What Is The Recommended Size Of The Urinary Catheter That Can Be Used In A 3-year-old Child?
Introduction
An average of 450,000 pediatric patients are admitted each yr in the U.s.a. for surgery. Elective surgery admissions mostly contain 40% of the surgical hospitalizations with 55% of admissions classified as either gastrointestinal, orthopedic, or urological.1 Consider the high volume of additional outpatient surgical procedures, representing over 60% of all surgeries in the The states in 2011, and the diligence to perioperative management in the pediatric patient is vital.2 While the immediate pathology at hand and surgical technique dictated are the chief focus of the surgical team, one facet that receives considerably less attention, if whatsoever, is the role of urinary catheter placement.
The decision to place a urinary catheter, or not, or another variant to decompress the bladder may seem trivial. However, a swoop into the topic only further complicates the thing. Consider that catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infection in the United States, accounting for more than 30% of infections reported by astute care hospitals.3 As this is associated with increased healthcare costs, hospital stays, morbidity and mortality rates, there has been a drive to determine when catheters should be utilized.4 In fact, national quality comeback measures to strictly determine rubber catheter usage are seen in campaigns such equally "Lose the Tube" of Choosing Wisely Canada.5
When the same dilemma is applied to the pediatric patient, the water is further dirty. Pediatric patients, in fact, are not merely small adults. With incompletely developed and developing physiology, more fragile anatomy, in addition to the function urinary catheterization has historically played in the postoperative healing in certain procedures, selecting the proper catheter – and knowing when to apply ane – is no unproblematic task.
In what follows, we hope to provide a basis for when catheterization should be employed in the pediatric patient more often than not. Building on this, we will explore how the intended procedure, approach, and underlying pathology may all influence this selection process so that clinicians may meliorate arrive at a audio decision.
When Should a Catheter Be Used?
In 2018 Meddings and colleagues prepare out to determine criteria for urinary catheter use in mutual general and orthopaedic surgeries using the RAND/UCLA appropriateness method.vi A assuming undertaking, the panel, consisting of two multidisciplinary sub-panels totaling 24 members utilized a standard process to independently charge per unit the clinical ceremoniousness for Foley catheter placement in 91 full general surgical procedures and 36 orthopaedic surgeries. With the aim to limit unnecessary catheterization and prioritize removal when urinary drainage was needed, prompted three recommended categories: (a) procedures for which indwelling urinary catheter placement should be avoided, (b) procedures to consider removing indwelling urinary catheters before leaving the operating room, and (c) procedures in which urinary catheters should remain in utilise until postoperative twenty-four hours i (Effigy i). One obvious omission in this panel review was the lack of review of urologic procedures.
 | Figure i Summary of perioperative urinary catheter utilise recommendations. Notes: Adapted from Meddings J, Skolarus TA, Fowler KE, et al. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common full general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Quality & Safety. 2018;28(i):56–66. © Author(south) (or their employer(s)) 2019. Re-apply permitted under CC BY-NC. Published by BM© Writer(s) (or their employer(due south)) 2019. Re-use permitted under CC BY-NC. No commercial re-apply. See rights and permissions. Published past BMJ. With permission from BMJ Publishing Grouping Ltd.half dozen |
In the general surgical realm, Foley catheter use was highly appropriate for all colorectal surgeries with appropriate timing of kickoff voiding trial occurring every bit early every bit postoperative day 0 or postoperative day 1. Routine catheter placement was accounted inappropriate for several procedures, including laparoscopic cholecystectomy, open up appendectomy, laparoscopic appendectomy without a suprapubic port, open up repair of reducible hernias (inguinal, femoral, umbilical, epigastric), and most laparoscopic repairs provided the patient voided preoperatively.
One area where catheter placement was almost highly dependent upon surgeon experience and training included whether or not suprapubic port placement in laparoscopic surgery impacted urinary drainage strategies. The panel discussed catheter placement may be avoided if the patient voided preoperatively with the pick of float scanning, but consensus appropriateness remained undecided regarding routine placement. Every bit expected, many practices are determined past surgeon training and if whatever surgeon had experienced bladder or other urologic complications with suprapubic port placement. Past convention, nigh urologists place urinary catheters, at least intraoperatively, for about pelvic surgeries, including both open and laparoscopic approaches to minimize chance of inadvertent iatrogenic damage to the bladder.
For orthopaedic procedures, the competing interests were the need to subtract catheterization where infections are a real take a chance to hardware and operative fourth dimension. In general terms, most routine hip and knee procedures tin can safely be performed without catheter placement if completed in under two hours. In those that concluding longer than two hours, catheters could oftentimes be removed before leaving the operative suite or on postoperative day 1 with no increase risk in postoperative complications.
Postoperative Urinary Retention – What Is It and What Mitigation Strategies Exist?
The overall risk of postoperative urinary retention (POUR) in the general (non–urologic) surgical population is three.8%, though the cited incidence can vary widely from 5 to lxx% based on the blazon of surgery.7 In pediatric patients undergoing lower extremity orthopedic limb surgery, upward to i–third of patients may develop Pour.8
The alterations in physiology in the postoperative period can event from diverse types of anesthesia employed. The effects may be due to anesthesia itself, the procedure performed and technique utilized, polypharmacy intraoperatively, and postoperative pain. Although in that location has been a recent push away from postoperative opiate pain management, opioids are usually still used intraoperatively and are known to decrease the sensation of bladder filling by parasympathetic inhibition.9 Additionally, they increase sphincter tone. The event, and subsequent urinary retention, is greater with neuraxial opioids compared to intravenous administration. Full general anesthesia also contributes to urinary retentiveness by increasing polish musculus relaxation, and, conversely, decreasing bladder contractility. Finally, local neuraxial local anesthetics human action at the immediate afferent and efferent junctions in the pathways pivotal to micturition. As such, longer acting agents bear a greater gamble for postoperative bladder dysfunction.
While several distinct and competing criteria have been used to diagnose Cascade generally the condition can be diagnosed based on history and physical examination, need for bladder decompression, and, more than recently, ultrasonography.10,11 Suprapubic hurting at rest and with at palpation as well equally a distended, palpable bladder can clue the clinician into ongoing Pour, though this method does lack sensitivity. In adult patients, palpable dullness to the level of the umbilicus is a reliable surrogate in measuring bladder volumes of approximately 500 mL.12 Bladder catheterization offers both a diagnostic tool and therapeutic mensurate for POUR, as some criteria diagnose Pour if 100% of expected adult volume is drained (500–600 mL in adults) and more than the calculated bladder chapters at a sure age in a child ([age in years + 2] 10 xxx).13 Finally, ultrasonographic investigation has proven a useful offshoot in diagnosing POUR as it is non-invasive, painless and has a high sensitivity, with stiff correlation between volumes measured by bladder catheterization and ultrasound.fourteen,15
Strategies to subtract the risk of Cascade take been heavily studied and resulted in alterations in operative direction by the surgical team and anesthesia management. Judicious intravenous fluid administration based on calculated maintenance fluids, and bookkeeping for insensible loss, is imperative. This approach should be employed when possible, though there are instances when a surgeon may request hyperhydration, such equally in urologic upper tract reconstruction, to induce a physiologic hydronephrosis.
Other approaches to decrease risk include being cognizant of surgical duration. Keita et al demonstrated that surgical elapsing alone, specifically procedures lasting 80 minutes or longer, were independently associated with increased gamble of Cascade. This is likely multifactorial, due to the increased intravenous fluid administration and use of opiate pain control for full general anesthesia. Still, pain command in the postoperative setting is crucial as poor pain command can effect in increased sympathetic discharge which further predisposes a patient to Pour.16
Catheter Size in Children – One Size Does Not Fit All
Catheterization in the pediatric patient, unlike the adult patient, is often performed in conjunction with diagnostic equally well every bit therapeutic procedures. Examples in which catheterization is diagnostic include dissimilarity-enhanced imaging modalities such every bit that seen in cystourethrography. Though the procedure is commonly performed and relatively rubber, in that location are relative contraindications to immediate catheterization including pelvic fractures, known trauma to the urethra, or blood at the meatus.17 Complications are rare considering how frequently catheterization is performed, however, they do ascend. Examples include false passage creation, urethral perforation, hematuria secondary to traumatic placement, infection and subsequent delayed complication of urethral stricture formation.
Primal to avoiding, or at to the lowest degree minimizing, complications is appropriate catheter size option. The method for doing and so varies widely and traditional selection processes rely on the child'due south age, body weight, or both.eighteen–21 Exact formulas take even been derived to provide an ideal and custom arroyo to proper catheter sizing in children. One relies on a patient'due south age to estimate body weight (in kg) upwards to 10-years:22 Weight may non e'er be the about accurate, however, as there tin can be smashing variance of expected weight for a given historic period. To address this, Kopac devised a formula based entirely on body weight (up to 30 kg) and correlated this with catheter size:
This formula was verified to help those clinicians apace determine the advisable catheter size who may not have readily available admission to published nomograms for summit and weight or who may not often treat pediatric populations. Equally the formula is based on published relations betwixt urinary catheter size and a kid'south historic period and body weight, the formula holds strong correlation upwardly to 30 kg.23
Special Considerations
Hypospadias Repair
Management of urine postoperatively post-obit surgical repair of hypospadias is, in itself, a highly debated topic in the realm of pediatric urology. Archetype reasons for placing a urethral stent or other urinary drainage device such as a Foley include the belief that voiding postoperatively may evidence painful or cause discomfort that may predispose a kid to develop urinary memory – by leaving a urethral stent, the adventure for re-cannulating a fresh hypospadias repair is avoided. Additionally, others believe urethral stenting provides a concrete framework around which a repair may heal, especially if the urethral plate is reconstructed and tubularized equally in the tubularized incised plate repair (TIP process).24 To address this exact question, El-Sherbiny prospectively randomized boys undergoing a TIP process to either stented (due north=35) or unstented (n=29) groups for postoperative management. Findings from this study demonstrated painful voiding in the first calendar week was seen in fourteen% and 45% of stented and unstented patients, respectively. Additionally, none of the stented patients developed urinary retentiveness or extravasation compared to 24% and 17% in unstented patients. In regards to postoperative meatal stricture, meatal dilatation was required in 6% of stented patients versus 17% of unstented patients. Finally, the re-operative rate trended lower in the urethral stented group (9% vs 20%), though the difference was not statistically pregnant.25 Based on these findings, his conclusion was that urethral stenting afterward TIP repair for hypospadias is advantageous.
Notwithstanding, several studies take evaluated healing in unstented hypospadias repair procedures. Hafez and colleagues utilized a rabbit model to study the temporal healing after TIP urethroplasty. They used a combination of retrograde urethrograms and microscopic examination at varying intervals and constitute no instances of fistulae or stricture in xiii performed procedures. Additionally, complete healing of the peri-urethral connective tissue with minimal fibrosis was seen.26 This has since been replicated numerous times in boys with several studies demonstrating that successful hypospadias repair is independent of the employ of a urethral stent.27
Now the use of urethral stenting and urinary diversion after hypospadias repair rests mostly on surgeon preference and grooming, or in the case of re–do repairs. Most options for transurethral drainage include a modified catheter of acceptable size, typically six Fr or 8 Fr, or a feeding tube ranging 5–8 Fr placed atraumatically with verified drainage and secured via a glans stay suture (Figure 2). Time to removal varies likewise, with a traditional dwell time of 7 days, though recent studies have shown that removal postoperative day ane (overnight urethral stenting), is not associated with whatever significant increase in adverse outcomes.28
 | Effigy 2 Urinary diversions – urethral stents and urinary catheters. Left one-half of picture represents feeding tubes which may be fashioned into urethral stents, ranging 3.v–8 Fr. On the right half of the pic are various catheters, six–12 Fr. |
Urinary Retentiveness
De-novo urinary retention outside the setting of postoperative urinary retention, known neurological disorder and neonates is a rare entity. In their comprehensive review of pediatric presentation of acute urinary memory in the emergency setting between 2000 and 2012, Nevo et al found an overall incidence of urinary retention of eight.48 cases per 100,000 children. Additionally, 75% of children presenting were male. Underlying causes included mechanical obstruction (25%), infection or inflammation (xviii%), severe fecal constipation (thirteen%), and previously unknown neurologic disorders (11%). Interestingly, upwards to 21% were idiopathic. Of note, all patients with mechanical obstruction were boys and 5 of xiv patients had a pelvic tumor.29
Age was also a factor – a bimodal distribution was noted with 29% of events occurring betwixt 3 and 5 years of age, and 32% between the ages of 10 and 13. Based on the alarming rate of concerning underlying pathology, astute onset urinary retention in a previously salubrious child – excluding the postoperative period, known neurological disorder, and neonate historic period – should prompt swift and comprehensive evaluation.
In another report, adverse drug furnishings (peculiarly with antihistamines and neuroleptics such every bit haloperidol and carbamazepine) and behavioral dysfunctional voiding were six times more common in boys.13
Neurogenic Float
Neurogenic bladder or neurogenic detrusor-sphincter dysfunction encompasses abnormalities in the voiding arc that may develop due to a lesion at any level in the nervous organization. This status contributes to various forms of lower urinary tract dysfunction and can contribute to urinary tract infections, incontinence, and vesicoureteral reflux. In the long term, it can lead to renal scarring and compromised upper tracts, portending to chronic renal failure.xxx
The master goals of therapy are aimed to prevent deterioration of the urinary tract and to help the kid achieve continence at an advisable age. Direction of neurogenic bladder, and its associated sequelae, has seen enormous gains, in large part to the introduction of clean intermittent catheterization (CIC). This has increased adherence to conservative management principles, which has allowed deferment of surgical intervention, if needed, until an age where success is most probable.
European Association of Urology (EAU) emphasizes and celebrates the overwhelming success CIC has had on early direction of neurogenic float, and how, if started soon after birth, children exercise not develop upper tract deterioration.thirty Kochakarn et al detailed the basis for early CIC and its upshot by randomizing children with neurogenic bladder secondary to myelomeningocele to early intervention (i year of age or less, due north = 36) or late intervention (CIC >3 years sometime, due north = 31). Children who were started on CIC later had earlier renal deterioration and worse renal function (measured past increases in blood urea nitrogen and serum creatinine). Hydronephrosis was observed in 10 patients who received early intervention and eighteen patients who were in the later handling group. Patients in the later treatment group also had before and more than astringent hydronephrosis. Interestingly, in cases where surgery was performed, in either grouping, results of surgery were better in those who received early on CIC, though surgery was required earlier in the late CIC grouping. Of annotation, no divergence in urinary tract infection was seen between the two groups.31 A major barrier to the success of CIC, however, relies on complete support and credence by the patient, parents, and schools to ensure timely drainage.32
In those requiring CIC, hydrophilic, self-lubricating catheters are preferred and are associated with decreased take a chance of symptomatic urinary tract infection, bacteriuria, hematuria and pain, and increased patient satisfaction.33
For patients who have progressively worsening renal role despite CIC, definitive interventions include Mitrofanoff, Monti, or bladder augmentation. In such cases, a advisedly selected, historic period-advisable, urethral catheter is left indwelling for iii to four weeks typically. For redundancy, a minimum of a 12 Fr catheter is also placed suprapubically to maximize drainage and as well irrigate mucus droppings as needed. This is typically removed i to two weeks later on the urethral catheter is removed and the patient is able to reliably demonstrate appropriate manipulation of the reconstructed diversion.
Posterior Urethral Valves
With an estimated incidence of 1 in 5000–12,500 alive-births, posterior urethral valves (PUV) are one of the few life-threatening congenital anomalies of the urinary tract.34,35 Ofttimes diagnosed antenatally on routine ultrasonography, proper direction is imperative to avoid continued, and typically irreversible, kidney damage. Antenatal management is a rather recent handling option afforded past incredible achievements in maternal-fetal management, technology, and bold surgical sense. A detailed discussion of such treatment is beyond the scope of this text, merely antenatal treatment is reserved for only the most astringent cases and consists of percutaneous vesicoamniotic shunt placement.36 This intervention is only offered at the most specialized of institutions that are able to offer jointly the obstetric, pediatric urologic, and potential pediatric care necessary to all-time maximize success.
Postnatally, if PUV is suspected in a newborn male, prompt drainage of the bladder is necessary, followed by voiding cystourethrogram (VCUG), if possible, which volition demonstrate the archetype "keyhole" sign (Figure 3). A neonate may exist decompressed with a feeding tube ranging from iii.5 to viii Fr, though 5 Fr is typically performed. six Fr balloon catheters may also be utilized, and in rarer instances, iv.eight or 6 Fr ureteral double j-coiled stents can be used. Of note, the utmost care must be taken to not inflate the balloon within the urethra, inevitably causing more trauma. It is our recommendation that a 5 Fr feeding tube or double-j stent over a guidewire be placed if possible and confirmed with bedside fluoroscopy or ultrasound. However, a 6 Fr urethral catheter may also exist used without inflating the balloon and appropriately secured with tegaderm or tape.30 Alternative methods, if the transurethral approach fails, include suprapubic catheter insertion or cutaneous vesicostomy. In one case the urinary arrangement is decompressed, valve ablation typically is the definitive intervention and is performed once the child is condom to undergo anesthesia. A urethral catheter is placed during definitive treatment and left in identify until the creatinine nadirs, which typically occurs 24 to 48 hours after repair.
 | Figure 3 Voiding Cystourethrogram (VCUG) of male infant demonstrating dilated prostatic urethra with classic "key hole" sign secondary to posterior urethral valve. Some upper tract deterioration is already noted on the right given the meaning dilatation from increased intravesical pressures. |
Urinary Decompression Subsequently Urologic Reconstruction
The role of urinary drainage via trans-anastomotic ureteral stenting or percutaneous drainage remains heavily debated with the emergence of "stent-less" ureteral reconstruction, specifically in pyeloplasty.37 While this fence continues for upper tract urinary decompression, urethral catheterization is seemingly ubiquitous to drain the lower urinary tract. Conventionally, the float is decompressed for at least 24 hours, or overnight, in instances where extravesical ureteral reimplantation is utilized unless the patient has a history of voiding or bowel dysfunction, or both. More than variability is seen in intravesical ureteral reimplant equally the bladder wall and mucosa are violated. Urethral catheter dwell time in these instances is based on surgeon preference.
Catheter Placement in the Pediatric Trauma Patient
Equally previously mentioned, relative indications for immediate urethral catheter placement in the setting of pediatric trauma include unstable pelvic fractures, known trauma to the urethra, or blood at the meatus.
The bladder is the 2d nearly common genitourinary (GU) injury in children, owing to the proportionately larger attribute in children and lack of protection from the pubic symphysis due to incomplete prevarication within the pelvis from immature skeletal development.38,39 Bladder injuries can more often than not be categorized as either intraperitoneal or extraperitoneal. Cystography or computed tomography (CT) are preferred to manifestly moving picture, with CT imaging the modality of option in evaluating a suspected bladder injury. Prompt surgical exploration is required for intraperitoneal ruptures to avoid intraperitoneal infection, peritonitis and decease. Adequate urethral catheter drainage – past ensuring continuous drainage free of clots or debris – is typically sufficient for uncomplicated extraperitoneal rupture. Adequate drainage is ensured past appropriate size pick, equally previously mentioned, and gentle irrigation with normal saline equally needed to guarantee patency.
Rarely, urethral catheter drainage is also used in conjunction with ureteral stenting for upper tract (ureter and/or renal) injuries to guarantee a low-force per unit area organisation with continued drainage in instances where urinary extravasation is noted from the proximal ureter or renal pelvis.39
Blood at the meatus in a presenting pediatric trauma patient warrants conscientious consideration. Electric current American Urological Association (AUA) guidelines on Urotrauma provide a stepwise approach for such a patient. Guideline statement 19 recommends clinicians should perform retrograde urethrography after pelvic or genital trauma resulting in blood beingness seen at the meatus. If partial disruption is noted with some contrast passing to the float, then the guidelines emphasize that a unmarried attempt with a well-lubricated catheter may be attempted by an experienced provider, in this example, a urologist. If complete distraction is noted, suprapubic tube placement is warranted; additionally, in near cases of pelvic fracture associated with urethral injury (PFUI), suprapubic drainage is preferred.40,41
Catheter Preference in Female and Male person Patients
Cather preference is less an event when considering gender difference than ensuring strict sterile technique. Aside from an obvious abnormality (such every bit hypospadias or stricture) the beefcake of a male infant is like to that of an adult male person, though smaller and lacking secondary sexual characteristics. A physiologic phimosis is frequently encountered during childhood, but the foreskin should not exist forced to exist retracted. Intendance should be taken to avert forceful catheter placement as the tissue of a male baby is much less resilient compared to an adult male.18
Again, the most important factor when it comes to Foley placement in male versus female patients, is technique. In females, exposure is important and may require additional personnel to ensure contamination is minimized. This increased take chances of infection in females results from their significantly shorter urethra (4 cm in adult female vs 20 cm in adult male). Anatomic differences are reflected in the difference in size of male and female catheters used in CIC (Figure four).
 | Figure four Urinary catheters for intermittent catheterization, 12 Fr female catheter (top) vs 12 Fr male person catheter (bottom) representing anatomic difference in overall urethral length (MagicthreeGet Hydrophilic catheters, BARD). |
Two common scenarios in male pediatric urologic patients cause bang-up anxiety amongst guardians and providers unfamiliar with their presentation – uncorrected hypospadias and uncircumcised boys with physiologic phimosis. Anecdotally, the urethral opening and plate in uncorrected hypospadias often is able to accommodate normal, historic period-appropriate, catheterization in the absence of a concomitant urethral stricture, which is exceedingly rare in uncorrected hypospadias. In the setting of physiologic phimosis in the male infant, spatial awareness of the expected location of the meatus tin can oft time let passage of the urethral catheter. Another, well-documented arroyo, is the awarding of steroid cream with gentle retraction to manual release any adhesions. If the acuity necessitates more than immediate attention, dorsal slit may e'er exist performed. Cognition of these common weather condition, and how to address each, tin greatly reduce many phone calls the pediatric provider experiences.
Function of Antibiotics and Catheter Materials
Antibody Prophylaxis – Is In that location a Office?
Much like the role of urethral stenting in hypospadias repair, there is substantial variation in do methods amongst pediatric urologists with regards to antibiotic prophylaxis with urinary catheterization and small-scale lower urinary tract procedures. Although guidelines be, these are geared toward the adult urologic patient.
To address this chasm, in 2017, Glaser and assembly surveyed members of the Lodge for Pediatric Urology regarding antibiotic use with catheterization. A pregnant majority, 78%, prescribed daily prophylaxis with a hypospadias stent in place, but disagreement abound thereafter. Interestingly, urologists over 50 years and fellowship-trained pediatric urologists were more than likely to prescribe prophylaxis for hypospadias stents. All-encompassing variation existed with prophylaxis for Foley catheters, percutaneous nephrostomy tubes, suprapubic tubes and internal double–j ureteral stents, with thirty–fifty% of respondents not prescribing prophylaxis for these drainage systems. Additionally, the majority of respondents practice not routinely prescribe a dose of prophylaxis prior to tube removal aside from removal of a ureteral stent.42
The use of urine cultures and civilisation data differed widely, too. The bulk practice not routinely obtain urine culture prior to removal of a hypospadias stent (xc%), Foley catheter (75%), nephrostomy tube (59%), suprapubic tube (69%) or ureteral stent (67%). A void for consensus regarding prophylaxis in the pediatric-patient exists with such wide variation in actual exercise, coupled with the potential price of treatment and morbidity for urinary tract infection. This topic remains heavily debated, and researched.
In 2018 Canon and colleagues shed calorie-free on this debate in their evaluation of the incidence of symptomatic urinary tract infection (UTI) following stented, distal hypospadias repair. Additionally, they evaluated the impact of prophylactic antibiotic therapy on UTI incidence. Urinalysis and/or urine cultures were obtained intraoperatively from 48 patients aged 0 to 5 years who did non receive preoperative antibody regimens. These patients were randomized to prophylaxis vs no prophylaxis groups in equal numbers. While the incidence of symptomatic UTI was low in this small pilot study, information technology did non vary betwixt groups and safety antibiotic therapy did not appear to lower the incidence of symptomatic UTI.43
Catheter Coatings
Biofilm formation and encrustation are two dreaded natural progressions with repeated and chronic catheter use. Both can develop despite appropriate oral or intravenous antimicrobial therapy. With the increased morbidity associated, many have considered special catheter materials to reduce formation. Johnson and others sought to answer how coated catheters faired against traditional silicone or latex foleys. In a meta-assay totaling over xiii,000 patients, they found there was low-quality evidence favoring nitrofurazone-impregnated catheters in patients catheterized for brusk durations, less than i week. The do good was observed in an overall decreased risk of bacteriuria without whatever increased risk of antimicrobial resistance.44
Other catheter coatings have also shown some modest benefit. Silver-coated catheters have been heavily studied and low-quality evidence suggests a benefit over traditional latex catheters. Endpoints demonstrated a decreased risk of bacteriuria and no evidence of urethral irritation or antimicrobial resistance. Differences were significant but with silver alloy-coated catheters but not silver oxide-coated catheters. Specifically, silver blend-coated catheters reduced the chance of asymptomatic bacteriuria compared to standard latex catheters, but this significance was lost when compared to standard, all-silicone catheters.45
Traditional latex catheters have fallen out of favor due to concerns over latex allergy. Silicone is a ubiquitous catheter textile now and is preferred in patients with long-term catheterization due to decreased likelihood of catheter encrustation. For those patients prone to catheter blockage secondary to encrustation, silicone catheters should be utilized.
Catheter Dwell Time
Just every bit significant consideration afforded to determining ceremoniousness of urinary catheter placement, equal consideration should be given to urinary catheter dwell fourth dimension. To assess the risk of catheter dwell fourth dimension, Letica-Kriegel et al studied a large retrospective cohort of 61,047 patients from half dozen different hospitals to assess how the risk for CAUTI changes over time. Their results demonstrated that each additional day of catheterization increases the risk of CAUTI, even when decision-making for sex, historic period, and patient comorbidities. Additionally, they as well identified female sex, pediatric historic period, and underlying neurologic issues every bit independent hazard factors for CAUTIs.46 These findings confirmed the long-held practise and drive amongst surgical teams to remove urinary catheters as shortly as possible (when safely and viable). It too served as a modern update to the archetype finding that adult patients with urinary catheters develop bacteriuria at a charge per unit of 8% per day during the first week.47
Conclusion
In the larger context of perioperative direction, urinary catheter choice in the pediatric is ofttimes an afterthought. In cases where urinary diversion is utilized, existing knowledge regarding catheter selection often complicates the process. A step-wise process should exist employed and begins with determining the need for catheter placement in the first place.
If warranted, either due to predictable operative fourth dimension, immobility, or pelvic laparoscopic surgery, amongst other reasons, careful attention to technique must be emphasized. The correct size for the pediatric patient, based on height and weight, aids in proper catheterization. Silicone-based catheters predominate currently and should be utilized when available. Once placed, a push should exist made to remove the catheter as presently as medically necessary, with a keen focus on antibiotic prophylaxis simply if necessary, to maintain antimicrobial stewardship. In cases where postoperative urinary memory, or underlying disease states (such as neurogenic bladder) may predispose to re-catheterization, CIC should always be employed starting time until no longer feasible– due to trauma or patient condition. Taken together, these mental checkpoints can ensure catheter usage remains judicious to decrease the use of CAUTI and whatever subsequent sequelae in the pediatric surgical patient.
Disclosure
The authors reported no conflicts of interest for this work.
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What Is The Recommended Size Of The Urinary Catheter That Can Be Used In A 3-year-old Child?,
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