Indwelling versus Intermittent Catheters in Post Operative Orthopedic Patients
Haneen Alaqrabawi
Ruthie Schreiber
Kliti Shentolli
Taylor Walsh
Scenario:
In a related question, the unit’s nurse manager has been advocating that instead of placing indwelling urinary catheters, post-op orthopedic patients who cannot use a bedpan should be “straight cathed” (using an as needed straight catheter which is only placed to empty the bladder at that time and then removed).
Clinical Question:
What can you tell the chief of the service about this question?
PICO Question:
In incontinent postoperative orthopedic patients does use of straight catheters instead of indwelling urinary catheters decrease adverse effects?
P: Postoperative, Incontinence, Orthopedic
I: Straight Catheter, Urinary Catheter, Intermittent Catheter
C: Indwelling Catheter, Foley Catheter
O: Adverse Effects, Urinary retention, Cost effective, UTIs
Search Strategy:
Searched Terms:
“orthopedics urinary retention”
“indwelling catheter post operative”
Database and Articles Returned:
PubMed
Search criteria and filters gave 57 results (first term)
Search criteria and filters gave 9 results (second term)
Filters: Meta-analysis, Randomized Control Trial, Systematic Review (first term)
Meta-analysis, Randomized Control Trial, Systematic Review, Free Full Text, 10 years (second term)
Trip Database
Search criteria gave 252 results
Search criteria gave 557 results
Selection Methods:
Chosen based on level of evidence, applicability to clinical scenario, and year of study. The Zhang and Ma articles were included due to their high level of evidence, both were meta-analyses. The Hälleberg article was chosen due to its unique view of the clinical question, it analyzed cost-effectiveness. The Shoei article was chosen for the background information it provides on the topic.
Articles Chosen:
1.Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.
Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z
PMID: 26146830
Abstract
OBJECTIVE:
The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.
METHODS:
We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity.
RESULTS:
Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01).
CONCLUSIONS:
Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively.
- Intermittent versus indwelling urinary catheterisation in hip surgery patients: a randomised controlled trial with cost-effectiveness analysis.
Hälleberg Nyman M1, Gustafsson M, Langius-Eklöf A, Johansson JE, Norlin R, Hagberg L.
https://www.ncbi.nlm.nih.gov/pubmed/23768410
Abstract
BACKGROUND:
Hip surgery is associated with the risk of postoperative urinary retention. To avoid urinary retention hip surgery patients undergo urinary catheterisation. Urinary catheterisation, however, is associated with increased risk for urinary tract infection (UTI). At present, there is limited evidence for whether intermittent or indwelling urinary catheterisation is the preferred choice for short-term bladder drainage in patients undergoing hip surgery.
OBJECTIVES:
The aim of the study was to investigate differences between intermittent and indwelling urinary catheterisation in hip surgery patients in relation to nosocomial UTI and cost-effectiveness.
DESIGN:
Randomised controlled trial with cost-effectiveness analysis.
SETTING:
The study was carried out at an orthopaedic department at a Swedish University Hospital.
METHODS:
One hundred and seventy hip surgery patients (patients with fractures or with osteoarthritis) were randomly allocated to either intermittent or indwelling urinary catheterisation. Data collection took place at four time points: during stay in hospital, at discharge and at 4 weeks and 4 months after discharge.
RESULTS:
Eighteen patients contracted nosocomial UTIs, 8 in the intermittent catheterisation group and 10 in the indwelling catheterisation group (absolute difference 2.4%, 95% CI -6.9-11.6%) The patients in the intermittent catheterisation group were more often catheterised (p<0.001) and required more bladder scans (p<0.001) but regained normal bladder function sooner than the patients in the indwelling catheterisation group (p<0.001). Fourteen percent of the patients in the intermittent group did not need any catheterisation. Cost-effectiveness was similar between the indwelling and intermittent urinary catheterisation methods.
CONCLUSIONS:
Both indwelling and intermittent methods could be appropriate in clinical practice. Both methods have advantages and disadvantages but by not using routine indwelling catheterisation, unnecessary catheterisations might be avoided in this patient group.
- Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial.
https://www.ncbi.nlm.nih.gov/pubmed/30611266
Abstract
OBJECTIVE:
The purpose of this study is to compare the rates of urinary tract infection (UTI) and postoperative urinary retention (POUR) in patients undergoing lower limb arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.
METHODS:
We conducted a meta-analysis of relevant randomized controlled trials (RCT) to compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization. A comprehensive search was carried out to identify RCTs. Study-specific risk ratios (RR) with 95% confidence intervals (CI) were pooled. Additionally, a meta-regression analysis, as well as a sensitivity analysis, was performed to evaluate the heterogeneity.
RESULTS:
Nine RCTs with 1771 patients were included in this meta-analysis. The results showed that there was no significant difference in the rate of UTIs between indwelling catheterization and intermittent catheterization groups (P>0.05). Moreover, indwelling catheterization reduced the risk of POUR, versus intermittent catheterization, in total joint surgery (P<0.01).
CONCLUSIONS:
Based on the results of the meta-analysis, indwelling urinary catheterization, removed 24-48 h postoperatively, was superior to intermittent catheterization in preventing POUR. Furthermore, indwelling urinary catheterization with removal 24 to 48 hours postoperatively did not increase the risk of UTI. In patients with multiple risk factors for POUR undergoing total joint arthroplasty of lower limb, the preferred option should be indwelling urinary catheterization removed 24-48 h postoperatively.
LEVEL OF EVIDENCE: Level I
- Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women.
Tobu S, Noguchi M, Hashikawa T, Uozumi J.
https://www.ncbi.nlm.nih.gov/pubmed/24215579
Abstract
Aim
The aim of the present study was to evaluate risk factors for postoperative urinary retention (POUR) in female patients with femoral neck fractures.
Methods
We recruited 72 female patients (age 86.5 ± 6.7 years) from among 90 cases of hip surgery carried out between January and December 2011 at Goto Chuo Hospital. We evaluated the risk factors for POUR, including the administration of anticholinergic drugs, diabetes mellitus, preoperative dementia and/or delirium, neurological disorders, age, hypertension, overactive bladder, and the postoperative duration of the use of an indwelling urethral catheter using a multiple logistic regression analysis.
Results
In the present study, POUR occurred in eight out of 72 cases (11.1%). The multivariate analysis showed that the indwelling period of the urethral catheter (per 1‐day increase; P = 0.04, OR 0.33 95% CI 0.11–0.96), and preoperative dementia and/or delirium (P = 0.03, OR10.4, 95%CI 1.21–89.2) correlated with the occurrence of POUR. Diabetes mellitus (P = 0.78), anticholinergic agents (P = 0.23), neurological disorders (P = 0.83), age (P = 0.86), hypertension (P = 0.76) and overactive bladder (P = 0.34) did not significantly correlate with the occurrence of POUR.
Conclusions
The present study showed that the early removal of the urethral catheter, and preoperative dementia and/or delirium had significant correlations with POUR. The femoral neck fractures and the surgical procedure used for the hip surgery do not induce damage to the bladder and nerve system related to the voiding function, and the voiding function in all of the patients recovered after short‐term intermittent catheterization. Physicians should not place permanent indwelling urethral catheters without carrying out urological assessments.
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc. ) |
Outcome(s) studied | Key Findings | Limitations and Biases |
| Wei Zhang, An Liu, Dongcai Hu, Deting Xue, Chao Li, Kai Zhang, Honghai Ma, Shigui Yan, Zhijun Pan | Level 1; Meta-analysis & Systematic Review | 9 RCT with 1771 patients (870: indwelling catheterization group, 901: intermittent catheterization group)
|
Rate of UTI and postoperative urinary retention(POUR) in patients undergoing lower limb arthroplasty after indwelling or intermittent catheterization |
1) No difference in risk of UTI between 2 groups [95%Cl, (0.7, 1.51), P=0.29]
2) Indwelling catheterization with removal 24-48 h postoperatively reduced risk of POUR compared to intermittent |
1) No precise definition of “POUR”
2) Small number of RCTs included 3) Lack of known comparability between the groups with respect to use of opiates & antibiotics 4) Publication year of RCTs spanned a long period (1988-2014) |
| Hälleberg Nyman M, Gustafsson M, Langius-Eklöf A, Johansson JE, Norlin R, Hagberg L | Level 2 – Randomized Control Trial | Sample
459 patients evaluated, 277 excluded for not meeting inclusion standards (see below) or refusal to participate, the 170 included patients were randomized using a computer generated sequence for block randomization into intermittent catheterization (85) and indwelling catheterization (85) groups. Inclusion criteria – patients undergoing hip fracture surgery or hip replacement surgery due to osteoarthritis. Exclusion Criteria – age below 50 yrs, indwelling urinary catheter or cognitive impairment at admission, or lack of informed consent. Treatment Intermittent Catheterisation Urinated as needed, bladder scans q 4 hrs, if unable to urinate and bladder scan over 400 ml patient intermittent catheterisation was used Indwelling Catheterisation Indwelling catheter was inserted upon arrival to orthopaedic ward and removed POD then bladder scanned q 4hr until normal bladder function returned, patients were re-catheterised if bladder volume was over 400ml and unable to urinate Setting Orthopedic department at a university hospital in Sweden. |
Data was collected:
1 – during hospital stay 2 – at discharge 3 – 4 weeks after discharge 4 – 4 months after discharge Clinical Outcome Measures Primary Nosocomial UTI Secondary 1 – Time to normal bladder function 2 – Number of catheterisations 3 – Number of bladder scans Cost Effectiveness Measures 1 – Quality of Life 2 – Cost
|
No statistically significant difference in:
1 – Frequency of nosocomial UTIs between the two groups 2 – QALYs 3 – Costs
Statistically significant differences: 1 – Time to normal bladder function intermittent group (24 hrs), indwelling (48hrs) 2 – Number of bladder scans intermittent group (6), indwelling (2) 3 – Number of catheterizations intermittent group 1), indwelling (0)
|
This study is included in the Wei Meta-Analysis and systematic review
This study was done in Sweden, particularly limiting with respect to cost analysis and use of SF-36.
The hospital where the study was conducted used indwelling catheterisation as its standard of care.
The data collected at 4 weeks and 4 months was done via telephone call or post and received poor attrition rates.
Small sample size (170 patients)
Publication year of 2013
Astra Tech provided only intermittent catheters |
| Tobu, Shohei Noguchi, Mitsuru
Hashikawa, Takeshi Uozumi, Jiro |
Level 3- A prospective cohort descriptive study | Sample size of 90 female patients (ages 80 – 93) who had femoral neck fracture surgery were recruited for this study. 18 were excluded for having a history of chronic urinary retention. The remaining 72 pts received indwelling urethral catheters intra‐ and postoperatively; catheters removed postoperatively. No control group was included. This study was conducted in Gotu Chuo Hospital, Goto, Japan. | Rate of POUR risk factors occurring, in elder female patients who had hip surgery, after received indwelling catheterization. Evaluated risk fractures include administration of anticholinergic drugs, diabetes mellitus, preoperative dementia and/or delirium, neurological disorders, age, hypertension, overactive bladder, and postoperative duration of use of indwelling urethral catheter. | 1) POUR occured in 8/72 cases (11.1%)
2) Post-op self‐ decannulation d/t post-op deliria occured in 11/72 cases (15.7%) 3) There was a significant correlation between the duration of indwelling catheter and incidence of POUR. POUR and early removal of indwelling catheter correlated as well. |
1) Subjects limited to one gender.
2) Sample size too small. 3) Preoperative bladder dysfunction was not assessed before the operation. 4) Study limited to one location, Japan. 5) Study done in 2013, somewhat old. |
| Yimei Ma and Xiaoxi Lu | Level 1
meta-analysis of randomized controlled trial |
Meta-Analysis of 7 independent RCTs were included with a total sample size of 1533 patients, 750 from indwelling catheter group and 783 from non-indwelling catheter group. All 7 studies were published between 2000-2018. | 1)Urinary retention= No significance data difference between the two groups.
2)Urinary tract infection= Patients in the indwelling group had a higher risk of urinary tract infection than the group in the non-indwelling group. 3)Duration of surgery= No significant difference between the two groups. 4)Length of hospital stay= No significant difference between the two groups. |
The main finding in the current meta-analysis is that patients in the indwelling catheter group had a higher risk of urinary tract infection than patients in the non-indwelling catheter group. Additionally, there was no significant difference between the two groups in terms of urinary retention, duration of the surgery, and length of hospital stay.
Also, urinary catheterization during TJA, it can increase the postoperative urinary tract infection, may not be required for the patients undergoing TJA.
|
– Only 2 out of the 7 RCT studies were double blinded. On the other 5, research staff were not blinded.
– The study wasn’t clear on the specific treatment the non-indwelling catheter group received. – Small number of RCTs in this meta-analysis.
|
Conclusion(s):
In post-operative orthopedic patients UTI risk is increased with the use of intermittent and indwelling catheterisations. Current research indicates that there is no cost difference when comparing use of intermittent catheterization versus indwelling catheterization. However, it has been shown that intermittent catheterisation can decrease the time to normal bladder function. On the other hand, there is still debate over whether or not indwelling catheters increase risk of UTIs when compared to intermittent catheters. Additionally, there is still debate over whether there is a difference in postoperative urinary retention rate between the two groups.
Clinical Bottom Line:
Based on the above conclusion the decision to use an indwelling or intermittent catheter should be made on a patient to patient level. When making this decision the care team should take into consideration the patient’s risk factors, comorbidities, and preferences.
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