Transcript A new technique for fast and safe collection of urine in newborns

A new technique for fast and safe
collection of urine in newborns
Herreros Fernández ML, González Merino N,
Tagarro García A, Pérez Seoane B, de la Serna
Martínez M, Contreras Abad MT, García-Pose A.
Arch Dis Child. 2013 Jan;98(1):27-9
Clinical question
• 7 day old infant presents
with temperature > 38.
• Off feeds but otherwise
appears well
• Mildly coryzal but no other
clear focus
• Full septic screen
– Blood cultures
– Lumbar puncture
– Urine – how would you
obtain? Before or after
antibiotics?
Background to the study
• Urine samples from infants and children are frequently
requested:
– Septic screen
– Other clinical reasons eg. TORCH/metabolic screen
• Collection in neonates and infants is challenging
• Several methods have been trialled
–
–
–
–
SPA (invasive, uncommonly performed)
Catheterisation (invasive)
Bag/pad urine (difficult to interpret the results if positive)
Mid stream/ clean catch (patience required!)
Local guidelines
• SCH advise that a “midstream urine” or “cleancatch” is the preferred option
• Recognise may be difficult
and pad urines etc are
acceptable
• If “not possible” or “practical”
catheter samples or SPA
should be performed
• Should not delay treatment
when waiting for a urine if
child appears unwell
• Obtain x 2 urines if possible
Collection of clean catch urine samples –
local guidelines
• Perineum cleaned with water
• Small cardboard urine
collecting pot held near the
urethral opening until child
passes urine
• No indication as to how long to
wait (!)
Image removed for
copyright reasons
Need for a new method…
Image removed for copyright reasons
The solution…
• Utilise “stimulation
techniques” that facilitate
emptying of bladder in
cases of bladder
dysfunction
• Purpose of this study is to
assess if can be used in
neonates to encourage
micturition and obtain a
clean catch urine
Picture removed for copyright purposes
Methods
• Prospective “feasibility and safety study”
• Assessed 90 infants who needed urine collecting for a
variety of clinical reasons – all less than 30 days
• Primary end point was the success rate in obtaining an
MSU within 5 minutes
• Secondary variables were time to obtain the sample and
any complications
• No comparison group
Procedure
• Feed the baby
– Breastfeed or bottle feed
• 25 minutes after feeding clean
the genitals
• Administered sucrose to “lessen
crying”
• Hold the baby under the arms
with legs dangling
• Gently tap on bladder for 30
seconds
• Massage sacrum for 30 seconds
• Catch the urine
Video demonstration
• http://adc.bmj.com/content/98/1/27/suppl/DC1
Video removed for copyright purposes
Results
• 90 children included in study
– 10 excluded due to “poor oral intake”
•
•
•
•
•
•
Mean age approximately 6 days
86% succcess rate (passing urine within 5 minutes)
Mean time for collection was 57 seconds
No complications
“Controlled crying” in all infants
Now adopted as preferred method of urine collection in
authors’ centre
Critical appraisal
• Difficult to appraise using CASP criteria or GATE as no
direct comparison group
• One previous study used a “vibration device” – times
typically took one hour for infants to pass urine (Davies
et al., 2008)
• There is some previous evidence for technique
– Abdominal vibration (similar to percussion) effective in patients
with MS (Prasad et al., 2003)
– Massage of lumbar region can cause detrusor contraction
• No evidence of its use in neonates or infants prior to this
study
Limitations
• Lack of control group
– Eg. Would neonates fed 30
minutes before pass urine
anyway when nappy removed?
• No indication of parental
preference
– Is it more acceptable than eg
catheterisation?
• Do not comment on
contamination rate/false
positives for MSU from this
technique
• What is success rate if child not
been fed recently (could it be
used in our clinical scenario)?
• Is it effective in older children?
Conclusion
• Undoubtedly a clinical problem
• Is it an effective solution?
• Results need replicating in different centre with control
group
• Wider range of ages should be included (? less than one
year)
• Would be useful to know parental opinions about
technique and whether acceptable
Will you be trying it?
References
Davies P, Creenwood R, Benger J. Randomised trial of a
vibrating bladder stimulator—the time to pee study. Arch
Dis Child 2008;93:423–4.
Prasad RS, Smith SJ, Wright H. Lower abdominal pressure
versus external bladder stimulation to aid bladder emptying
in multiple sclerosis: a randomized controlled study. Clin
Rehabil 2003;17:42–7.