Catheterization of the bladder in infants and children

Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation

Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.

Intraperitoneal Rupture of Urinary Bladder during Micturating Cystourethrography in a Child

Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some complications. Bladder rupture during MCUG is a very rare complication and only a handful of cases have been reported in world literature. We report the case of a 2.5-month-old boy who had intraperitoneal bladder rupture during an MCUG needing surgical repair. At operation, the child had a bladder tear at the dome of the bladder which was repaired successfully. The postoperative recovery was uneventful and the child is doing well in follow-up. Although individual management of bladder rupture may differ, a majority of infants need surgery for the same. Thorough vigil and attention to the technique are a must to prevent such incidents in children.

Urine Trouble: Reducing Midstream Clean Catch Urine Contamination Among Children 3-17 Years Old

BACKGROUND

Children, caregivers, and clinicians often prefer midstream clean catch technique to urethral catheterization for obtaining urine cultures. However, contamination is common, potentially resulting in unnecessary medical intervention and cost. With this resident-led initiative, we aimed to reduce pediatric midstream clean catch urine culture contamination over 6 months.

METHODS

A bundled intervention was implemented in the emergency department, inpatient units, and outpatient clinics at our institution. Baseline contamination rates were collected April 2016 to September 2017; the intervention was introduced October 2017 to March 2018 and evaluated April 2018 to September 2018. Sustainability was measured October 2018 to September 2020. Balancing measures included rates of repeat urine cultures, positive cultures, and contaminated cultures by urethral catheterization.

RESULTS

Rates of midstream clean catch urine culture contamination were 45.3% preintervention and 30.9% postintervention, a 14.7% (95% confidence interval: 8.0% to 21.5%) absolute decrease. Before and after intervention, girls and patients 16 to 17 years old had the highest rates of midstream clean catch contamination. Six months postintervention, the rate of repeat urine culture decreased from 4.9% to 0.9% with no change in positive culture results or contaminated cultures by urethral catheterization. Over the subsequent 2 years, the impact of the intervention decreased (rate of contamination over 30 months postintervention: 38.4%, a 7.3% [95% confidence interval: 2.9% to 11.6%] absolute decrease; rate of repeat urine culture: 3.2%).

CONCLUSIONS

An intervention to improve midstream clean catch urine culture collection was associated with a clinically meaningful decrease in contamination. Impact of the resident-led intervention decreased over time.

Urine Collection Methods in Children: Which is the Best?

Urinary tract infection is one of the most common bacterial infections in infants and young children. There are 5 collection methods commonly used to obtain a urine sample from an infant or small child: suprapubic aspiration, urethral catheterization, clean catch void, urine collection bag, and urine collection pad. Although invasive, suprapubic aspiration and urethral catheterization are less likely to cause contamination of the specimen. When deciding which method to use, providers must take into consideration the clinical presentation of a child as well as presenting and past medical history, while weighing benefits versus risks.

Adverse Events Following Diagnostic Urethral Catheterization in the Pediatric Emergency Department

OBJECTIVES

The purpose of this study was to assess adverse events associated with diagnostic urethral catheterization (UC) in young children and to determine their impact on the patient and their family.

METHODS

This was a prospective cohort study conducted in the emergency department of a tertiary-care pediatric hospital. All 3- to 24-month-old children with fever who had a diagnostic UC were eligible. Parents who consented to participate were contacted by phone within 7 to 10 days after the UC to answer a standardized questionnaire inquiring about complications. The primary outcome was the occurrence of an unfavourable event in the seven days following UC, defined as painful urination, genital pain, urinary retention, hematuria or secondary urinary tract infection. Secondary outcomes included the need for further medical care and the need for parents to miss school or work.

RESULTS

Of the 199 patients who completed the study, 41 (21%) reported a complication: painful urination in 19 (10%) children, genital pain in 16 (8%), urinary retention in 11 (6%), gross hematuria in 9 (5%), and secondary urinary tract infection in 1 (0.5%). Three (1%) parents reported the need for further medical care and three (1%) missed work. Two independent variables (male sex and age 12-23 months) were associated with a higher risk of adverse events.

CONCLUSIONS

Urethral catheterization is associated with adverse events in 21% of young children in the week following the procedure. Accordingly, this procedure should be used judiciously in children, considering its potential to cause unfavourable events.

Urinary bladder rupture during voiding cystourethrography

Voiding cystourethrography (VCUG) is a commonly performed diagnostic procedure for the evaluation of vesicoureteral reflux with urinary tract infection or congenital renal diseases in children. The procedure is relatively simple and cost-effective, and complications are very rare. The iatrogenic complication of VCUG range from discomfort, urinary tract infection to bacteremia, as well as bladder rupture. Bladder rupture is a rare complication of VCUG, and only a few cases were reported. Bladder rupture among healthy children during VCUG is an especially uncommon event. Bladder rupture associated with VCUG is usually more common in chronically unused bladders like chronic renal failure. Presented is a case of bladder rupture that occurred during a VCUG in a healthy 9-month-old infant, due to instilled action of dye by high pressure. This injury completely healed after 7 days of operation, and it was confirmed with a postoperative cystography. The patient's bladder volume, underlying disease, velocity of the contrast media instilled, catheter size, and styles of instillation are important factors to prevent bladder rupture during VCUG. Management of bladder rupture should be individualized, but the majority of infants are treated with the operation. In conclusion, bladder rupture is a rare complication, however, delicate attention is needed in order to prevent more dire situations.