Suprapubic catheterization in Pediatrics

A suprapubic catheterization is basically an indwelling catheter that is placed directly through the abdomen. The catheter is inserted above the pubic bone. This catheter must be placed by a urologist.

Indications

• Urine analysis or urine culture in neonates or children younger than 2 years
• Phimosis
• Chronic infection of the urethra or periurethral glands
• Long-term catheterization
• Urethral stricture
• Urethral trauma

Contraindications

Absolute

Empty or unidentifiable bladder (e.g., child’s last urination within 1-hour, nonpalpable bladder)

Relative

• Known bladder tumor
• Lower abdominal wounds or scaring
• Overlying cellulitis
• Coagulopathy

Complications

• Bladder stones
• Blood infections
• Hematuria
• Skin breakdown
• Bowel perforation and intra-abdominal visceral injuries
• Urine leakage around the catheter
• UTI
• After many years of catheter use, bladder cancer may also develop.
• Post obstruction diuresis: Child should be monitored for 2-3 hours. If it occurs, intravenous (IV) fluid administration and correction of electrolyte is necessary.

Equipment Needed

A sterile tray containing:

• Sterile gloves
• Antiseptic solution
• Gauze pieces
• Sterile drapes
• Anesthetic solutions without epinephrine
• Syringe 10 mL
• Needles 18 and 25 G
• Scalpel blade no. 11
• Syringe 60 mL
• Percutaneous suprapubic catheter set
• Needle obturator
• Connecting tube
• One-way stopcock
• Sterile urine bag l’s
• Drain sponges
• Skin tape or nylon suture (3.0) with a needle driver

Patient Preparation

• Tell the patient or his parents that the doctor will insert a soft plastic tube through the skin of the abdomen and into the bladder,and then connect the tube to an external connection bag.
• Explain that the procedure is done under local anesthesia, that it causes little or no discomfort.
• It takes 15-45 minutes for completion of the procedure.
• Teach the parents about postoperative care of the catheter, collection bag, and surrounding skin.
• If possible, arrange for a visit by an entero-stomal therapist for more information.
• Ensure that parents or guardian has signed a consent form.
• Place the patient supine on a gurney with his or her legs spread apart.

Procedure for Suprapubic Catheterization

• Perform hand hygiene and don gloves.
• Provide adequate parenteral analgesia with or without sedation.
• Clean the lower abdominal wall.
• Shave the suprapubic area if the patient is hirsute.
• palpate the distended bladder and mark the insertion site at the midline and 2 inches (4-5 cm) above the symphysis pubis.
• With the use of ultrasonography better to verify the bladder location and to ensure that no loops of bowel are present between the abdominal wall and the bladder.
• Apply an antiseptic solution from the pubis to the umbilicus.
• Repeat the application of the antiseptic solution two more times and allow the area to dry.
• Apply sterile drapes and verify the insertion site by palpating anatomic landmark.
• Fill the 10-mL syringe with the local anesthetic agent and use the 25-gauge needle anesthetize the insertion site.
• Advance the needle through the skin, subcutaneous tissue, rectus sheath, and retropubic space, while alternating injection and aspiration, until urine enters the syringe. Note the direction and depth required to enter the bladder.
• Using the no. 11 blade, make a 4-mm stab incision at the insertion site with the blade facing inferiorly.
• Insert the needle obturator into the malecot catheter and lock it into the part by twisting it so that the needle tip projects 2-5 mm from the distal end of the catheter.
• Connect the 60-mL syringe to the part of the needle obturator.
• Place the tip of the catheter-obturator unit into the skin incision and direct it caudally and at a 20-30° angle from true vertical toward the patient’s legs.
• The practitioner’s nondominant hand should be placed on the lower abdominal wall, and the unit should be stabilized between the thumb and index finger.
• The dominant hand should be used to advance the unit, while aspirating until urine enters the syringe.
• Once urine enters the syringe, advance the unit 3-4 additional cm into the bladder.
• While securing the unit with the nondominant unscrew the obturator from the catheter.
• Advance the catheter approximately 5 additional cm over the obturator and then completely withdraw the obturator needle.
• Connect the extension tubing to the catheter and connect the tubing to a urinometer or a leg bag.
• Gently withdraw the catheter to lodge the balloon against the bladder wall.
• Undrape the patient and apply the skin preparatory solution, for example, Lenzoin to the skin.
• Apply drain dressings around the catheter at the insertion site.
• Stitch the catheter to the skin.

Post procedure Care

• Monitor the child for post obstructive diuresis for 2-3 hours.
• If this complication occurs, patients should be started with IV fluid administration and monitoring and correction of electrolytes.
• The insertion site should be inspected and cleaned with soap and water to prevent cellulitis and abscess formation.
• Simple irrigation with normal saline (NS) should resolve most catheter obstructions.
• If displacement or malpositioning of catheter occurs, the urologist should be notified, cystography can be performed.
• Every effort should be made to ensure the bladder position with palpation and ultrasonography to minimize or prevent the chances of complications.
• Ensure that the child drinks fluids adequately.
• Ensure that drainage bag is below the level of waist.
• Maintain a closed drainage system to minimize the number of times disconnecting the bag.
  Check the catheter for troubleshooting such as kinking of catheter, urine color is cloudy or catheter, balloon not deflated or bleeding. Inform the doctor immediately and take appropriate measures.

Nurse’s Responsibility

• Monitor vital signs, intake and output, and fluid status.
• Encourage coughing and deep breathing exercises and early ambulation.
• Ensure adequate drainage and tube patency.
• Check the suprapubic catheter at least hourly for the first 24 hours after insertion.
• Carefully document the color and amount of drainage from the tube, note particularly color changes.
• Assess catheter patency by checking the amount of urine in the drainage bag and by palpation for bladder distention.
• Ensure that collection bag is below waist level to enhance drainage and prevent backflow, which can lead to infection.
• As ordered, perform a voiding trial by closing stopcock (or clamping the tube) for 4 hours asking the child to attempt urination and then reopening the tube and measuring residual urine.
• To prevent kinks in the tube, curve it gently but do not bend it.
• Tape the catheter securely in place on the abdominal skin to reduce tension and prevent dislodgement.
• Becomes dislodged, immediately notify the doctor.
• Irrigate the suprapubic catheter as ordered.
• Check the catheter frequently for kinks or obstruction. If mucous or a blood clot blocks the tube, try milking it to restore patency.
• If you cannot clean the obstruction promptly, notify the physician.
• Check drainage often and change often at least once per day or as ordered.
• Observe the skin around the insertion site for signs of infection and encrustation.

Home Care Instructions

• Teach the child/his parents how to change the dressing and how to empty and reattach the collection bag.
• Encourage to drink plenty of fluids to reduce the risk of complications.
• Stress the importance of regular follow-up examination to allow early detection of possible complications.
• Tell the patient/his family to notify the doctor promptly any signs of infection or encrustation such as discolored or foul-smelling discharge, impaired drainage or swelling, redness, and tenderness at the tube insertion site.

Duration of Changing the Catheter

• once a month to decrease infection.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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