Original Articles
Early Removal of Urinary Catheter After Surgery Requiring Thoracic Epidural: A Prospective Trial

https://doi.org/10.1053/j.jvca.2014.05.009Get rights and content

Objectives

To prevent urinary retention, urinary catheters commonly are removed only after thoracic epidural discontinuation after thoracotomy. However, prolonged catheterization increases the risk of infection. The purpose of this study was to determine the rates of urinary retention and catheter-associated infection after early catheter removal.

Design

This study described a prospective trial instituting an early urinary catheter removal protocol compared with a historic control group of patients.

Setting

The protocol was instituted at a single, academic thoracic surgery unit.

Participants

The study group was comprised of patients undergoing surgery requiring thoracotomy who received an intraoperative epidural for postoperative pain control.

Interventions

An early urinary catheter removal protocol was instituted prospectively, with all catheters removed on or before postoperative day 2. Urinary retention was determined by bladder ultrasound and treated with recatheterization.

Measurements and Main Results

The primary outcomes were urinary retention rate, defined as bladder volume>400 mL, and urinary tract infection rate. Results were compared with a retrospective cohort of 210 consecutive patients who underwent surgery before protocol initiation. Among the 101 prospectively enrolled patients, urinary retention rate was higher (26.7% v 12.4%, p = 0.003), while urinary tract infection rate improved moderately (1% v 3.8%, p = 0.280).

Conclusions

Early removal of urinary catheters with thoracic epidurals in place is associated with a high incidence of urinary retention. However, an early catheter removal protocol may play a role in a multifaceted approach to reducing the incidence of catheter-associated urinary tract infections.

Section snippets

Methods

Data were collected while an early urinary catheter removal protocol was implemented within the University of Virginia’s division of thoracic surgery. As a quality-improvement measure, this study was considered exempt from full review by the institutional review board. Adult patients who underwent surgery through a thoracotomy incision and who required a thoracic epidural for postoperative pain control were included. Exclusion criteria were postoperative hemodynamic instability (mean arterial

Results

Between July 2011 and May 2012, 106 consecutive patients were enrolled into the prospective study. Five patients were excluded due to incomplete auditing records. The historic control group included 218 consecutive patients who underwent surgery between May 2010 and July 2011. Of these, 8 were excluded due to hemodynamic instability, prolonged intubation, or presence of end-stage renal disease. Demographic characteristics for the 101 early-removal patients and the 210 control patients are shown

Discussion

The benefits of epidural analgesia after thoracotomy are numerous, including augmentation of respiratory function and decreases in incidences of arrhythmias, renal failure, and respiratory infections.20 However, incidence of POUR historically has been high in the presence of thoracic epidurals. High-dose epidurals using bupivacaine, 0.25%, have been associated with POUR rates as high as 33%,21 while rates of less than 5% have been reported with lower doses.22 Although the potentially harmful

Conclusion

A protocol endorsing indwelling catheter removal within 48 hours postoperatively among patients receiving thoracic surgery with epidural analgesia is associated with a significantly higher rate of POUR. However, an early-removal protocol may contribute to a multifaceted approach to reducing the rate of CAUTI. When implementing such a protocol, providers must first consider the need for diligent and frequent monitoring for urinary retention.

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