11/16/2013

1

Sheramy Vandernat RN BSN ANM

Aimee Wilson RN BSN CPAN 

Marilyn Evans RN CPANMarilyn Evans RN CPAN

Heather Meisterling RN BSN

Objectives & Overview

Scope of the problem

Literature search

Survey tool and algorithm

Results

Conclusions Conclusions

References

Q & A

11/16/2013

2

Why POUR? Varying hospital to  Posty g phospital practice

Inconsistent MD orders

Inconsistent nursing practice within our unit

PACU space is expensive and health care cost 

Post

Operative

Urinaryand health care cost containment is prudent

OR flow dynamics

Patient satisfaction considerations

Urinary

Retention

11/16/2013

3

What is POUR?

Inability to void in spite of a 

bladder volume > 600 mls

What were our goals?

To assess the risk factors for POUR

To develop a tool to standardize nursing care in the PACU

To evaluate the usefulness of developed tool

11/16/2013

4

Evidence Based Practice InquiryThe Johns Hopkins Nursing Evidence Based The Johns Hopkins Nursing Evidence Based 

Practice Model

Methods

11/16/2013

5

6

5

Primary Literature 

Randomized Controlled Trial

Quasi‐experimental

1

p

Non‐experimental

Qualitative

Non‐research

23

Quality Rating

Number of sources

High (A) 1

Good (B) 12

Low (C) 3

11/16/2013

6

Goal 1:

Influential FactorsType of Surgery History of Urinary Type of Surgery Highest Risk

Anorectal (25‐50% increased risk)

Hernia/Pelvic (5‐26% increased risk)

Urology

History of Urinary Retention POUR

Urinary hesitancy

Incontinence surgeries

Moderate Risk

GYN (4% increased risk)

Low Risk

All other surgeries

Influential Factors continuedType of Anesthesia IV FluidsType of Anesthesia

Spinal

Low dose/short acting (Chloroprocaine) vs. high dose/long acting (all others)

Intrathecal narcotic

General

IV Fluids>1200 cc intraoperative

>500 cc PACU

Increased IVF does not appear to hasten voiding, but instead increases bladder volume and 

Lower risk than spinal anesthesia

> 120 minutes of GA increases risk  

increases bladder volume and may make retention more likely

11/16/2013

7

Influential Factors continued

C bidi iComorbidities

Benign prostatic hypertrophy

Prostate disease

Neurological disorders

Diabetic neuropathy Pain

d h• Increased sympathetic tone  increased risk of POUR

Influential Factors continuedAgeN ti Age

>50 years

Sex

M=F

Narcotics

• Escalating dosing of    narcotics leads to higher likelihood of POUR

• Intrathecal narcotics

11/16/2013

8

Goal 2:

The ToolType of Surgery

4 = High Risk (anorectal, hernia/pelvic, urology)

2 =  Moderate Risk (gyn)

Pain

1= Not‐tolerable

0 = Tolerable2 =  Moderate Risk (gyn)0 =  Low Risk

History of Urinary Retention 2 = Yes 0 = No

Spinal Administration 2 = Long acting spinal1 = Short acting spinal0 = No spinal

Fluid Administration

1= >1200cc intraop

0 = <1200 cc intraop

Comorbidities

1 = Present (BPH, DM, neuro)

0 = None present0   No spinal

Length of General Anesthesia 1 = >120 minutes0 = < 120 minutes

Age1 = >500 = <50

Narcotic Administration

2 = Escalating doses

1 = Minimal narcotics

0 = No narcotic

Total Score = 0 ‐ 15

Low Risk :score 0‐3

Void?Yes d/c

N d/c with No d/c with instructions

11/16/2013

9

Moderate Risk :score 4‐7

Attempt to void

Unable to void

(no MD orders)

High risk surgery/Hx retention

Bladder scan, clinical exam, notify service

Low risk surgery/no hx 

retention

d/c  with instructions

Able to voidd/c with 

instructions

High Risk :score 8‐15

Attempt to void

Unable to void 

(no MD orders)

Bladder scan > 600 

cc 

Contact MD

Catheter or  re‐attempt void

d/c with instructions

blAble to void

d/c with instructions

11/16/2013

10

Goal 3: 

Assess Usefulness of Tool How would you rate this tool/algorithm in evaluating How would you rate this tool/algorithm in evaluating and treating your patient’s need to void prior to discharge?

How would you rate this tool/algorithm in assisting you with advocating for your patient’s needs with the service/physician?

What is your overall impression of this tool for clinical use?

29%

Nurses Response to Tool

58%

29%

13%Not useful

Neutral

Useful

11/16/2013

11

How has our PACU practice evolved? Staff education

Add d    h     h  EHR    id  di h   Added smart phrases to the EHR to guide discharge teaching

Most of our patients are low risk for POUR

Effective screening tool to capture high risk POUR patients

W  h  th   d d i t t (bl dd   We have the recommended instrument (bladder scanner) to help diagnose POUR

Nurses empowered to advocate for patients as it relates to POUR and ambulatory surgery discharge

11/16/2013

12

ReferencesMulroy, Michael, Francis Salinas, et al. "Ambulatory patients may be discharged before voiding after short-

acting spinal and eidural anesthesia." Anesthesiology. 97.2 (2002). Print.

Pavlin, D. Janet, Edward Pavlin, et al. "Management of bladder function after outpatient surgery." Anesthesiology. 91.1 (1999): 42-51. Print.

Luger, Thomas, Ivo Garoscio, et al. "Management of temporary urinary retention after arthroscopic knee surgery in low-dose spinal anesthesia: development of a simple algorithm." Archives of Orthopedic Trauma Surgery. 128. (2008): 607-612. Print.

Orbey, B.C., Z. Alanoglu, et al. "Do we still need to restrict preoperative fluid administration in ambulatory anorectal surgery under spinal anaesthesia?." Techniques in Coloproctology. 13. (2009): 35-40. Print.

Voelckel, Wolfgang, Lukas Kirchmair, et al. "Unilateral anesthesia does not affect the incidence of urinary retention after low-dose spinal anesthesia for knee surgery." International Anesthesia Research Society. 109.3 (2009): 986-987. Print.

Gudaityte, jurate, Irena Marchertiene, et al. "Low-dose spinal hperbaric bupivicaine for adult anorectal surgery: a double-blinded, randomized, controlled study." Journa of Clinical Anesthesia. 21. (2009): 474-481. Print.

Lin, Yu-Hua, Kuang-Wen Liu, et al. "Haemorrhoidectomy: prevalence and risk factors of urine retention among post recipients." Journal of Clinical Nursing. 19. (2009): 2771-76. Print.

Toyonaga, Takayuki, Makoto Matsushima, et al. "Postoperative urinary retention after surgery for benign anorectal disease: potential risk factors and strategy for prevention." International Journal of ColorectaDisease. 21. (2006): 676-82. Print.

Wohlrab, Kyole, Elizabeth Erekson, et al. "The association between regional anesthesia and acute postoperative urinary retention in women undergoing outpatient midurethral sling procedures." American Journal of Obstetrics & Gynecology. 200.571 (2009). Print.

Ruhl, Maureen. "Postoperative voiding criteria for ambulatory surgery patients." AORN Journal. 89.5 (2009): 871-4. Print.

Darrah, Daniela, Tomas Griebling, and Jeffrey Silverstein. "Post operative urinary retention." Anesthesiology Clin. 27. (2009): 465-484. Print.

Mulroy, Michael. "Outpatients do not need to void after short neuraxial blocks." Anesthesiology. 111.6 (2009): n. page Printpage. Print.

Feliciano, Terry, Jo Montero, et al. "A retrospective, descriptive, exploratory study evaluating incidence of postoperative urinary retention after spinal anesthesia and its effect on PACU discharge." Journal of Perianesthesia Nursing. 23.6 (2008): 394-400. Print.

Shadle, Benjamin, and Casey Barbaro. "Predictors of postoperative urinary retention." Presented at the 20th Annual Scientific Meeting of the Southern CA Chapter of the American College of Surgeons. (2009):. Print.

Cetinel, Bulent, and Okaty Demirkesen. "Risk factors influencing the complication rates of tension-free vaginal tape-type procedures." Current Opinions in Obstetrics abd Gynecology. 17. (2005): 530-34. Print.

Gehrich, Alan, John Aseff, et al. "Chronic urinary retention and pelvic floor hypertonicity after surgery for endometriosis: A case series." American Journal of Obstetrics & Gynecology. 193. (2005): 2133-7. Print.

Baldini, Gabriele, Hema Bagry, et al. "Postoperative Urinary Retention, Anesthetic and PerioperativeConsiderations." Anesthesiology. 110. (2009): 1139-57. Print.

Chaney Mark "Side effects of intrathecal and epidural opioids " Canadian Journal of Anesthesiology 42 10Chaney, Mark. Side effects of intrathecal and epidural opioids. Canadian Journal of Anesthesiology. 42.10 (1995): 891-903. Print.

Malinovsky, J.M., L. Le Normand, et al. "The urodynamic effects of intravenous opioids and ketoprofen in humans." Anesthesia and Analgesia. 87. (1998): 456-61. Print.

ASPAN American Society of Perianesthesia Nurses. N.p.. Web. May 2013. <http://www.aspan.org/Clinical-Practice/FAQs>.

Rosow, CE, P Gomery, et al. "Reversal of opioid-induced bladder dysfunction by intravenous naloxone and methylnaltrexone." Clinical Pharmacology and Therapeutics. 82.1 (2007): 48-53. Print.