Abstract & Commentary
Commentary by Raemma Paredes Luck, MD, assistant professor of pediatric emergency medicine and director of continuing medical education of the International Health Program at Temple University Children’s Medical Center, Philadelphia.
Source: Chen L, et al. Utility of bedside bladder ultrasound before urethral catheterization in young children. Pediatrics 2005;115:108-111.
Infants suspected to have urinary tract infections (UTIs) and who are not toilet-trained must undergo urinary catheterization or suprapubic aspiration to obtain an adequate specimen for urinalysis and culture. Urinary catheterization is the method of choice used by most physicians and nurses in the ED. Because there is little certainty as to the amount of urine in the bladder, this uncomfortable procedure is often repeated.
The authors investigated the utility of bedside ultrasound of the bladder before catheterization and its usefulness in decreasing the number of unsuccessful attempts. Children from 0-24 months of age were enrolled in a two-phase study at an urban pediatric ED from August 2003 to February 2004. In the observation phase, the amount of urine obtained by the first catheterization was recorded for every patient. In the intervention phase of the study, the pediatric emergency medicine physician performed a rapid bedside bladder ultrasound. If there was a sufficient amount of urine (defined as > 3mL), catheterization was performed. If not, the bedside ultrasound was performed every 30 minutes until sufficient urine was noted.
Results showed that the overall success rate for obtaining an adequate urine specimen (defined as >2 mL) for urinalysis and culture on the first catheterization was 72%. With the use of bedside bladder ultrasound, the overall success rate increased to 96% (p < 0.001). Time spent performing the scan was estimated to be less than one minute.
Commentary
This elegant study shows once again that ultrasonography is an invaluable skill that emergency medicine physicians must master. It is important not only in trauma and pregnancy-related evaluations but, as shown in this study, in other conditions as well.
Our adult emergency medicine colleagues are much more advanced in acquiring this skill and making it part of their emergency medicine residency curriculum. Pediatric emergency medicine physicians, however, still have a long way to go in terms of training and incorporating this skill in their daily practice.1
Aside from checking the bladder before catheterization, ultrasonography also would be ideal in other pediatric conditions (e.g., ruling out pyloric stenosis, intussusception, and testicular torsion; and locating foreign bodies in the esophagus or on subcutaneous surfaces).1 It also might obviate the need for other radiologic studies that are time consuming or involve excessive radiation. At this point, however, the use of ultrasound in these pediatric conditions by both adult and pediatric emergency medicine practitioners is very much in its infancy; more formal confirmatory studies by our radiology colleagues are very important in the management.
While bacteremia is becoming less of a concern in the work-up of the immunized febrile infant, the prevalence of UTIs remains unchanged.2 UTIs can occur concurrently, albeit at a much lower rate, in other infections such as otitis media and bronchiolitis.2,3 The diagnosis requires an adequate specimen for urinalysis and culture. Results of the urinalysis will determine whether treatment should be initiated immediately. The use of bedside bladder ultrasound will help us make the diagnosis more rapidly and more reliably with the least discomfort to our patients.
References
1. Hegenbarth M. Bedside ultrasound in the pediatric emergency department: Basic skill or passing fancy? CPEM 2004;5:201-216.
2. Shaw KN, et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998;102:e16.
3. Levine DA, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004;113:1728-1734.
Infants suspected to have urinary tract infections and who are not toilet-trained must undergo urinary catheterization or suprapubic aspiration to obtain an adequate specimen for urinalysis and culture.
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