Does the VIT Vellore Campus PVR
Combined spinal epidural urinary retention
Participation in the study begins at the patient's request for a laboratory analgesia. The patient is asked to urinate and a post-void residual (PVR) is measured via ultrasound. If the PVR & gt; 100 ml, the patient will be excluded from the study. If the CSE is not preserved during CSE placement or the CSE technique is abandoned for any other reason, the patient will be excluded. If the PVR <100 ml and the combined spinal epidural analgesia is successful, they will be randomized to either receive routine Foley catheter placement or start the spontaneous micturition protocol. The last cervical exam and VRS pain are recorded at this point.
Subjects are prepared in the usual manner for the combined spinal epidural with hemodynamic monitoring and intravenous (IV) access.
The anesthetist routinely performs a combined epidural analgesia of the spine by the test person in a sitting position using sterile technology in the L3-4 space (± one vertebral space). The epidural space is found using the loss of resistance technique with either 3 ml of air or saline and a 17G Touhy needle. After the epidural space is identified, the dura is punctured with a 27G pencan and 2.5 mg simple bupivacaine + 15 μg fentanyl is injected. The epidural catheter will be inserted into the catheter up to 3-5 cm in the epidural space and a test dose of 3 ml 1.5% lidocaine + 1: 200,000 adrenaline will be the epidural catheter secured and the PCEA initiated at the standard infusion rate and boluses administered by the patient below Use of 0.06% bupivacaine + 2 mcg / ml fentanyl. Post-procedure vital signs will be monitored in the usual way.
Patients randomized to the control group will receive a Foley catheter placed after the CSE performed as is customary in this facility. Your bladder volume is assessed using ultrasound before the Foley catheter is placed. The one in the Foley bag is used to validate our ultrasonic measurements.
Patients randomized to the spontaneous micturition algorithm are examined for spontaneity and post-void residual volume (PVR) using ultrasound at regular intervals. First, the patient's bladder volume is measured using ultrasound. this is followed by an attempt at spontaneous micturition. The patient will have an attempt at spontaneous micturition only if their bladder & gt; Contains 100 ml of urine. This ensures the inability to micturate is not due to insufficient urine in the bladder prior to their attempt to micturate spontaneously to ensure that the patient has no urinary retention required when placing the Foley catheter.
The first attempt at spontaneous urination occurs two hours after the analgesic dose to the spine. A study by Campbell et al. showed no urinary retention with this intrathecal dose, but it is possible that the spinal dose is still present and has a different effect than the epidural analgesic dose. As a result of this possibility, we decided that if a patient has a urinary retention dose on this first attempt, 2 hours after the spine injection, they will have a straight catheterization and will get another chance of spontaneous micturition more than 3 hours after the spine dose injection . This ensures the spine is completely worn out and the epidural analgesic dose is effective before committing the patient to a bedpan or Foley catheter.
Most patients will have their ability to spontaneously urinate and examine at least twice for their ability to perform spontaneous urination and have their PVR volumes ultrasound before being assigned to a bedpan every 2 hours or Foley catheter placement. If the patient is able to spontaneously micturate twice and their PVR is & lt; 100ml, they are assigned to a bedpan every 2 hours A patient can be given a PVR & gt; Do not mictle 100 ml. He is given a Foley catheter.
The spontaneous micturition algorithm allows a maximum of 3 micturition attempts before a patient is obliged to either use a bedpan every 2 hours or place a Foley catheter. In the event a patient can mictate spontaneously but has an incomplete bladder emptying with a PVR of 100-250 ml, they can continue one-third of the algorithm and make a last attempt at spontaneous micturition. If the patient is able to spontaneously mictate on this last attempt with a PVR volume & lt; 100 ml, they are assigned to a bedpan every 2 hours, but if their PVR & gt; If 100 ml remains, a Foley catheter is placed.
Occasionally, patients meanwhile require a rescue bolus with higher concentration local anesthesia work for breakthrough pain. In this case, the usual rebolus dose of up to 15 ml bupivacaine 0.125% is administered in incremental doses that are tailored to the patient's comfort. With this rebolus, the infusion rate is increased as usual to 20 ml / h. If a patient who previously had to use a bedpan every 2 hours requires a rescue bolus of local anesthetic, their ability to spontaneously urinate will be reassessed 2 hours following the rebolus to determine if reassignment to Foley catheter placement is required higher doses of bupivacaine.
If a patient who should use a bedpan every 2 hours needs a second rebolus, he must receive a further rebolus dose of up to 15 ml bupivacaine 0.125%, the concentration of the epidural bupivacaine infusion is reduced to 0.11% bupivacaine + 2 mcg fentanyl / ml increased As is our normal practice, they are automatically assigned to a Foley catheter for placement.
If a study patient needs a cesarean section, a Foley catheter is inserted at the time, opting for cesarean section delivery and removed 24 hours after the procedure as usual practice at our institution.
The primary outcome (urine culture positive rate) of this study is assessed by collecting a twenty-four to forty-eight hour urine sample and performing a urine culture. The clinical and laboratory criteria for defining a urinary tract infection in a woman immediately after birth is unknown. If the patient is considered straightforward (normal female urinary physiology) then she would only be treated if she has symptoms. If the patient is considered complicated (pregnant urinary physiology) then she would be treated for bacterial growth on urine culture, even if asymptomatic. For this reason, and for the purpose of this study, if the patient is asymptomatic for a urinary tract infection but has a positive urine culture with 50,000 Colony Forming Units (CFU) / ml bacteria, the patient's obstetricians will be notified and they will likely be treated with antibiotics if they are suspected Urinary tract infection. This is more conservative than the current guidelines for asymptomatic bacteriuria in pregnancy. If a positive urine culture is identified and the patient is symptomatic (at least 1 sign / symptom) with the number of bacterial colonies exceeding 10,000 CFU / ml, the obstetrician will be notified and treated with antibiotics for suspected urinary tract infection. This is more conservative than the catheter-related infection guidelines.
In addition to the primary outcome data, the following information is collected: Satisfaction with the bladder treatment protocol (100 mm scale, 0 mm = not satisfied at all 100 mm = very satisfied), total length of work, length of stage 2, type of delivery, presence and degree of cuts, weight of the fetus, duration of Foley catheterization, time to first spontaneous cavity after delivery or removal of the Foley catheter, total fluid administered during labor, and total dose of epidural analgesics.
In addition, a postvoidal remnant (PVR) is examined 8 to 24 hours after the ultrasound. Delivery or removal of the Foley catheter to assess postpartum urinary retention. If the PVR is At a postpartum value of & gt; 100ml this will be considered urinary retention and obstetrician and co-investigator (urogynecologist) will be notified.
The following demographics are also collected: maternal age, height, weight, pre-pregnancy weight, and gestational age.
A telephone follow-up examination 8 weeks after delivery will examine the patient's treatment of urinary tract infections and urinary retention during or after discharge from the hospital. .
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