Indwelling Catheter Management: From Habit-based to Evidence-based Practice
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Although suprapubic catheters are thought to have advantages such as lower infection rates, increased patient acceptance, and ease of self-care, they are not without problems.6 Suprapubic catheters are contraindicated in patients with intrinsic sphincter deficiency or chronic unstable bladders.7 Complications such as urinary tract infection, leakage from the urethra or stoma, bladder spasms,9 and difficult catheter removal10 all have been reported. European studies indicate that patients with suprapubic catheters have lower rates of urinary tract infection; however, they have a significant increase in bladder stone formation.11,12 In the US, scant research has produced few clinical articles regarding the use, indications, and complications of suprapubic catheterization.
An important aspect of management of the patient with a suprapubic catheter is catheter securement. Unsecured catheters lead to enlargement of the stoma tract, leakage, and the need for larger diameter catheters. Difficult removal with trauma and bleeding from the stoma tract can occur from balloon cuffing on deflation, especially with silicone catheters.13
Urinary catheters are available in latex and silicone. Hydrogel, silicone elastomer, and antimicrobials are common catheter coatings, designed to provide a smooth surface that protects against irritation of the urethral mucosa and encrustation. Each coating varies somewhat in its performance and benefits. Quality catheters have coatings applied to inner and outer surfaces.
Latex. Latex catheters are soft, flexible, conformable, and low cost — they continue to be one of the best catheter choices available.6 Red rubber latex catheters have the added benefit of being radiopaque; the addition of barium to the latex also makes these catheters firmer and less likely to kink. Due to the rise in latex sensitivity, some facilities are removing all latex products and going “latex free.”
Although latex sensitivity can be an issue for some patients, the actual prevalence of latex allergy in the general public is low (around 1%).14 Latex sensitivity most commonly occurs in medical personnel, rubber industry workers, or patients with repeated exposure, such as children with spina bifida.15 In addition, individuals with a history of atopy or allergies to bananas, avocado, kiwi, or chestnuts may cross-react to latex15; therefore, taking a thorough history to identify latex-sensitive patients is important. Strict latex precautions, including use of latex-free catheter kits and drainage systems, should be followed with latex-sensitive patients. Since 1998, the Food and Drug Administration (FDA) has required that medical devices containing latex be identified by including a latex warning statement on the product label.16 Nurses should check labeling before selecting a catheter for patients with known latex sensitivity.
Silicone. Silicone catheters are available uncoated or hydrogel-coated. Studies have shown that silicone is more biocompatible with urethral tissue than latex, leading to reduced incidence of urethritis and possibly of urethral strictures.17 However, animal studies of catheters used for more than 6 weeks showed no difference between silicone and latex catheters in terms of inflammatory changes.17 Some catheter manufacturers use a leaching process to remove latex proteins and processing chemicals that could lead to reactions. One advantage of silicone catheters is that the thinner walls provide larger internal lumens per external diameter and are less prone to collapse during aspiration.18 This feature results in greater flow and is advantageous for patients with blood clots or sediment in their urine.
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