Early versus delayed removal of indwelling urinary catheter after elective cesarean delivery: systematic review and meta-analysis of randomized controlled trials

Development and psychometric evaluation of the catheter assessment, management and performance (CAMP) scale for nurses

AIM

To develop and test the psychometric properties of a self-administered scale to assess the knowledge, skills, attitudes and behaviour of nurses to support the self-management of patients living with indwelling urinary catheters.

BACKGROUND

Nurses are pivotal in supporting patients with urinary catheter self-management to prevent potentially avoidable hospital presentations. However, no validated scale is available to assess nurses' attitudes and readiness for this task.

DESIGN

A quasi-experimental design was used to collect survey data both at baseline and after the completion of the intervention. A total of 128 participants were recruited from the Western Sydney region (New South Wales, Australia), who were working in community healthcare settings. Research Electronic Data Capture (REDCap™) database was used to manage the survey data collected for data analysis purposes. This study has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN126210 0 0683831) METHODS: Using a three-stage process of concept identification, item construction and pilot testing to develop the Catheter Assessment, Management and Performance (CAMP) scale, followed by factorial and discriminant validity and reliability testing. This 23-item CAMP scale is theoretically informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model, recognised for its effectiveness in understanding and influencing behaviour change. The scale was distributed to nurses working in three community health care settings to assess their knowledge, attitude and behaviour regarding catheter management and performance.

RESULTS

Four factors were identified using scree plot, accounting for 63.36 % of total explained variance, which reflected the four dimensions of the COM-B model. Cronbach's alpha of the overall CAMP scale (0.93) and subscales (0.92, 0.87, 0.85 and 0.86) indicate good internal consistencies. The CAMP scale was able to detect changes in nurses' self-reported behaviour change following educational intervention (85.53 versus 95.98, p < 0.001).

CONCLUSION

The CAMP scale is valid and reliable scale, capable of assessing nurses' capability, opportunity and motivation to support patients, through delivery of catheter self-management education that can potentially prevent catheter-related complications and avoid hospital presentations. Future research could explore using CAMP scale among non-specialist nurses and in various clinical settings to enhance its effectiveness and generalisability.

The awareness of enhanced recovery after surgery (ERAS) cesarean delivery guidelines among anesthesiology and reanimation assistants in Turkey; a questionnaire study

BACKGROUND

To reduce maternal-fetal morbidity and mortality, it is becoming increasingly important for anesthetists to understand and implement enhanced recovery after surgery (ERAS) cesarean delivery guidelines. Our aim was to reveal the knowledge of anesthesia assistants in Turkey about ERAS during cesarean delivery and to increase their awareness of ERAS.

METHODS

This descriptive study was conducted in the city of Isparta, Turkey in 2023. The survey, which was approved by the ethics committee, was distributed to participants across Turkey via e-mail and online messages. The survey comprises of a total of 42 questions evaluating perioperative ERAS recommendations.

RESULTS

Of the 404 participants in our survey, 59.9% were associated with university hospitals and 65.8% had completed three or more years of education. A total of 87.9% of the participants were familiar with ERAS; however, only 42.8% had received ERAS training. Although 93.8% of the participants' institutions performed a cesarean delivery, ERAS recommendations were only implemented at a rate of 48%. This may be due to the absence of an ERAS team, which was identified in our survey at a high rate of 66.6%.

CONCLUSION

Awareness about ERAS was high among the participants, but the implementation rates of some recommendations were low. The reason for this may be the inability to form a multidisciplinary team and inadequate training of participants. For this purpose, we recommend the formation of a multidisciplinary team for ERAS protocol implementation and increased participant training opportunities.

Timing of Catheter Removal and Effect on Urinary Retention After Cesarean Birth

OBJECTIVE

To determine the association between timing of indwelling catheter removal and urinary retention after cesarean.

DESIGN

Retrospective cohort study.

SETTING

Eight hospitals in suburban, rural, and urban Colorado and Montana.

PARTICIPANTS

Women who gave birth by cesarean from January 1, 2021, to April 30, 2022 (N = 3,493).

METHODS

We categorized participants who gave birth between January 1, 2021, and June 30, 2021, (before implementation of the Enhanced Recovery After Surgery initiative) into Group A and participants who gave birth between July 1, 2021, and April 30, 2022, (after implementation of the Enhanced Recovery After Surgery initiative) into Group B. We used descriptive statistics to report the proportion of participants in both groups who experienced urinary retention after birth. We performed chi-square tests to determine the association between the time of catheter removal and incidence of urinary retention. We used the Wilcoxon rank sum test to determine the association between length of stay and urinary retention.

RESULTS

Urinary retention rates were 5.8% in Group A and 12.6% in Group B (p < .001). In both groups, participants who received epidural anesthesia experienced significantly more urinary retention than those who received spinal anesthesia (p < .001). Participants who received epidural anesthesia and experienced urinary retention pushed 16.9% longer than those without urinary retention (p < .001). The proportion of participants who experienced urinary retention after catheter removal was 19.4% at 7 hours, 4.6% at 16 hours, and 9.9% at 12 hours after birth. Length of stay was determined to be inconclusive.

CONCLUSION

We determined that the optimal time of catheter removal to minimize the rate of urinary retention was 12 to 16 hours after cesarean among women who received morphine sulfate as the anesthesia.

Timing of Urinary Catheter Removal After Urethroplasty: A Systematic Review

OBJECTIVE

To synthesize existing evidence to evaluate the outcomes of different urinary catheter removal timing (early vs late) after urethroplasty.

METHODS

We performed a comprehensive search of PubMed, Embase, the Cochrane Library, and Web of Science from inception to August 7, 2022. Articles were initially screened by title, abstract, and subsequently by a full paper review before being included in the final analysis. All comparative studies that assessed the association between urethral catheterization duration and frequency of extravasation and recurrence rate in patients who underwent urethroplasty were included in the analysis. Exclusion criteria were case reports, case series, letters to editors, and non-English studies. The risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of the 439 relevant records in the literature databases, 5 studies involving 634 patients were included. In all 5 studies, the extravasation rate was not significantly different between the early and late catheter removal groups. Among the 3 studies that reported recurrence rates, the recurrence rate was low, with no statistically significant difference between the early and late catheter removal groups. Wound and urinary tract infections were among the most common complications, with a higher rate in patients with late catheter removal.

CONCLUSION

Early catheter removal following urethroplasty does not increase the rate of extravasation or recurrence during long-term follow-up. The existing evidence can serve as the foundation for additional research with a larger sample size.

Enhanced Recovery after Cesarean Section (ERAC): Where are We in Austria?

OBJECTIVE

Enhanced recovery after surgery (ERAS) recommendations for cesarean section (ERAC), likely the most common reason for laparotomy in women, were issued in 2018-19. We examined how current perioperative management at cesarean section in Austrian hospitals aligns with ERAS recommendations.

STUDY DESIGN

We surveyed the 21 largest public obstetric units in Austria for alignment with 20 of the 31 strong ERAS recommendations regarding perioperative maternal care at cesarean section. We also looked at how the German-language clinical guideline for cesarean section (AWMF Guideline Sectio caesarea) aligns with ERAS recommendations.

RESULTS

The 21 obstetric units cared for about 51% of all births in Austria in 2019. Cesarean section rates ranged from 17.7% to 50.4%. All 21 units implemented the five strong recommendations regarding patient information and counselling, regional anesthesia, euvolemia and multimodal analgesia. The least implemented strong recommendation was the one for the use of pneumatic compression stockings to prevent thromboembolic disease (0/21 units). Overall, all 21 units implemented ≥11 and 13 (62%) implemented ≥15 (≥75%) of the 20 strong recommendations; no unit implemented all 20 strong recommendations. There were no differences in the implementation of strong recommendations according to hospital volume.

CONCLUSIONS

Even in the absence of formal adoption of ERAS program for cesarean section many perioperative ERAS recommendations are already implemented in Austria. The least implemented recommendations were the use of pneumatic compression stockings (0 of 21 units) and immediate catheter removal (4 of 21 units). Only 10 of the 20 ERAS recommendations we looked at are included in the current German-language clinical guideline for cesarean section.

CATHETER-ASSOCIATED URINARY TRACT INFECTIONS AFTER CAESAREAN SECTION IN UKRAINE: RESULTS A MULTICENTER STUDY (2020-2022)

OBJECTIVE

The aim: To obtain the first national estimates of the current prevalence rate of catheter-associated urinary tract infections (CAUTIs) after caesarean section (CSEC) and antimicrobial resistance of causing pathogens in Ukraine.

PATIENTS AND METHODS

Materials and methods: Prospective multicentre surveillance was conducted from January 2020 to December 2022 in 15 women hospitals of Ukraine. Definitions of CAUTIs were adapted from the CDC/NHSN. Antibiotic susceptibility was done by the disc diffusion test as recommended by European Committee on Antimicrobial Susceptibility Testing guidelines.

RESULTS

Results: A total of 15,892 catheterized women undergoing primary CSEC and 13.6% CAUTI were identified. The most common uropathogen was Escherichia coli, Proteus mirabilis, and Enterococcus species followed by Providencia stuartii and Pseudomonas aeruginosa. Many uropathogens isolated from CAUTI cases were found to be multidrug resistant.

CONCLUSION

Conclusions: This study showed that CAUTIs in catheterized women undergoing primary CSEC in Ukraine is a common occurrence and many cases are caused by pathogens that are resistant to antibiotics. Optimizing the management and empirical antimicrobial therapy may reduce the burden of CAUTIs in catheterized women undergoing primary CSEC, but prevention is the key element.

Effect of urinary catheter removal at different times after caesarean section: A systematic review and network meta-analysis

OBJECTIVE

To assess the optimal time for removal of a urinary catheter (UC) following caesarean section (CS).

METHODS

Several electronic databases were searched from inception to 31 December 2021 regarding the timing of UC removal following CS. The effect of UC removal at different times following CS was calculated using odds ratio (OR) or standardized mean difference and 95% confidence interval (CI). The surface under the cumulative ranking curve (SUCRA) was used to determine the best time for UC removal. All analyses were performed using Stata Version 14.0.

RESULTS

In total, 19 studies including 3086 women were included in this review. Compared with UC removal 0-6 h after CS, UC removal 6.1-12 h, 12.1-24 h and > 24 h after CS were more likely to result in urinary tract infection (UTI), with pooled OR of 5.95 (95 % CI 1.58-22.38), 11.26 (95 % CI 2.99-42.44) and 27.25 (95 % CI 6.82-108.90), respectively. UC removal > 24 h after CS was more favourable to prevent urinary retention than immediate UC removal (OR 0.05, 95 % CI 0.00-0.64). UC removal 0-6 h after CS was the optimal timing to prevent UTI and frequent urination, and reduce length of hospital stay as well as time to first ambulation, with maximum SUCRA values of 92.30 %, 85.00 %, 80.60 % and 72.60 %, respectively.

CONCLUSION

UC removal 0-6 h after CS may be the optimal timing to prevent several complications in the absence of a clear indication for UC removal after CS. This study may provide a scientific basis for the timing of UC removal after CS.

The research frontier of cesarean section recovery: A bibliometric analysis

Background

Cesarean section (CS) has become an effective means to solve dystocia and some obstetric complications, and to save the lives of women and perinatal women. Disparities in quality obstetric care and rehabilitation in CS result from differences in health care systems across regions, and more scientific and reasonable rehabilitation programmes and management measures will benefit more parturient and newborns worldwide who must take CS. In this study, we performed a bibliometric analysis to collect a graphical representation of the CS recovery.

Methods

A total of 995 documents of CS recovery were retrieved from the Web of Science Core Collection (WOSCC) on December 31, 2021, and then VOS viewer 1.6.18 was used for visual analysis.

Results

Over the last 20 years, the researches of CS recovery have gradually increased and it will continue to grow in the next period. Anesthesia and Analgesia is the most popular journal in CS recovery. Most of the representative achievements are concentrated in the relevant institutions of European and American countries, Brendan Carvalho and Ian J. Wrench are among the outstanding scholars in this field, but the overall outcome is limited by limited regional work and lack of broad cooperation and representation. "CS," "surgery," "management," "recovery," "enhanced recovery," and "risk factors" are high frequency keywords, and there is a close relationship between "management" and "enhanced recovery" around the CS and they also become one of the key factors to regulate the condition of patients.

Conclusion

This work firstly analyzed the research condition of CS recovery by a bibliometric analysis. According to the practice guideline, it produces some outstanding representative productions, which involves enhanced recovery after surgery (ERAS) and will continue to be the focus of researchers. More substantive research articles and large-scale clinical studies may greatly enhance the scientific value, and it is necessary to strengthen the ERAS guideline and cooperation between researchers, generate broader consensus and results, and ultimately provide help for CS recovery.

Impact of early postoperative indwelling urinary catheter removal: A systematic review

BACKGROUND

Indwelling urinary catheters (IDUCs) are associated with complications and early removal is therefore essential. Currently, it is unknown what the effect of a specific removal time is and what the consequences of this removal time are.

RESEARCH QUESTION

To present an overview of the available evidence to determine the effects of three postoperative IDUC removal times (after a certain number of hours, at a specific time of day and flexible removal time) on the development of complications in hospital.

METHODS

PubMed, Medline, Embase, Emcare and Cochrane Central Register of Controlled Trials were searched till 6 June, 2021. Studies were included that described the effect of the removal time in relation to re-catheterisation, urinary tract infections (UTIs), ambulation time, time of first voiding and hospital stay. The quality of the studies was assessed with the Newcastle-Ottawa Scale and the Cochrane Effective Practice and Organisation of Care. A narrative descriptive analysis was performed. PRISMA guidelines were followed in reporting this review.

RESULTS

Twenty studies were included from which 18 compared removal after a number of hours, 1 reported on a specific removal time and 1 reported on both topics. The results were contradicting regarding the hypothesis that later removal increases the incidence of UTIs. Earlier removal does not lead to a higher re-catheterisation rate while immediate removal is beneficial for reducing the time to first ambulation and shortening the hospital stay. Studies reporting on specific removal times did not find differences in outcomes. No study addressed flexible removal time.

CONCLUSIONS

There is inconclusive evidence that earlier removal results in less UTIs, despite the incidence of UTIs increasing if the IDUC is removed ≥24 h. Immediate or after 1-2 day(s) removal does not lead to higher re-catheterisation rates while immediate removal results in earlier ambulation and shorter length of hospital stay.

IMPLICATIONS OF KEY FINDINGS

Nurses should focus on early IDUC removal while being aware of urinary retention.

Strategies for the removal of short-term indwelling urethral catheters in adults

BACKGROUND

Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%. This is an update of a Cochrane Review first published in 2005 and last published in 2007.

OBJECTIVES

To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting.

DATA COLLECTION AND ANALYSIS

Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment.

MAIN RESULTS

We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure. Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence). Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence). Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence). Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.

AUTHORS' CONCLUSIONS

There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions. Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.

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.

Eight-hour versus 24-h urethral catheter removal following elective caesarean section for reducing significant bacteriuria: A randomized controlled trial

Background:

There is no consensus on the preferred time to remove urethral catheter post caesarean section.

Aim:

To compare rate of significant bacteriuria and urinary retention following 8-h (study) and 24-h urethral catheter removal (control) post elective caesarean section.

Methods:

A randomized controlled trial of eligible participants that underwent elective caesarean section under spinal anaesthesia between March 2019 and November 2019 was conducted. Participants (150 in each arm) were randomly assigned (1:1 ratio) to either 8-h or 24-h group. Primary outcome measures included rates of significant bacteriuria 48-h post-operatively and acute urine retention 6-h post urethral catheter removal. Analysis was by Intention-to-treat. (www.pactr.org:PACTR202105874744483)

Results:

There were 150 participants randomized into each arm and data collection was complete. Significant bacteriuria was less in 8-h group (3% versus 6.0%; risk ratio (RR): 0.85 CI: 0.60 to 5.66; p = 0.274), though not significant. Acute urinary retention requiring repeat catheterisation was significantly higher in 8-h group (11(7.3%) versus 0(0.0%); RR: 0.07; CI: 0.87 to 0.97; p = 0.001). Mean time until first voiding was slightly higher in 8-h group (211.4 ± 14.3 min versus 190.0 ± 18.3 min; mean difference (MD): 21.36; CI: −24.36 to 67.08; p = 0.203); but patient in this group had a lower mean time until ambulation (770.0 ± 26.1 min versus 809 ± 26.2 min; MD: −38.8; CI: −111.6 to 34.0; p = 0.300). The 8-h group were significantly more satisfied (82/150 (54.7%) versus 54/150 (36.0%); p = 0.001)

Conclusions:

An 8-h group was associated with significant clinical satisfaction and acute urine retention compared to 24-h removal. The timing of urethral catheter removal did not affect rate of significant bacteriuria and other outcomes