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Top panel: Ultrasound scan of patient # 1 revealed no urinary catheter in the bladder. Bottom panel: The balloon of Foley catheter was seen in membranous urethra, 7 cm from the tip of penis.
Source publication
We report the anecdotal observation of substandard urological care of elderly paraplegic patients in the community suffering from long-term sequelae of spinal cord injuries. This article is designed to increase awareness of a problem that is likely underreported and may represent the 'tip of the iceberg' related to substandard care provided to the...
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Background:
Children aged 6 months to 5 years with diaphyseal femur fractures are typically treated with spica casting, as recommended by the American Association of Orthopaedic Surgeons clinical practice guideline. We aimed to determine the incidence of secondary interventions after early spica casting for femur fractures in children aged 6 years...
Citations
... Many physicians face concerns regarding proper follow-up monitoring of these individuals. Studies report that, even in developed countries, patients after SCI are often not monitored appropriately [5][6][7][8][9][10][11][12][13]. The aim of this review is then to summarize and appraise currently available data and make consensual recommendations to help clinicians offer adequate follow-up of their SCI patients. ...
Purpose:
To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice.
Methods:
Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR).
Results:
Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy.
Conclusion:
Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.
... Another reason is the habit of using spinal cord injury patients, especially elderly persons, for "practising clinical skills" by student nurses and trainee doctors, be it administration of intramuscular injection, or transurethral catheterisation. Unless this custom is halted, spinal cord injury patients will continue to suffer from iatrogenic complications and receive substandard clinical care [2]. ...
Background
Inflating the balloon of Foley catheter in urethra is a complication of urethral catheterisation. We report five patients in whom this complication occurred because of unskilled catheterisation. Due to lack of awareness, the problem was not recognised promptly and patients came to harm. Case series1.A tetraplegic patient developed pain in lower abdomen and became unwell after transurethral catheterisation. CT pelvis revealed full bladder with balloon of Foley catheter in dilated urethra. 2.Routine ultrasound examination in an asymptomatic tetraplegic patient with urethral catheter drainage, revealed Foley balloon in the urethra. He was advised to get catheterisations done by senior health professionals. 3.A paraplegic patient developed bleeding and bypassing after transurethral catheterisation. X-ray revealed Foley balloon in urethra; urethral catheter was changed ensuring its correct placement in urinary bladder. Subsequently, balloon of Foley catheter was inflated in urethra several times by community nurses, which resulted in erosion of bulbous urethra and urinary fistula. Suprapubic cystostomy was performed. 4.A tetraplegic patient developed sweating and increased spasms following urethral catheterisations. CT of abdomen revealed distended bladder with the balloon of Foley catheter located in urethra. Flexible cystoscopy and transurethral catheterisation over a guide-wire were performed. Patient noticed decrease in sweating and spasms. 5.A paraplegic patient developed lower abdominal pain and nausea following catheterisation. CT abdomen revealed bilateral hydronephrosis and hydroureter and Foley balloon located in urethra. Urehral catheterisation was performed over a guide-wire after cystoscopy. Subsequently suprapubic cystostomy was done. Conclusion
Spinal cord injury patients are at increased risk for intra-urethral Foley catheter balloon inflation because of lack of sensation in urethra, urethral sphincter spasm, and false passage due to previous urethral trauma. Education and training of doctors and nurses in proper technique of catheterisation in spinal cord injury patients is vital to prevent intra-urethral inflation of Foley catheter balloon. If a spinal cord injury patient develops bypassing or symptoms of autonomic dysreflexia following catheterisation, incorrect placement of urethral catheter should be suspected.
... 1 The risk of misplacement of transurethral catheter is greater when catheterization is performed by inexperienced health professionals. 2 A tetraplegic patient who attended accident and emergency with blocked urethral catheter has been reported in this article. After three unsuccessful attempts of catheterization, a three-way catheter was inserted by a junior doctor who failed to follow instructions on the catheter package. ...
... Moreover, mature, accomplished health professionals are likely to be familiar with changes in body systems due to old age, compounded further by spinal cord injury. 2 Tetraplegic subjects tend to have decreased muscle mass, and consequently, creatinine level is low. The patient had the creatinine level of 19 µmol/L on day 1; 6 days later, the creatinine level had increased to 46 µmol/L (range: 0-135 µmol/L). ...
A male tetraplegic patient attended accident and emergency with a blocked catheter; on removing the catheter, he passed bloody urine. After three unsuccessful attempts were made to insert a catheter by nursing staff, a junior doctor inserted a three-way Foley catheter with a 30-mL balloon but inflated the balloon with 10 mL of water to commence the bladder irrigation. The creatinine level was mostly 19 µmol/L (range: 0-135 µmol/L) but increased to 46 µmol/L on day 7. Computerized tomography urogram revealed that the bilateral hydronephrosis with hydroureter was extended down to urinary bladder, the bladder was distended, prostatic urethra was dilated and filled with urine, and although the balloon of Foley catheter was not seen in the bladder, the tip of the catheter was seen lying in the urethra. Following the re-catheterization, the creatinine level decreased to 21 µmol/L. A follow-up ultrasound scan revealed no evidence of hydronephrosis in both kidneys. Flexible cystoscopy revealed inflamed bladder mucosa, catheter reaction, and tiny stones. There was no bladder tumor. This case report concludes that the cause of bilateral hydronephrosis, hydroureter, and distended bladder was inadequate drainage of urinary bladder as the Foley balloon that was under-filled slipped into the urethra resulting in an obstruction to urine flow. Urethral catheterization in tetraplegic patients should be performed by senior, experienced staff in order to avoid trauma and incorrect positioning. Tetraplegic subjects with decreased muscle mass have low creatinine level. Increase in creatinine level (>1.5 times the basal level) indicates acute kidney injury, although peak creatinine level may still be within laboratory reference range. While scanning the urinary tract of spinal cord injury patients with indwelling urinary catheter, if Foley balloon is not seen within the bladder, urethra should be scanned to locate the Foley balloon.
... Therefore, spinal cord injury patients should be preferably treated by senior, experienced health professionals. 3 This report describes a mishap that occurred in daily clinical practice. In order to prevent such mishaps, health professionals should be educated regarding possible causes and early detection of doubling back of urethral catheters (see 'Learning points' below). ...
A 51-year-old man with C-6 tetraplegia had ureteric calculi, developed ureteric stricture and required bilateral nephrostomy. Following change of the left nephrostomy, bloody urine was drained per nephrostomy. The urethral catheter was also changed; bloody drainage per urethral catheter was attributed to blood seeping from the left kidney. The length of the Foley catheter outside the penis appeared correct; therefore, it was presumed that the catheter had been introduced into the bladder. The following day, bladder washout could not be performed due to blockage of the catheter. CT of the kidneys and bladder revealed doubling back of the Foley catheter in the bulbar urethra with the balloon inflated in the urethra. The urethral catheter was removed and another catheter inserted satisfactorily by a senior doctor. From this experience we learned that a 'Long Catheter Sign' will not be positive if the catheter doubles back in the urethra. When in doubt, imaging studies should be performed immediately to check the position of the Foley catheter.
Admitting and discussing medical or surgical errors with patients is a delicate and daunting task for the surgeon. The ramifications of admitting a mistake made by the surgeon are enormous, ranging from simple embarrassment to suffering through lengthy malpractice litigation. Due to these issues, open reporting of errors is not as well established in the medical profession as it is in other industries. Although hampered by the legal system, discussion of these errors is vitally important for patient safety and should be peer-reviewed and published. Only by analysis of the root cause will we be able to address common errors that harm our patients.
