098. Complications of Urologic Procedures and Devices

Foley Catheter

Catheter types: Standard Double Lumen, Coude – anterior bent, for BPH, Silicone – more rigid – go down in size, good for strictures, also good with latex allergies.
Male Urethra: S-shaped curve. About 20cm. Female Urethra: 4cm.
4 step approach:
  1. Relax them – relax external sphincter. deep breaths, viscous lidocaine (urojet).
  2. Position them – elongate penis at 60-90 degrees.
  3. Good technique – slow, steady pressure. Insert to Y-hub and then inflate. STOP if pain.
  4. Obstruction – BPH patients: coude or larger catheter. Strictures: use silicone catheter. If not, call urology.

References

The Foley that Won’t Go In, Ramin Tabatabai, Essentials of EM 2014

098. Complications of Urologic Procedures and Devices

096. Male Genital Problems

Testicular Torsion

1 in 4000 men under 25yo. Incidence bimodal – neonates and age 12-18. Case review showed 31% of patients presented with abdominal pain alone.

Loss of cremasteric reflex is not 100% sensitive, particularly in young boys. There can be history of similar pain in the past. If pain is intermittent, can have a ‘normal’ US with intermittent torsion.

 

References/Resources

EMRAP, Medical Legal Briefs: Testicular Torsion, December 2017

096. Male Genital Problems

094. Urinary Tract Infections and Hematuria

Renal Infarctions

Commonly missed as misdiagnosis of kidney stone or pyelonephritis vs musculoskeletal pain. Usually embolic (afib, cardiomyopathy, LV aneurysm, MV stenosis/prolapse, artificial valve) vs in-situ thrombosis (aneurysm, dissection). Presents as acute onset flank pain. Hematuria (32-72%), fever (10%). Creatinine usually normal. LDH very sensitive (usually >300). Diagnosis with CT with contrast. Tx: anticoagulation. Look for big picture – embolic syndrome. Needs likely TEE as well. (USC Rounds, 10/12/17).

 

 

6 UTI myths

  1. Cloudy/foul urine is usually an UTI. Cloudy/foul likely related to hydration status of patient; does not mean patient is having UTI.
  2. Positive bacteria means UTI. Asymptomatic bacteremia is common in all ages groups. Virtually 100% of indwelling catheters colonize within 2 weeks.
  3. Nitrite positive means UTI. Study showed in nursing home patients with both positive nitrite/leukocyte esterase, only 48% positive for true UTI.
  4. Pyuria means UTI. 6-10 WBC can be related to hydration status as well.
  5. AMS and bacteruria – can be observed for 1-2 days for possible resolution of AMS before treating (no realistic in my experience).
  6. Yeast/Candida in Urine with catheters needs treatment. Colonization. Very rare to cause symptoms. Isolation of candida in urine of noncatherized patients should raise concerns for vaginal or external contamination.
094. Urinary Tract Infections and Hematuria

092. Rhabdomyolysis

General

Acute necrosis of skeletal muscle fibers and leakage of cellular contents into circulation.

MCC: alcohol (chronic alcoholics also have deficits in hypokalemia/hypomagnesium/hypophosphatemia which can exacerbate) as well as drugs of abuse (cocaine, PCP, LSD, amphetamines). 3 categories: traumatic (crush injuries), non-traumatic exertional (marathoners), non-traumatic non-exertional (drugs)

Other drugs: antipsychotics, lipid-lowering agents (statins, chofibrate), SSRIs, zidovudine, colchine, lithium, antihistamines, narcotics.

Infectious causes: influenza, legionella

Causes of Rhabdomylosis. Taken from Tintinalli

Clinical Features

Myalgias, stiffness, weakness, malaise, low-grade fever, dark urine. Swelling/tenderness to involved muscle groups though can be localized or diffuse (postural muscles common: thigh, calves, lower back).

Diagnosis

Elevated CK correlates with amount of muscle injury and severity of illness though does not correlate with chances of renal failure or mortality. Usually 5x normal range. Rises 2-12 hours after vent, peaks at 24-72 hours, then drops at about 40% per day afterward.

Myoglobin rises before CPK. Contains heme so urine dipstick will be positive though negative RBCs. About 20% of rhabdo will have myoglobinuremia (Alhedi, 2014). Very specific, though not very sensitive.

BUN/Cr will be lower likely less than 10 due to elevated creatinine rise with muscle breakdown. Look for elevated potassium/phosphate due to muscle cell breakdown.

Treatment

Complications include DIC, elevated LFTs, renal failure (obviously)

IV fluids is the maintain of therapy. NS > LR. Need urine output at 250cc/hr if admitted.

Urine alkalization (theory is myoglobin which typically causes the nephrotoxicity is worse in acidic environment; sodium bicarb 1amp/1 NS L at 100cc/hr), diuretics, mannitol have no benefit in the ED (or likely at all).

Healthy patients with exertional rhabdo with no co-morbidites can be discharged after oral and IV fluids. Paper looking at patients at risk for severe renal failure only showed if initial creatinine > 1.7 was only true RF (Fernandez, 2005). Also consider >6000 and continuing to trend upward.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 92: Rhabdomyolysis

CrashingPatient.com, Rhabdomyolysis

EMRAP, C3 Project, June 2012

EMCAST, November 2009

092. Rhabdomyolysis

091. Acute Renal Failure

General

3 types: pre-renal (decreased blood flow), intrinsic (renal parenchyma insult) and post-renal (obstructed renal outflow). In the community, pre-renal is the most common cause usually secondary to volume depletion.

Normal GFR for child is >120, decreases by 8 every decade. Lower muscle mass (women, elderly) leads to lower baseline creatinine.

Acute renal failure usually asymptomatic until severe uremia: nausea/vomiting, drowsiness, fatigue, confusion, coma.

Renal US is the imaging study of choice initially. Can be down bedside in the ED. If seeing hydronephrosis, likely need non contrast CT to look for where and what is the obstruction.

Pre-Renal

Tubular/glomerular function maintained. Usually presents with thirst, orthostasis, lightheadedness, decreased urine output.

Causes include hypovolemia (N/V/D, burns), hypotension from hemorrhage, decreased cardiac output (MI, cardiomyopathy, anti-HTN medications, nitrates). Prlonged pre-renal failure can cause ATN.

BUN/Cr ratio > 20, though not specific/sensitive. Also look for increased urine specific gravity. FeNa: Una/Pna x Ucr/Pcr. Usually < 1% in pre-renal. Limitations as well. Also have hyaline casts.

CHF/cirrhosis: can have volume overload but have intra-arterial volume loss. Diuretcs may worsen renal failure and volume loss.

Treatment: IVF, augment cardiac output.

Intrinsic

Disease of glomeruli, intrarenal vasculature, interstitium. Most common cause is ATN (acute tubular necrosis), also sometimes called acute kidney injury. Due to ischemia from cardiac arrest, sepsis, hypotension, trauma/surgery.

Check urine and urine electrolytes. Look for granular casts.

Acute glomerulonephritis: hematuria, proteinuria and RBC casts. Dark urine + edema along with fever, malaise, rash.

Pulmonary-renal syndromes: Goodpasture, Wegeners – cough, SOB, hemoptysis.

Radiocontrast-induced nephropathy: increasing creatinine over 3-5 days with usually complete resolution. Need to consider not doing IV contrast with GFR < 60.

Acute interstitial nephritis: usually due to drug (PCN, diuretics, NSAIDs) and infection. Rash, fever, eosinophilia and proteinuria. Treat underlying cause.

Post-Renal

Usually secondary to BPH or functional bladder neck obstruction (neurogenic bladder).

Renal US initially, then non contrast CT to look for cause of obstruction.

Post-obstructive diuresis can result in significant volume loss. Usually with prolonged obstruction. If output is >250mL/hr for >2 hrs, may need to consider admission.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 91: Acute Renal Failure

Rosens, Chapter 87: Renal Failure

091. Acute Renal Failure