Addressing Common Indwelling Catheter Problems
Catheter Associated Urinary Tract Infection (CAUTI)
Patient safety has become the cornerstone of care and preventing healthcare- associated infections remains a priority.⁶⁰ NICE(2012). CAUTIs compromise patient safety and they account for 80% of hospital acquired infections.⁸² Pellowe C 2009 In community settings a prevalence rate of 8.5% was found in 3 Primary Care Trusts⁸³ Getliffe K & Newton T, 2006. It is no wonder that the DoH Quality, Innovation, Productivity & Prevention (QIPP) Safe Care Workstream includes 'Urinary Tract Infections in Patients with Catheters' as being part of a quality improvement programme to develop safer systems in hospital and community settings so that harmfree patient care is ensured.⁸⁴´⁸⁵⁺⁸⁶ DOH 2010; NHS INSTITUTE 2012 & NHS 2011-12
Since reducing CAUTI's is closely tied to Commissioning for Quality & Innovation (CQUIN) targets for local Trusts it is important that qualified healthcare professionals are educated on how to reduce the risk of CAUTI's, in order to promote safe care, enhance the quality of patient outcomes and reduce the costs of unnecessary and harmful urinary catheterisation procedures.
Distinguishing between asymptomatic bacturia and symptomatic bacturia is important given that bacteriuria is vitually inevitable in patients with long-term catheters in situ. Asymptomatic bacturia is described as 'a significant number of bacteria in the urine which manifests without the usual symptoms of urinary tract infection (UTI).' Symptomatic bacteriuria, on the other hand is described as, 'a significant number of bacteria in the urine when the symptoms of UTI are present.' ⁸⁷ Mangnall 2011
Although impossible to eradicate, a reduction in the number of CAUTI's can be achieved by adherence to the implementation of aspects discussed in the indwelling catheterisation sections pertaining to both urethral and suprapubic catheterisations, paying particular attention to selection of the appropriate catheter characteristics when making choices that suit the indication for catheterisation itself. As the insertion of an indwelling catheter must be undertaken using an aseptic procedure, the utilisation of an aseptic non-touch technique is essential.
Aseptic Non-Touch Technique (ANTT)
ANTT is defined as 'a unique and contemporary practice framework for aseptic technique. By demand, it has become the de facto standard aseptic technique in the UK National Health Service and it is now used widely internationally' ⁸⁸ ANTT 2012
The ANTT model for safe practice incorporates 3 elements ie
- a theoretical framework and process for clinical practice, of which, all staff should be educated
- a clinical guideline for indwelling urethral catheterisation that translates the foundation principles into practice
- and an implementation audit cycle.'⁸⁸ANTT 2012
Of significance, is the availability of a clinical good practice guideline for indwelling catheterisation depicted as a pictorial step-by-step instructional guide through the catheterisation procedure. Enquiries regarding this can be made contacting The Association of Safe Aseptic Practice at email@example.com⁸⁸ ANTT 2012
Catheter Encrustation, Blockage and CAUTI
Excluding the commonest causes of catheter blockage or failure of urine to drain in the first instance should be undertaken. According to Getliffe K (2002)⁸⁹ Getliffe 2002 these include:
- Drainage bag above the level of the bladder
- Drainage bag more than two-thirds full
- Twisted drainage tubing
- Constipation causing pressure on the urethra from a full bowel
- Bladder spasm
- Bladder mucosa sucked into the catheter eyelets and inhibiting drainage
- Sitting position in female patient
- Bladder calculi
- Catheter encrustation by mineral deposits'⁸⁹ Getliffe 2002
Catheter encrustation by mineral deposits is a main cause of recurrent catheter blockage which results from a build up of these precipitated from urine. Encrustation may occur on the outer surface tip of the catheter and balloon which are in contact with the urine or in the inner lumen of the catheter for the same reason. As a result, pain and trauma may occur when the catheter is removed and a distinct smell of ammonia from the urine may be detected due to its alkalinity.
Alkaline urine occurs when the urine and indwelling catheter become colonised with micro-organisms. Micro-organisms, such as Proteus mirabilis, and their products create a biofilm on the catheter which continues to grow over the mineral deposits cementing them firmly to the catheter. This makes them difficult, if not impossible, to remove. The biofilm serves to protect the micro-organisms from the host's natural defences as well as from antibiotics and antimicrobial agents.⁸⁰⁺ ⁸⁹ Wilson M & Getliffe 2002 It is important that the manufacturer's stipulated maximum duration that a catheter may remain in situ is not exceeded for these reasons as it appears that, to date, regardless of various specialised catheter materials used for long-term urethral and suprapubic catheterisation, all currently remain susceptible to biofilm formation. ⁸⁹Getliffe 2002
It is logical then to broadly classify patients as 'blockers' (ie patients who consistently and repeatedly develop extensive encrustation within a few days or weeks, resulting in shorter catheter life due diminished flow or leakage) or 'non blockers' (ie no encrustation formation even when the catheter is in situ for weeks to months).⁷² Careful recording when catheter blockage occurs along with monitoring of urinary pH using an indicator strip and observation of visible signs of encrustation, can result in pre-empting blockage by timely planning catheter changes to be undertaken on a more frequent basis. ⁸⁹ Getliffe 2002
Bladder Maintenance Solutions to Extend Catheter Life
However, it may be more appropriate in some cases to attempt to extend catheter life rather than avoid potential blockage. The use of appropriately prescribed acidic catheter maintenance solutions to dissolve mineral deposits and reduce the build up of encrustation may be instilled. However, their use remains controversial since it is considered that even weak acidic solutions may cause bladder endothelial damage without effectively removing catheter encrustation. Furthermore, the belief that bladder irrigation can lead to an increased shedding of urothelial cells, which play an important role in fighting infection in the bladder could cause additional problems.⁹⁰ Evans & Painter
Autonomic Dysreflexia and Catheter Blockage
Autonomic Dysreflexia (AD) is an over-activity of the autonomic nervous system causing an abrupt onset of excessively high blood pressure. ⁶² SARI
Healthcare professionals should be alert for the signs and symptoms of AD dysreflexia in patients with spinal cord injuries at or above the sixth thoracic vertebra. Apart from hypertension, a number of other symptoms may be experienced including a pounding headache, facial flushing, sweating, nasal congestion, blurred vision, slow pulse and anxiety. ⁶² SARI
Bladder problems are the main cause of AD and causes include catheter blockage resulting in bladder overdistention, kidney or bladder stones, high pressure voiding, UTI, kinked catheter tubing or an excessively over full catheter bag. Other causes include constipation, haemorrhoids or anal fissure, skin irritations eg. wounds, pressure sores, burns, and in-growing toenails, broken bones, pregnancy, appendicitis, and other medical complications.
AD can occur suddenly resulting in seizures or a stroke. It can be a life threatening condition. Deal with the situation immediately. ⁶² SARI
- Identify the source of the problem
- Reduce blood pressure by placing patient in a sitting position
- Check bladder- if catheterised, empty the drainage bag and ensure there are no kinks in tubing. Change catheter immediately if it appears blocked insert a lubricated anaesthetic gel to ease insertion and prevent further distress and trauma
- Perform intermittent catheterisation if this is the patient’s method of bladder management
- If infection is suspected commence antimicrobial treatment in line with local antimicrobial guidelines, after taking appropriate specimens for microbiological investigation (e.g. blood culture, CSU)
- Perform digital rectal examination to check for rectal over-distension and check for other potential causes
- Manage hypertension appropriately. Where blood pressure fails to return to normal or a cause cannot be found, Nifedipine 10mgs (or appropriate dose for children) sub-lingually is recommended
- Be aware that rebound hypotension may occur'⁷⁵ (Source: SARI 2011)
Urethral Trauma and CAUTI
Catheter associated urinary tract infections can occur as a consequence of trauma to the urethra during catheterisation as well as from the catheter itself.⁹¹ Kyle The use of a single lubricant prior to urethral catheterisation along with the use of the smallest possible catheter calibre to minimise the risks have been advocated by key national and international sources. ⁶⁰´⁶¹´⁶⁴´⁹²⁺⁹³ NICE 2011 CG139; EAUN 2012; Pratt et al 2007; Tenke; Mangnall 2012 However, the debate over which type of lubricant should be selected remains.
There are 4 types of lubricant available to preform the urethra:
- Water soluble lubricants
- Water soluble lubricants with chlorhexidine (antiseptic)
- Water soluble lubricants with anaesthetic lignocaine/lidocaine
- Water soluble lubricants with anaesthetic lignocaine/lidocaine and chlorhexidine' ⁶¹ EAUN
Given that current evidence suggests practitioners are attempting to achieve three patient-specific outcomes when using a lubricant, i.e.
- To reduce the risk of urethral damage
- To reduce the risk of procedure-related infection
- To minimise pain and discomfort during the procedure⁶⁰⁺⁶¹ NICE 2011 CG139; EAUN
It stands to reason that product selection should be based upon whether it meets the specific needs of both male and female patients in relation to these outcomes.⁹³ Mangnall 2012
Reduce the Risk of Urethral Damage
Damage to the urethra during catheterisation can be reduced with the application of an unbroken film of lubricant. An added benefit is that a water-based lubricant can to dilate the urethra making it more visible.⁹⁴⁺⁹⁵ Woodward S (2005); Devine A (2003)
Reducing the Risk of Procedure-Related Infection
Given that Chlorhexidine is a widely used antiseptic, a single-use lubricating gel containing this will minimise the risk of both trauma and infection. However, some patients may be sensitive to Chlorhexidine so asking them before considering usage is important, given that it may (although rarely) trigger anaphylaxis.⁹⁶Ebo If unknown, healthcare professionals should also be mindful of immediate problems such as acute urticaria which may lead to anaphylactic shock and even late-onset hypersensitivity and eczema.
Reducing Pain and Discomfort
Both males and females can find catheterisation to be a painful experience.⁶¹EAUN A lubricant containing the local anaesthetic property, Lidocaine, is effective in reducing pain and discomfort compared with water-based lubricant. It is effectively absorbed from mucous membranes and is a useful surface anaesthetic in concentrations up to 10%.⁹⁷Joint Formulary Committee However, lubrication containing Lidocaine or Chlorhexidine should not be used if the skin is inflamed, infected or damaged as increased absorption into the blood increases the risk of systemic side-effects. Additionally, the local anaesthetic effect may be reduced by altered pH levels.⁷⁸ Mangnall 2012 However, a single application of a topical lidocaine preparation does not generally cause systemic side-effects. ⁹⁷Joint Formulary Committee
Permission to use an antiseptic, anaesthetic lubricating gel should be sought from the Urologist (or other relevant medical doctor) if the patient suffers from severe conduction of the impulse system or epilepsy. Likewise, for women in the first trimester of pregnancy or who are breastfeeding. ⁶¹EAUN
The recommended amount of anaesthetic, antiseptic lubricating gel for instillation into the urethra is generally 10-15mls for males and 6mls for females ⁶¹EAUN. However, it is important that the recommended amount stipulated by the manufacturer should be adhered to.
According to the EAUN (2012), although a 3-5 minute gap has been recommended between instillation of the gel and commencing catheterisation, it is important to follow the manufacturer's guidance. By achieving a maximised anaesthetic effect helps the patient to relax making the insertion of the catheter easier. ⁶¹EAUN