Could the incidence of postoperative urinary tract infection be reduced by reversing the sequence of vaginal cleansing and urethral catheterization?

A large bladder hematoma resulting from infectious hemorrhagic cystitis after pelvic reconstruction with transvaginal mesh: An unusual complication

A large hematoma resulting from hemorrhagic cystitis after uncomplicated pelvic reconstruction surgery with a transvaginal mesh is rare. A 66-year-old female who underwent pelvic reconstruction with transvaginal mesh presented with acute urinary retention and hematuria on postoperative day 10. Leukocytosis, pyuria, and hematuria were noted in the emergency room. After using cystoscopy to irrigate the coagulum, there was no mesh erosion or bladder perforation on inspection. A large bladder hematoma resulting from infectious hemorrhagic cystitis was confirmed, and uropathogenic Escherichia coli was isolated. The clinical condition improved after a 1-week treatment with an indwelling Foley catheter and oral antibiotics. Careful aseptic techniques and antibiotic prophylaxis reduce bacterial contamination only for brief periods of time, and patients may still be at risk for delayed infections. The possible modalities to prevent postoperative urinary tract infection after pelvic reconstruction surgery with transvaginal mesh include shortening the indwelling Foley catheter period and administration of an additional antibiotic during catheter removal. However, the antibiotic policies for pelvic reconstruction with transvaginal mesh demand further cost analyses.

Identification of complications that have a significant effect on length of stay after spine surgery and predictive value of 90-day readmission rate

OBJECT

Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates.

METHODS

Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS.

RESULTS

The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n = 2), UTI (n = 2), and neurological deficit (n = 1). Complications affecting LOS were not found to be predictive of readmission (p = 0.029).

CONCLUSIONS

Postoperative complications in patients who have undergone spine surgery are not uncommon and are associated with prolonged hospital stays. In the current cohort, the occurrence of pulmonary complications, UTI, and new neurological deficit had the greatest effect on overall LOS. Further study is required to determine the causative factors affecting readmission. These specific complications may be high-yield targets for cost reduction and/or prevention efforts.

Integrative review: evidences on the practice of intermittent/indwelling urinary catheterization

OBJECTIVE

to seek the best evidence available in the literature concerning the knowledge produced and related to the techniques of intermittent and indwelling urinary catheterization, so as to place the nursing care given to patients submitted to urinary catheterization on a scientific foundation and to prevent urinary tract infections.

METHOD

the literature search was undertaken in the Pubmed and Cochrane databases for the development of the integrative review. The sample was of 34 articles. These were analyzed by two independent researchers using an instrument adapted for ascertaining the level of evidence and the grade of recommendation, in addition to the use of the Jadad scale.

RESULTS

the evidence available related to the nursing care for patients submitted to urinary catheterization is: the infection rate in the urinary tract does not alter whether the perineum is cleaned with sterile water or not, or with the use of povidone-iodine solution or chlorhexidine; or using clean or sterile technique. The use of an intermittent catheter with clean technique results in low rates of complications or infections compared to the use of an indwelling catheter. The removal of the catheter in up to 24 hours after surgery and the use of an antimicrobial-impregnated or hydrophilic-coated catheter reduce urinary tract infection .

CONCLUSIONS

there are controversies in relation to periurethral cleansing technique, the type of material the catheter is made of, and some procedures for the maintenance and removal of the catheter. This review's results represent an updating of the nurse's conducts and decision-making for the prevention of urinary tract infections in urinary catheterization.

Short term urinary catheter policies following urogenital surgery in adults

BACKGROUND

Urinary catheterisation (by the urethral or suprapubic routes) is common following urogenital surgery. There is no consensus on how to minimize complications and practice varies.

OBJECTIVES

To establish the optimal way to manage urinary catheters following urogenital surgery in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised trials register (searched 30 May 2005) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials were identified. Studies were excluded if they were not randomised or quasi-randomised trials of adults being catheterised following urogenital surgery.

DATA COLLECTION AND ANALYSIS

Data collection was performed independently by two of the review authors and cross-checked. Where data might have been collected but not reported, clarification was sought from the trialists.

MAIN RESULTS

Thirty nine randomised trials were identified for inclusion in the review. They were generally small and of poor or moderate quality reporting data on only few outcomes. Confidence intervals were all wide. USING A URINARY CATHETER VERSUS NOT USING ONE: The data from five trials were heterogeneous but tended to indicate a higher risk of (re)catheterisation if a catheter was not used postoperatively. The data gave only an imprecise estimate of any difference in urinary tract infection. URETHRAL CATHETERISATION VERSUS SUPRAPUBIC CATHETERISATION: In six trials, a greater number of people needed to be recatheterised if a urethral catheter rather than a suprapubic one was used following surgery (RR 3.66, 95% CI 1.41 to 9.49). SHORTER POSTOPERATIVE DURATION OF CATHETER USE VERSUS LONGER DURATION: In 11 trials, the seven trials with data suggested fewer urinary tract infections when a catheter was removed earlier (for example 1 versus 3 days, RR 0.50, 95% CI 0.29 to 0.87) with no pattern in respect of catheterisation. CLAMP AND RELEASE POLICIES BEFORE CATHETER REMOVAL VERSUS IMMEDIATE CATHETER REMOVAL: In a single small trial, the clamp-and-release group showed a significantly greater incidence of urinary tract infections (RR 4.00, 95% 1.55 to 10.29) and a delay in return to normal voiding (RR 2.50, 95% CI 1.16 to 5.39).

AUTHORS' CONCLUSIONS

Despite reviewing 39 eligible trials, few firm conclusions could be reached because of the multiple comparisons considered, the small size of individual trials, and their low quality. Whether or not to use a particular policy is usually a trade-off between the risks of morbidity (especially infection) and risks of recatheterisation.