Indwelling Catheter Management: From Habit-based to Evidence-based Practice
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More than 40% of all nosocomial infections are catheter-associated.3 More than 1 million patients per year in hospitals and extended care facilities will acquire a CAUTI, and studies suggest that CAUTIs are associated with substantially increased death rates.3 Although not all CAUTIs can be prevented, it is believed that a large number could be prevented by proper catheter management.8 The CDC guideline (see Table 3) addresses prevention of CAUTI for the care of patients with short-term urinary catheters; however, patients with chronic indwelling catheters may have different needs.8 Catheter-associated urinary tract infections have been identified as a leading source of nosocomial antibiotic- resistant pathogens,3 and silver alloy-hydrogel catheters are recommended to reduce infection rates and cost.3,19
Diagnosis of urinary tract infection can be difficult in a patient with a long-term indwelling catheter, especially because patients may be asymptomatic.36 Specific guidelines for initiation of treatment for UTI in catheterized patients are outlined in Table 4.37,38 Because bacteriuria is present in all patients with indwelling catheters, colony counts are used to distinguish between colonization and actual clinical infections. Urine cultures obtained from the drainage bag safe-sampling port that show colony counts of >102-3 cfu/mL are considered to be indicative of a true CAUTI.3
Changing the catheter when antibiotics are started is important, as studies show this intervention hastens clinical improvement, reduces febrile days, and decreases the rate of relapse.37
Catheter leakage. No other catheter management issue causes more unnecessary catheter changes than leakage or bypassing. Catheter leakage is thought to affect as many as 25% to 65% of patients with indwelling catheters.39 Long-term indwelling catheters can lead to small non-compliant bladders, and leaking can occur with small amounts of urine in the bladder. Causes of leakage include bladder spasms, infection, fecal impaction or constipation, luminal occlusion, catheter encrustation, and loss of elasticity of the urethra (female).39-41
The nurse must focus first on identifying the cause of the leakage; interventions then can be tailored to the cause of the problem. Changing the catheter is indicated if the lumen is occluded, but practices such as adding fluid to a catheter balloon or increasing the catheter or balloon size can lead to increased spasm and leakage and are contraindicated (see Table 5).
Bladder spasms are involuntary contractions of the bladder and are common in patients with urinary catheters, spinal cord injuries, or diseases that lead to neurological deficits.39 Bladder spasms can be strong enough to push the catheter out of the urethra with the balloon inflated. Antispasmodic drugs such as oxybutynin and flavoxate can be effective at treating bladder spasms, but may have undesirable central anticholinergic effects.6 Known bladder irritants such as caffeine and alcohol should be avoided in patients with known bladder spasms, as well as large-sized catheters and balloons that may add pressure on the sensitive trigone area. Symmetrical balloon inflation, catheter securement, and adequate fluid intake all help reduce the risk for bladder spasms and resultant leakage.
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