indwelling catheters; bladder shrinkage; much more; rough 2 days

So I was just editing an absurdly long post and apologizing for posting it in identical form on Andy's and Simon's boards when it disappeared. I really don't want to do this again but here goes, I do hope in better form than the previous draft
It's written in the search for answers to two questions.

1: Might it, especially in old quads, be better to inflate 5-cc balloons with five or even four or three ccs of sterile water than 8 or 10? I was taught to ask for 8.
2: May supra-pubic catheters be riskier than urethral ones, particularly in old quads whose bladders have shrunk?

Here's what's brought me to the questions.

I've used an indwelling catheter since 1963 except for a year or so in 1964-5 using a Texas. In 1989 I developed epididimytis and, at my doctor's advice, switched from a urethral to a supra-pubic catheter. I was told in 1989 that supra-pubic's were now preferred, though I suspected it was the sort of issue on which opinions would change from decade to decade.

Maybe two years ago I had a routine catheter change except that, the balloon inflated, there was no return. We waited, there was still no return, the nurse deflated the balloon, repositioned, inflated, irrigated--yes in, no out--, deflated, repositioned, and then used a second new catheter. It drained. This happened twice more with her and has now happened twice in five changes here in Tucson. I like the new catheter to be lubed and ready for immediate insertion after the old is removed. This is at least partly, I think, superstition. I've found, though, that the longer the catheter is out, the more problems seem to arise. (This ignores a 6-month stretch in 1988-9, but that's a long story, and this one's already quite long enough.) After my NY nurse eventually accepted my request to put the new in as soon as the old was out without bothering to wash me in between, there was no recurrence of the problem.

I came to Tucson the end of last October and my nurse here has done five changes. The first went fine, though I mentioned before it and before the second that I liked mere moments to intervene between removal and insertion. The second, we got no return, and she tried this and that, then tried a second catheter, then a third, then called the ambulance and I was off to the ER, frustrated and dysreflexic.

The third change here I was more forceful about timing. I also had my aide, an uncertified friend, watch. The change was uneventful but when I questioned my friend I learned that the nurse had inserted the new catheter farther in than I think best. With a urethral-catheter insertion I always taught that the catheter should be inserted nearly to the Y, the balloon inflated, and the catheter then be gently withdrawn till it lodges at the neck of the bladder. With the suprapubic I taught the changer to notice when removing the old catheter how far in it had been inside me, and then to insert the new catheter a little farther in, a half inch or an inch, hold it in place, inflate the balloon, and draw it back. I mentioned this to my Tucson nurse the fourth change, also uneventful, but we were alone so I didn't know if she'd done it.

The fifth change was day before yesterday and, you lucky lucky people, you can read about it now.

I was to fly to NY yesterday, Friday March 30, and after the last change had asked the nurse to do the cath change 3/26 or 3/28. I do my bowel routine every other day, and since dysreflexic bowel symtoms are (I think) indistinguishable from dysreflexic bladder symptoms, I prefer to do cath changes on nonbowel days or, if necessary, after the bowel routine is done or very nearly done. My nurse called 3/22 to tell me she would be out of town 3/26-28 and I suggested another nurse do the change. (I'd have had a friend do it, but my Medicare coverage seems to be based on the catheter changes being done through an approved agency, which is then free to give me other Medicare-covered help.) The eventual decision was that my nurse would do the change 3/29, after I received the bowel-routine suppositories I use but before the bowel-nurse arrived. This seemed to me the worst strategy but I knew it would likely be okay. I also didn't like doing the change the very day before I flew, but that too shouldn't be a problem. At 7 3/29 the suppositories were used, and at 7:30 the cath change was begun. We got no flow, repositioned, deflated, inflated, tried to irrigate, tried this tried that, tried a new catheter, got no where, and called the ambulance. But this situation was more dire than the others because, fool that I am, I had taken my morning 40 mg of Lasix, so I knew my bladder was filling fast.

Miraculously, the ER experience was relatively good. By 9, the catheter was working. Nor was it even a new one. The student doctor had irrigated a blood clot out of the way and minimally deflated the balloon and my bladder had emptied. My blood pressure had only hit 170/, wheras the earlier Tucson incident it had hit 195/ at least several times. So the shorter-term consequences boded well, but, because I have a damaged reflux valve and under pressure urine, not to mention blood, can easily flow from my bladder to my kidney, I knew I might be facing trouble soon. I felt lousy, but we were lucky with the bowel routine--no accident to from or at the ER or after--, and good results when we finished it that evening. And, I thought, if I got a solid night's sleep I'd a decent chance of flying. I got the sleep but knew when I waked that flying would be at best stupid. I collected a urine sample and started on Cipro. By 3 P.M. my oral temp was 102.8, so I knew/assumed I had a kidney infection. It dropped to 100.5 by 5:30, was 98 this morning, and at 7:15 MST is holding around 100.5. I plan to fly 4/2 if I've no fever to speak of Sunday night or Monday.

Which all leads me to my first question. Those of us who use indwelling catheters a long time rarely have full bladders; our bladders shrink. I didn't have this no-flow problem, at least didn't have it often, till more than 40 years catheterized. Might it be avoided by using only 4 or 5 ccs of water? Does the balloon with 8 ccs in it sometimes lodge against the shrunken bladder wall, occluding the opening where urine enters, in a way a less-filled balloon for the most part might not. Do inflation-of-bulb studies exist?

We move on.

In the first New York incident, after a lot of increasingly discomfiting repositioning attempts, between a quarter cup and half cup of blood flowed from my penis. Three weeks later a drop or two of blood would have come from my penis overnight. I wanted to figure what had happened to avoid a recurrence. Reasonable. My best guess, perhaps dependent on my ignorance of anatomy, was that somehow the uninflated catheter tip had entered and wounded my urethra. It seemed possible it had even been minimally inflated there, but I thought either way that the urethral exit from the bladder was alikely site of the damage. There seemed to be little or no urine mixed with the blood. My nurse insisted this couldn't have happened but offered no alternate theory. The next two no-flow incidents in NY there was only minimal blood from my penis, a drop or two. Nor was there blood from my penis in the first incident here.

Day before yesterday there was plenty. When I asked the ER student doc and her supervisor about my urethral theory they thought it unlikely because of the placement of the urethral-passage bladder-exit. I assume that urine comes from kidneys to bladder through one or two passages and exits the bladder via a single urethral passage. With a urethral catheter at least one of these 'holes' is filled by the catheter. I gather that in the early days and years after an SCI there are arguably compelling reasons to use a supra-pubic rather than a urethral cath. But, especially in older quads, are there more problems with supra-pubics? Have studies been done? I Googled but the articles that just might have been pertinent cost money and seemed likely to prove off-point. So here I am. My guess is that it's risky to insert a supra-pubic catheter to the Y, not just far enough, and that one of the risks involves urethral damage; if I'm right it's a reason to prefer urethral catheterization, though of course almost no single factor is conclusive. If anyone reading this knows something or knows someone who knows something, I'd love to hear.

	Author	Topic: indwelling catheters; bladder shrinkage; much more; rough 2 days (Read 3617 times)
0 Members and 1 Guest are viewing this topic.