is more likely to achieve satisfactory micturition.

Methods

One hundred sixteen (58 in each arm) term nulliparas in labor with filled bladders were randomized to mobilizing to the toilet or using bedpan to micturate. Primary outcome was satisfactory micturition defined as ultrasound derived post-void bladder volume < 150 ml. Following unsatisfactory micturition, participants crossover to the opposed intervention. Participants were catheterized if after crossover, residual bladder volume was ≥250 ml.

Results

Satisfactory micturition rates were 55/58 (95%) vs. 43/58 (74%) RR 1.28 95%CI 1.08–1.51 NNTb 4.8 95%CI 3.0–12.4 P = 0.008, failure to micturate 1/58 (2%) vs. 8/58 (14%) RR 0.13 95%CI 0.02–0.97 NNTb 8.3 95%CI 4.6–38.7 P = 0.047. After cross over following unsatisfactory bladder voiding, satisfactory micturition rates were 0/3 (0%) vs 13/15 (87%) P = 0.024, bladder catheterization rates were 3/58 (5%) vs. 2/58 (4%) RR 95%CI 1.5 (0.26–8.65) P = 0.648, maternal satisfaction with allocated intervention 55/58 (95%) vs. 9/58 (16%) RR 95%CI 6.1 (3.3–11.2) NNTb 95%CI 1.3 (1.1–1.5) P <  0.0001 and preference for mobilizing to the toilet if micturition was needed again during labor 55/58 (95%) vs. 53/58 (92%) for mobilizing to the toilet compared to bedpan use arms respectively. Labor and neonatal outcomes were similar.

Conclusion

Satisfactory micturition was more frequently achieved with mobilization to the toilet than bedpan use. Women in both arms overwhelmingly prefer to mobilize to the toilet to urinate.

Trial registration

This study was registered with ISRCTN on 17/07/2019 with trial identification number: ISRCTN17787339. First participant was recruited on 31/07/2019. The last patient was recruited on 18/12/2019.

Risk factors for postoperative urinary retention following elective spine surgery: a meta-analysis

BACKGROUND CONTEXT

Limited studies have investigated risk factors for postoperative urinary retention (POUR) following elective spine surgery. Furthermore, some discrepancies have been found in the results of existing observational studies.

PURPOSE

This study aimed to review the available literature on risk factors associated with POUR following elective spine surgery.

STUDY DESIGN

A systematic review with meta-analysis was performed.

PATIENT SAMPLE

A total of 31,251 patients (POUR=2,858, no POUR=28,393) were included in the meta-analysis.

OUTCOME MEASURES

Demographics, type of elective spine surgery, country, definition of POUR, and potential risk factors for POUR were evaluated.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched to identify relevant studies. Binary outcomes were reported as odds ratio (OR). Weighted mean differences (WMD) or standardized mean differences (SMD), with 95% confidence intervals (CI), were used for meta-analysis of continuous outcomes.

RESULTS

Eleven studies (2 prospective and 9 retrospective) were included in the analysis. Patients with POUR were older than those without POUR (WMD, 7.13; 95% CI, 4.50-9.76). Male patients were found to have an increased risk of POUR (OR, 1.31; 95% CI, 1.04-1.64). The following variables were also identified as significant risk factors for POUR: benign prostatic hyperplasia (BPH; OR, 3.79; 95% CI, 1.89-7.62), diabetes mellitus (DM; OR, 1.50; 95% CI, 1.17-1.93), and previous urinary tract infection (UTI; OR, 1.70; 95% CI, 1.28-2.24). Moreover, longer operative time (WMD, 19.88; 95% CI, 5.01-34.75) and increased intraoperative fluid support (SMD, 0.37; 95% CI, 0.23-0.52) were observed in patients with POUR. In contrast, spine surgical procedures involving fewer levels (OR, 0.75; 95% CI, 0.65-0.86), and ambulation on the same day as surgery (OR, 0.65; 95% CI, 0.52-0.81) were associated with a decreased risk of POUR.

CONCLUSIONS

Based on our meta-analysis, older age, male gender, BPH, DM, and a history of UTI are risk factors for POUR following elective spine surgery. We also found that longer operative time and increased intravenous fluid support would increase the risk of POUR. Additionally, multi-level spine surgery may have a negative effect on postoperative voiding.

Medical and non-medical interventions for post-operative urinary retention prevention: network meta-analysis and risk-benefit analysis

Aims

To assess the efficacy in lowering post-operative urinary retention, urinary tract infection and lower urinary tract symptoms and the incidence of adverse events among 12 interventions and to perform risk-benefit analysis.

Methods

Previous randomized controlled trials were identified from MEDLINE, Scopus and CENTRAL database up to January 2020. The interventions of interest included early ambulation, fluid adjustment, neuromodulation, acupuncture, cholinergic drugs, benzodiazepine, antispasmodic agents, opioid antagonist agents, alpha-adrenergic antagonists, non-steroidal anti-inflammatory drugs (NSAIDs) and combination of any interventions. The comparators were placebo or standard care or any of these interventions. Network meta-analysis was performed. The probability of being the best intervention was estimated and ranked using rankogram and surface under the cumulative ranking curve. Risk-benefit analysis was done. Incremental risk-benefit ratio (IRBR) was calculated and risk-benefit acceptability curve was constructed.

Results

A total of 45 randomized controlled trials with 5387 patients was included in the study. Network meta-analysis showed that early ambulation, acupuncture, alpha-blockers and NSAIDs significantly reduced the post-operative urinary retention. Regarding urinary tract infection and lower urinary tract symptoms, no statistical significance was found among interventions. Regarding the side effects, only alpha-adrenergic antagonists significantly increased the adverse events compared with acupuncture and opioid antagonist agents from the indirect comparison. According to the cluster ranking plot, acupuncture and early ambulation were considered high efficacy with low adverse events, corresponding to the IRBR.

Conclusion

Early ambulation, acupuncture, opioid antagonist agents, alpha-adrenergic antagonists and NSAIDs significantly reduce the incidence of post-operative urinary retention with no difference in adverse events. Regarding the risk-benefit analysis of the medical treatment, alpha-adrenergic antagonists have the highest probability of net benefit at the acceptable threshold of side effect of 15%, followed by opioid antagonist agents, NSAIDs and cholinergic drugs.

Reduced Need for Urinary Bladder Catheterization in the Postanesthesia Care Unit After Implementation of an Evidence-based Protocol: A Prospective Cohort Comparison Study

Background

Postoperative urinary retention (POUR) is a known complication in the postanesthesia care unit (PACU). The variations in catheterization thresholds contribute to unnecessary invasive procedures.

Objective

In the current study, we implemented an algorithm for a sterile intermittent catheterization (SIC) threshold of 800 ml with volume-dependent bladder scan intervals and compared the incidence of SIC with that of a matched patient cohort threshold of 400 ml.

Design, setting, and participants

This comparative study of two prospective historical cohorts represented two thresholds for POUR, set at 400 ml without a standardized bladder scan protocol and 800 ml with a volume-dependent bladder scan protocol.

Outcome measurements and statistical analysis

The primary outcome was the frequency of catheterization during the PACU stay. Secondary outcomes evaluated patient safety aspects in occurrence of thresholds above 400/800 ml. The study was set at the PACU under the Department of Anesthesia, Center for Cancer and Organ Diseases, Rigshospitalet, Denmark.

Results and limitations

In total, 741 patients were consecutively included, with 307 in the POUR-400 and 434 in the POUR-800 group, and with comparable group characteristics. Significantly fewer patients fulfilled the SIC/catheter a’ demeure (CAD) criteria in the POUR-800 (5.0%) versus POUR-400 (14.3%) group, equivalent to a 65.0% relative reduction in SIC.

Conclusions

Implementation of a standardized ultrasound-guided protocol with volume-dependent scan intervals and an evidence-based catheterization threshold of 800 ml decreases the need for SIC by >65%, without increasing the need for urinary catheterization at the wards.

Patient summary

In this study, we implemented an algorithm for a sterile intermittent catheterization threshold of 800 ml with volume-dependent bladder scan intervals. A marked reduction was seen in catheterization in the postanesthesia care unit, without increasing catheterization rates at the ward.

Early removal or avoiding the use of perioperative indwelling urinary catheters with spontaneous pneumothorax surgery

OBJECTIVES

The study evaluated the safety and advantages of no using urinary catheters (UCs) during the perioperative period in patients undergoing spontaneous pneumothorax surgery.

METHODS

Forty-one patients aged 30 years or younger who underwent spontaneous pneumothorax surgery at our hospital between January 2018 and March 2020 were screened. Patients with postoperative recurrence were excluded. Patients were divided into three groups: the indwelling UC group (n = 10, group A), the group with UC removal in the operating room before extubation (n = 23, group B), and the no UC group (n = 8, group C). Perioperative circulatory complications, UC insertion or re-insertion, and time to getting out of bed after surgery and confirmation of initial urination were investigated by group.

RESULTS

There were no perioperative UC insertions or re-insertions, or perioperative circulatory problems in any group. The median time (interquartile range) required for confirmation of initial postoperative urination was shorter in groups B and C [group A: 13.5 (10.6, 17.3) vs group B: 6.0 (5.0, 6.8) vs group C: 5.5 (3.8, 6.8) h; p = 0.01]. However, the time to getting out of bed after surgery was not significantly different [10.5 (6.4, 15) vs 6.0 (5.0, 7) vs 5.0 (3.8, 8) h; p = 0.12)]. Multivariable analysis showed that group A had a significantly different time to confirmation of initial urination (p = 0.001).

CONCLUSIONS

Postoperative and intraoperative avoidance of indwelling UC use is acceptable in spontaneous pneumothorax surgery that satisfies certain conditions. Avoiding UC use has the potential to improve the patient experience and facilitate postoperative management.

Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study investigates postoperative urinary retention (POUR) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and the effects of postoperative analgesia and mobility on retention. High opioid use and decreased postoperative mobility are proposed risk factors for retention in adults. There is a paucity of literature on POUR in the adolescent population undergoing surgery for AIS. The impact of pain control and mobility on POUR in these patients is unknown.

METHODS

A retrospective cohort study was conducted of adolescents (11-18 years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8 h after catheter removal. Possible risk factors for retention including opioid usage and ambulatory status at the time of catheter removal were assessed on univariate and binomial logistic regression analyses.

RESULTS

One hundred and thirty-six patients were included, with 21 (15.4%) experiencing POUR. On the day of catheter removal, 24 patients had not attempted ambulation; these patients had 2.5 times higher rate of POUR than those who were walking (30% vs. 12%, p = 0.04). Patients who developed retention ambulated a mean threefold shorter distance than those without POUR (45 vs. 136 feet, p = 0.04). On binomial logistic regression, decreased ambulation distance was associated with retention (p = 0.038). While opioid use was not significant on univariate analysis, higher opioid use on the day of catheter removal predicted retention on logistic regression (p = 0.001). POUR resolved in all patients (median duration 0.5 days, range 0-12 days).

CONCLUSIONS

The development of POUR after PSF for AIS affects one in six patients but resolves quickly. Non-ambulatory patients and patients who received large doses of opioids on the day of catheter removal were more likely to develop POUR.

LEVEL OF EVIDENCE

III.

Systematic review of interventions for the prevention and treatment of postoperative urinary retention

Background

Postoperative urinary retention (PO‐UR) is an acute and painful inability to void after surgery that can lead to complications and delayed hospital discharge. Standard treatment with a urinary catheter is associated with a risk of infection and can be distressing, undignified and uncomfortable. This systematic review aimed to identify effective interventions for the prevention and treatment of PO‐UR that might be alternatives to urinary catheterization.

Methods

Electronic databases were searched from inception to September 2017. Randomized trials of interventions for the prevention or treatment of PO‐UR were eligible for inclusion. Studies were assessed for risk of bias using the Cochrane (2.0) tool. Two reviewers were involved at all review stages. Where possible, data were pooled using random‐effects meta‐analysis. The overall quality of the body of evidence was rated using the GRADE approach.

Results

Some 48 studies involving 5644 participants were included. Most interventions were pharmacological strategies to prevent PO‐UR. Based on GRADE, there was high‐certainty evidence to support replacing morphine in a regional anaesthetic regimen, using alpha‐blockers (number needed to treat to prevent one case of PO‐UR (NNT) 5, 95 per cent c.i. 5 to 7), the antispasmodic drug drotaverine (NNT 9, 7 to 30) and early postoperative mobilization (NNT 5, 4 to 8) for prevention, and employing hot packs or gauze soaked in warm water for treatment (NNT 2, 2 to 4). Very few studies reported on secondary outcomes of pain, incidence of urinary tract infection or duration of hospital stay.

Conclusion

Promising interventions exist for PO‐UR, but they need to be evaluated in randomized trials investigating comparative clinical and cost effectiveness, and acceptability to patients.

Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene

AIMS AND OBJECTIVES

To determine the effects of nursing interventions for people's nutrition, elimination, mobility and hygiene needs.

BACKGROUND

Patient experience of health care is sensitive to nursing quality. A refocus on fundamental nursing care is undermined by lack of evidence of effectiveness for interventions in core areas such as elimination, nutrition, mobility and hygiene.

DESIGN

Systematic review.

METHODS

We searched for and included experimental studies on interventions by professionally qualified and unregistered nurses that addressed participants' nutrition, elimination, mobility and hygiene needs. We extracted data on scope, quality and results of studies followed by descriptive narrative synthesis of included study outcomes using a novel form of harvest plots.

RESULTS

We included 149 studies, 35 nutrition, 56 elimination, 16 mobility, 39 hygiene and three addressing two or more areas simultaneously (67 randomised controlled trials, 32 non-randomised controlled trials and 50 uncontrolled trials). Studies into interventions on participant self-management of nutrition (n = 25), oral health (n = 26), catheter care (n = 23) and self-management of elimination (n = 21) were the most prevalent. Most studies focussed their outcomes on observational or physiological measures, with very few collecting patient-reported outcomes, such as quality of life, experience or self-reported symptoms. All but 13 studies were of low quality and at significant risk of bias. The majority of studies did not define primary outcomes, included multiple measures of identical concepts, used inappropriate analyses and did not conform to standard reporting quality criteria.

CONCLUSIONS

The current evidence for fundamental nursing care interventions is sparse, of poor quality and unfit to provide evidence-based guidance to practising nurses.

RELEVANCE TO CLINICAL PRACTICE

Researchers in nursing internationally should now undertake a programme of work to produce evidence for clinical practice in the fundamentals of care that is reliable, replicable and robust.