凝血酶治疗长期留置尿管合并尿道出血的疗效

目的:探讨凝血酶治疗长期留置尿管合并尿道出血的疗效.方法:将长期留置尿管合并尿道出血的患者47例随机分为两组,均给予1:5000呋喃西林膀胱冲洗,治疗组在此基础上加用凝血酶2000u溶于20ml生理盐水经尿管注入膀胱,比较两组患者24h及48h治疗有效率.结果:对照组24h及48h治疗有效率分别为26.09％、52.17％,治疗组分别为62.50％、87.50％,统计学分析有显著性差异(0.01＜P＜0.05).两组在治疗过程中未发现明显毒副作用.结论:凝血酶有良好的止血效果,对长期留置尿管合并尿道出血有明显疗效.     

Safer urethral catheters: how study of catheter balloon pressure and force can guide design

What's known on the subject? and What does the study add? The urethal catheter is a ubiquitous device that has not been modified or improved for safety in the last 20 years, although it can be associated with significant patient harm. This study utilizes force and pressure measurements of the urethral catheter in order to aid in future safety modifications.

OBJECTIVES

• ? To better define urethral catheter balloon pressures and extraction forces during traumatic placement and removal of urethral catheters.
• ? To help guide design for safer urethral catheters.

MATERIALS AND METHODS

• ? Measurements of balloon pressure were made upon filling within the urethra vs the bladder.
• ? Extraction forces were measured upon removal of a catheter with a filled balloon from the bladder.
• ? Models for the bladder and urethra included an ex vivo model (funnel, ‘bladder’, attached to a 30 F tube, ‘urethra’) and fresh human male cadavers.
• ? The mean (sem ) balloon pressures and extraction forces were calculated.

RESULTS

• ? In the ex vivo model, the mean (sem ) pressures upon filling the balloon with 10 mL were on average three‐times higher within the ex vivo‘urethra’ (177 [6] kPa) vs ‘bladder’ (59 [2] kPa) across multiple catheter types.
• ? In the human cadaver, the mean balloon pressure was 1.9‐times higher within the urethra (139 [11] kPa) vs bladder (68 [4] kPa).
• ? Balloon pressure increased non‐linearly during intraurethral filling of both models, resulting in either balloon rupture (silicone catheters) or ‘ballooning’ of the neck of the balloon filling port (latex catheters).
• ? Removal of a filled balloon per the ex vivo model ‘urethra’ and cadaveric urethra, similarly required increasing force with greater balloon fill volumes (e.g. 9.34 [0.44] N for 5 mL vs 41.37 [8.01] N for 10 mL balloon volume).

CONCLUSIONS

• ? Iatrogenic complications from improper urethral catheter use is common.
• ? Catheter balloon pressures and manual extraction forces associated with urethral injury are significantly greater than those found with normal use.
• ? The differences in pressure and force may be incorporated into a safer urethral catheter design, which may significantly reduce iatrogenic urethral injury associated with catheterization.

     

尿道会师术后导尿管留置时间的探讨

目的明确早期尿道会师术后支架导尿管留置时间与尿道愈合的关系。方法对３９例骨盆骨折合并后尿道断裂的患者采用导管周围尿道造影,对会师术后尿道愈合进行连续观察。结果３０例（７６％）导尿管留置时间在８周以上尿道始愈合;９例（２４％）在６周以内愈合;愈合时间最短者４周,最长者１８周。经１～１４年随访,排尿正常者２４例（６９％）,每年尿道扩张不超过２次;排尿基本正常者７例（２０％）。结论导尿管留置时间与尿道愈合、治疗效果呈正相关关系,而导管周围尿道造影可为支架导尿管的拔除提供可靠依据     

Incorrect Positioning of an Indwelling Urethral Catheter in the Ureter

An unusual case where a urethral catheter was indwelt in the left ureter is presented. A small contracted bladder and a patulous ureteral orifice appeared to be causative factors of this complication.     

Can normal saline be used to fill the balloon of a Foley catheter? The experience of a prospective randomized study in China

BACKGROUND: Despite the lack of evidence, using normal saline for inflating the balloon of a Foley urethral catheter is frequently regarded as a cause for deflation failure. We have investigated the issue by comparing the rate of deflation failure of Foley catheter balloon, using either sterile water or normal saline as the filling solution. METHODS: Four thousand latex Foley urethral catheters (14 Fr) were randomly assigned to one of two groups: sterile water or normal saline. Each of the catheter balloons would then be inflated with 10 mL of the corresponding fluid. They were subsequently put in water baths at 37 degrees C for 4 weeks. At the end of 4 weeks, all the balloons were deflated by people who were blind to the assignment of fluid inflated. Failure of deflation was defined as the balloon not being able to be deflated completely. The number of deflation failures was recorded and the amount of fluid aspirated from each balloon was also noted. RESULTS: Of the 4000 catheters, 17 (0.43%) were found to be defective and could not be used for the study. The remaining 3983 catheters were randomly allocated into the sterile water (2011) and normal saline (1972) groups. The failure rate of deflation for the sterile water group and normal saline group were 185 (9.2%) and 157 (8.0%), respectively, which was not statistically significant (P = 0.162). CONCLUSION: There was no difference in the rate of deflation failure of latex Foley balloons by using either sterile water or normal saline as the filling solution.     

Effect of urethral catheterisation on urethral sphincter emg and pressure profile

The impact on urethral sphincter EMG and pressure profile of the introduction of a catheter per urethram was assessed in 48 women with various voiding dysfunctions. Urethral EMG activity was recorded with vaginal surface electrodes placed behind the midurethra. A 5F urethral profile catheter was used in 13 patients (group I), an 8F in 23 patients (group II), and a 10F in 12 patients (group III). In all three groups a statistically significantly increased EMG activity was observed following the introduction of the catheter. This increased activity ceased after a median time of 3–5 minutes. The increased EMG activity did not affect the maximum urethral closure pressure and functional profile length. No correlation could be established between changes in EMG activity and changes in urethral closure pressure. It is concluded that the increased sphincter EMG activity provoked by catheterisation does not affect the urethral pressure profile significantly.     

自制尿道导向器在尿道损伤中的应用

目的：探讨自制尿道导向器在尿道损伤中的应用方法和疗效。方法：对38例尿道损伤患者第一时间于床边应用自制尿道导向器,轻贴尿道12点处缓慢推进,到达损伤部位,如能顺利滑人并通过受损部位,则证实为尿道黏膜损伤或尿道不完全断裂伤。将尿道导向器推人膀胱,置人斑马导丝或输尿管导管至膀胱,顺导丝推人剪开尖部小孔的二腔或三腔气囊导尿管,完成操作。如置入尿道导向器受阻,考虑尿道完全性断裂,标志并记住受损位置,送手术室在硬膜外麻或局麻下行耻骨上膀胱穿刺,插入弯型尿道导向器至断端处,由尿道口置人直型尿道导向器,两导向器在断端处对接,或由尿道外口置入输尿管镜于尿道断端处,发现弯型尿道导向器头部中心孔并对接,置入导丝通过对接口至膀胱,顺导丝推入导尿管。结果：本组38例均一次操作手术成功,术后均恢复正常排尿。其中5例有不同程度尿道狭窄,经3～6个月尿道扩张,均能达到正常排尿。2例尿道狭窄较明显患者行尿道镜检查,尿道瘢痕长度均小于1．5cm。结论：自制尿道导向器在尿道损伤中应用效果良好,在尿道黏膜损伤、尿道裂伤、尿道不完全断裂伤中能在第一时间于床边给予有效处理治疗。在尿道完全性断裂伤中,手术快速简单,治疗效果良好,能有效减少尿道狭窄的发生或减少瘢痕长度。     

输尿管镜下尿道会师术治疗尿道断裂伤

目的探讨输尿管镜下留置导尿管治疗男性尿道断裂伤的方法与疗效。方法2007年5月～2012年4月采用输尿管镜下留置导尿管治疗男性尿道断裂伤18例。术中镜下寻找尿道球部或膜部近端断裂处,插入导丝于膀胱,沿导丝置入气囊导尿管恢复尿道连续性。结杲术后平均随访6个月,13例拔除导尿管后恢复正常排尿,5例合并尿道狭窄,其中3例结合尿道内切开、2例定期尿扩后排尿通畅。结论输尿管镜下留置导尿管治疗尿道断裂伤安全和有效。     

Restriction of long-term indwelling urethral catheterisation in the elderly

Eighty-nine (16%) of 543 patients admitted to a chronic care centre in 1983 had an indwelling urethral catheter. Of the 89, 51 patients (57%) received the catheter in a general hospital, 4 (5%) at home and 34 (38%) in the centre. More than half of the catheters that were inserted in the hospital could be removed within 4 weeks of admission to the centre, implying that a more restricted use of indwelling catheters in hospitals is possible. Only 18% of the indwelling catheters remained in situ for the designated period of 1 month. The other catheters were changed before that time, mainly because of obstructed drainage or leakage of urine around the catheter. The incidence of bacteriuria among catheterised patients was 90%. The bacteria were multiresistant in 37% of these cases, compared with 25% of non-catheterised patients. Multiresistant microflora were present significantly more often in the urine of patients admitted from hospitals (irrespective of whether they had a catheter) and the catheterised residents of the centre than in that of the other patients (P less than 0.001). When all patients of the centre were considered, it was found that 30.6% were treated with antimicrobial agents in the course of the year; 10.9% were treated more than once a year. This latter group of patients received 58% of all prescribed antimicrobial drugs; 37% of them had an indwelling catheter. The majority of catheterised patients (65%) did not need antimicrobial treatment. No significant influence of catheterisation on mortality could be demonstrated.     

Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary‐care teaching hospital

OBJECTIVE

To examine the magnitude of potentially avoidable iatrogenic complications of male urethral catheterization (UC) within a tertiary‐care supra‐regional teaching hospital, and to evaluate risk factors and subjective feeling of interns in our institution on the adequacy of training on UC.

SUBJECTS AND METHODS

Male UC‐related morbidities were retrospectively identified from our computerized inpatient urology consultation system over a 1‐year period from July 2006 to June 2007. Relevant medical records were also reviewed. An anonymous questionnaire was used for the subjective assessment of interns about their training on UC. The primary outcome measures were the prevalence of urethral trauma secondary to UC by a non‐urological team member in non‐urological departments, risk factors and intern‐perceived adequacy of practical and theoretical training on UC during their intern year, and finally the supervision of interns during first UC.

RESULTS

Of 864 urological consultations, 51 (6%) were related to complications arising from male UC during the 1‐year period. The most common indication for UC was monitoring urinary output for acute medical illness (34/51, 67%). The most common complication was urethral trauma (35/51, 67%). The balloon was accidentally inflated in the urethra in six patients (12%). Of the 51 cases of UC‐related morbidity, 38 (74%) resulted from interns performing UC, and of these 28 (73%) occurred during the first 6 months of internship. Overall, 76% of interns felt that their practical training was none or inadequate; 52% (26/50) did not receive any supervision during their first UC.

CONCLUSIONS

UC‐related iatrogenic morbidity is not uncommon even in a tertiary‐care teaching hospital. This study identified that interns receive inadequate training on UC. Finally, most of the complications are potentially avoidable and can be prevented by adopting a proper technique of catheterization. Adequate training and supervision of medical students and interns can achieve this.     

1500例临时静脉留置导管透析的临床分析

目的探讨临时静脉内留置导管透析的血管选择、透析效果、并发症、影响因素及处理。方法静脉置管后观察导管血流量、留置时间、尿素清除指数（Kt／V）、再循环、血液流变学指标、并发症及其影响因素。结果颈内静脉、锁骨下静脉、股静脉是留置导管静脉常选静脉。1500例静脉留置导管总体使用良好，透析充分，Kt／V平均1．20±0．35；导管再循环率低为（10．5±2．5）％；留置导管常见的并发症依次为血流量不足、栓塞、感染、导管脱落等。大多数能通过调整导管位置、导管内溶栓及抗感染等处理改善；5例反复发生栓塞者血纤维蛋白原显著升高；导管尖端位于右心房者与上腔静脉者比较，前者具有更好的血流量、再循环率低[（285±50．5）ml／minVS（205±45．5）ml／mim（8±3．5）％VS（12±4．5）％，（P〈0．05）]；导管腔内高浓度肝素与低浓度肝素比较，前者导管留置时间明显延长（P〈0．05），检塞发生率减少（P〈0．05）。结论临时静脉内留置导管透析血流量充分，透析疗效确切。留置导管常见的并发症有血流量不足、栓塞、感染等，绝大多数能通过处理矫正。导管尖端位置、导管腔肝素浓度、血液粘度等对导管成活、血流量不足、栓塞有重要影响。     

An indwelling urinary catheter for the 21st century

What's known on the subject? and What does the study add? A vast literature has been published on the prevalence, morbidity and microbiology of catheter‐associated urinary tract infections. Research and development in recent years has focused on producing antibacterial coatings for the indwelling Foley catheter with insufficient attention to its design. This article provides a critical examination of the design of the indwelling Foley catheter. Design specifications are outlined for a urine collection device that should reduce the vulnerability of catheterised urinary tract to infection. The indwelling urinary catheter is the most common cause of infections in hospitals and other healthcare facilities 1 . As long ago as 1958, Paul Beeson 2 warned ‘… the decision to use this instrument should be made with the knowledge that it involves the risk of producing a serious disease which is often difficult to treat’. Since then, scientific studies have progressed revealing a greater understanding of the bladder's defence mechanisms against infection and how they are undermined by the Foley catheter 3 - 5 . In addition, the complications caused by the development of bacterial biofilms on catheters have been recognised and the ways in which these bacterial communities develop on catheters have become clear 5 , 6 . It is now obvious that fundamental problems with the basic design of the catheter, which has changed little since it was introduced into urological practice by Dr Fredricc Foley in 1937 7 , induce susceptibility to infection. These issues need to be addressed urgently if we are to produce a device suitable for use in the 21st century.     

膀胱尿道联合冲洗器用于留置尿管致泌尿系感染的效果

目的观察留置尿管致泌尿系感染患者行膀胱尿道联合冲洗的临床效果。方法将86例长期留置尿管所致泌尿系感染患者随机分为观察组与对照组各43例。在抗感染的同时,对照组进行常规密闭式膀胱冲洗,观察组应用自行设计的膀胱尿道联合冲洗器行膀胱尿道联合冲洗。冲洗液均采用0.2%呋喃西林溶液。两组于冲洗后第3、7、10、14天上午,冲洗前用一次性注射器抽取尿液行细菌培养及高倍镜检。结果观察组第3、7、10天感染阳性率显著低于对照组(均P<0.05)。结论对留置尿管致泌尿系感染患者进行膀胱尿道联合冲洗有利于加速病菌的清除,有较好的辅助治疗作用。     

颈静脉留置针穿刺治疗单纯性肾囊肿的体会

目的探讨颈静脉留置针穿刺治疗单纯性肾囊肿的疗效. 方法回顾分析61例单纯性肾囊肿在超声波定位下使用颈静脉留置针行囊肿穿刺并联合无水乙醇注射治疗的临床资料. 结果一次性治愈52例,复发9例,再次穿刺治愈6例,3例反复复发后改行囊肿去顶术治愈.除3例有一过性淡血尿外,余无并发症. 结论用颈静脉留置针行单纯性肾囊肿穿刺治疗具有微创、安全、有效和经济等优点.     

骨盆骨折后尿道断裂治疗体会

对后尿道断裂复位固定术进行改良。经膀胱尿道会师后，从膀胱颈４点和８点处采用１０号丝线缝向会阴，垫以橡皮圈结扎，使向上移位的前列腺尿道准确复位。该法避开常规的耻骨后区探查，仅在膀胱内操作，术野清晰、手术简单，且能使上移的前列腺处于复位的状态，从而避免了勃起神经和血管的医源性损伤。以该法治疗２２例后尿道断裂者均在３周左右康复，无阳萎和尿失禁，偶需尿道扩张     

Long-term urethral catheter drainage and bladder capacity

Bladder capacity has been registered with incremental water cystometry in 399 paticnts with continuous long-term urethral catheter drainage. The duration of cathcter drainage varied from a few weeks to 15 years. The real bladder capacity was assessed by abolishing bladder overactivity, when present, with an IM injection of 50 mg emepronium bromide. Bladder capacity was reduced with increasing duration of catheter drainage. and the relation was statistically significant (p < 0.001). During the first year of catheter drainage there was a fast reduction of real bladder capacity by 12 mlimonth from 360 ml to 220 ml; during the next 8 years a further reduction by 0.8 rnllrnonth to around 150 ml was registered. The significance of this process in the daily care of the patients was evaluated with a questionnaire to the nursing staff. Bladder overactivity, and to a minor degree. reduction of real bladder capacity caused an increased frequency of urinary leakage beside the catheter but influenced neither the frequency of change of catheter nor the discomfort of the patients.     

380例次长期深静脉留置导管临床应用的生存分析

目的提高对长期静脉留职导管的置管、使用、护理的认识，延长其使用寿命。方法随访本院血液净化中心患者380例次深静脉置管并长期留置的情况和并发症，记录导管使用终点。应用Kaplan-Meier法绘制导管使用寿命的生存曲线，计算中位生存时间。log-rank检验比较导管使用寿命的差异。分析评价置管方法、感染发生率、导管退出原因及透析充分性。结果导管静脉入路途径包括颈内、颈外、锁骨下及股静脉。3种静脉入路中位生存时间分别为颈内（31．0±2．8）月，颈外（30．0±4．0）月，锁骨下（19．0±2．9）月。log-rank生存曲线检验结果显示，颈内与锁骨下进路比较差异有统计学意义（P〈0．05）。导管使用终点113例次，其中患者死亡60例（53．1％），感染14例（12．4％），导管功能不良13例（11．5％），肾移植13例（11．5％），内瘘2例（1．8％），导管意外拉脱7例（6．2％），导管破损4例（3．5％）。导管内感染61例次，隧道感染2例次。结论长期留置导管首选颈内静脉入路，其次为颈外静脉入路。导管终点以患者死亡、感染及导管功能不良占绝大多数。