Urethral Catheter Knots

852

PEDIATRICS

Vol. 85 No. 5

May 1990

MARY ROBERTS, RN

ROY PATTERSON,

MD

Dept of Medicine

Northwestern University Medical School

McGaw Medical Center

Chicago, IL

REFERENCES

1. Barker PM, Warner JO. ‘An atypical pneumonia’ due to parakeet sensitivity: bird fancier’s lung in a 10-year old girl.

Br J Dis Chest. 1984;78:404-407

2. Wolf SJ, Stillerman A, Weinberger M, et ab. Chronic inter-stitial pneumonitis in a 3-year-old child with hypersensitiv-ity to dove antigens. Pediatrics. 1987;79:1027-1029

3. Stiehm ER, Reed CE, Toobey WH. Pigeon breeders lung in children. Pediatrics. 1967;39:904-915

4. Schlueter DP, Fink JN, Sosman AJ. Pulmonary function in pigeon breeders disease: a hypersensitivity pneumonitis.

Ann mntern Med. 1969;70:457-470

5. Bierman CW, Pierson WE, Massie FS. Nonasthmatic pul-monary allergic disease. In: Kendig EL, Jr, Chernick V, eds.

Disorders of the Respiratory Tract in Children. Philadelphia,

PA: WB Saunders; 1983:543-564

6. Mark EJ. Bronchial and bronchiolar disease. In: Lung Bi-opsy mnterpretation. Baltimore, MD: Williams & Wilkins;

1984:100-101

7. Fink JN, Sosman AJ, Barboriak J, et al. Pigeon breeders disease: a clinical study of hypersensitivity pneumonitis.

Ann Intern Med. 1968;68:1205-1219

8. Keith HH, Hobsclaw DS JR, Dunsky EH. Pigeon breeders disease in children: a family study. Chest. 1981;79:107-110 9. Whimster WS, ed. Clinical pathological conference: bird

fancier’s lung. Br Med J. 1977;2:1065-1069

10. Greenberger PA, Pien LC, Patterson R, et al. End-stage lung and ultimately fatal disease in a bird fancier. Am J Med. 1989; 86:119-122

Urethral Catheter

Knots

Balloon bladder catheters smaller than 8F are

available in the United States on a limited basis;

therefore, 3F and 5F feeding tubes are commonly

used as bladder catheters in neonates and small

infants. Knotting of these catheters in the bladder lumen has been reported in the urobogic’4 but not

the pediatric literature. It has been suggested that

knots occur when improper technique is used to insert and secure feeding tubes used to drain the

bladder3. Because pediatricians and pediatric

nurses commonly use feeding tubes as bladder

cath-eters, they should be aware that knotting is a pos-sible complication. We present an infant in whom

a 5F feeding tube knotted in the bladder. We then

discuss a noninvasive method of knot removal and

prevention of knotting.

CASE

PRESENTATION

Patient 1 was a 6-week-old white boy transferred to the Pediatric Intensive Care Unit from his local

hospital for respiratory failure, convulsions, and

hemodynamic instability. On admission, he was

hypotensive and in significant respiratory distress.

He required intubation, mechanical ventilation,

hemodynamic support, antibiotics, and

anticonvul-sants.

Received for publication May 5, 1989; accepted Jun 28, 1989.

Reprint requests to (A. L. P.-S.) Dept of Pediatrics, Medical College of Georgia, Suite BAA-383, 1120 15th St, Augusta, GA

30912-3758.

PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the

American Academy of Pediatrics.

A 5F feeding tube was inserted as a bladder

catheter to monitor urine output. Two days after insertion, it was noted that urine was leaking

around the catheter. An unsuccessful attempt was

made to remove the catheter by pulling it. With

traction, significant resistance was noted and

fur-ther attempts at removal were aborted. An

abdom-inal x-ray revealed that the catheter was coiled in

the prostatic urethra, possibly in a knot (Fig 1).

Due to uncertainty concerning the knot’s size and

position, a decision was made to visualize the knot

and remove it surgically. The child was

hemody-namically unstable, his bladder was not distended,

and urine continued to drain around the feeding

tube. Therefore, the catheter was left in place and

surgery was postponed. Four days after admission

when the patient was clinically stable, he was taken to the operating room for removal of the catheter

(Fig 2) . The knotted portion of the catheter was

removed through a suprapubic incision in the

blad-jI

:1’ \

.

J

Fig I. Abdominal x-ray showing catheter knotted in

urethra.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

. . .: 1

. I

Fig 2. Photograph of knotted catheter following re-moval.

ACKNOWLEDGMENT

Photography and illustrations are provided courtesy of

Tom Chumley, University Hospital, Augusta, GA.

ANTHONY

L.

PEARSON-SHAVER,

MD

EXPERIENCE

AND

REASON

853

der. The distal portion of the catheter was pulled through the urethra without complication. Follow-ing removal of the catheter, cystoscopy was

per-formed. No mucosal injury was noted. The patient’s postoperative course was uneventful, and he was discharged on the sixth postoperative day with fol-low-up to be performed by the urologic and

pedi-atric services.

DISCUSSION

Intracardiac and bladder catheters have been

noted to form intralumenal knots.”5’6 A small flex-ible catheter will knot if the intralumenal length of the catheter is long enough to allow the catheter to

form loops.6 A knot forms as the distal end of the

catheter becomes entangled in the catheter loops.

As one pulls the distal end of the catheter, a tight

knot will form which may be too large to pass

through the catheter’s point of entry. This

compli-cation can be avoided if care is taken to insert only

as much catheter as is necessary.

Several methods of catheter removal have been

described.”36 Methods for removing knotted

in-tralumenal catheters include: (a) extraction of the knotted catheter using sustained traction and a full

bladder,’ (b) loosening the knot with a wire

guide,”4’6 (c) urethral dilation followed by sustained

traction with or without anesthesia,3 and (d)

sur-gical removal. The least invasive and easiest

method uses a wire guide to assist catheter removal.

If a knot is not closed tightly, a wire guide can be

inserted into the catheter lumen and used to stiffen and straighten the catheter. Once inserted, the wire

is manipulated gently back and forth. Initially re-sistance is noted that will be released when the

catheter straightens. The catheter and wire can

then be withdrawn simultaneously. A 0.21-inch

flexible guide wire will pass through 3F and 5F

feeding tubes.

No article discussing appropriate bladder cathe-ter sizes for children appears in print. The original

balloon catheter diameter (1GF to 18F) has been

decreased in an attempt to limit the incidence of

catheter complications due to compression of the

urethral lining. The development of narrower,

shorter catheters makes the use of balloon catheters feasible in children. A “6F” latex catheter is avail-able, but its effective size actually measures larger, usually 8F. However, the 8F catheter is the smallest

functional balloon catheter that can be made using latex.

A

balloon catheter must maintain two lumens,

one for urine drainage and one to service the

bal-loon. The manufacturing process and the material

used to make balloon catheters limits the functional

size of the catheter’s lumens. Latex will not reliably

maintain two lumens if the overall catheter

diam-eter is less than 8F. Recently, a European firm

developed a silicone 6F balloon catheter that is now

available in the United States through TXF

Medi-cal Corporation (Alpharetta, GA). Silicone

cathe-ters are manufactured by extrusion (not dipping as

with latex catheters) which allows accurate and

reliable production of small balloon catheters. At

this time, 6F is the smallest balloon catheter made

(D.

Emm, Marketing Manager, TXF Medical

Cor-poration. Personal communication, 1989).

Sugar and Firlit3 suggest that feeding tubes

should not be used for bladder drainage and that

bladder catheters should be inserted only as far as

necessary to obtain urine. Gaisie and Bender’

sup-port the use of feeding tubes as bladder catheters

and suggest that intralumenal redundancy can be

avoided by limiting the length of catheter insertion.

Given the fact that balloon catheters smaller

than GF are not available, feeding tubes will

con-tinue to be used as bladder catheters in pediatric

and neonatal practice. To prevent knotting when

feeding tubes are used as urethral bladder catheters,

we suggest that catheters be advanced only a short

distance after urine flow begins and then secured

with tape. This will eliminate excessive catheter length in the bladder lumen and prevent knotting.

The feeding tube used as a bladder drainage

catheter is a fact of life for those who care for

critically ill infants and neonates. Knotting can be

prevented if proper technique is used to insert and

secure the catheter.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

MARY

H.

ANDERSON,

MD

Department of Pediatrics Medical College of Georgia

Augusta, Georgia

854

PEDIATRICS

Vol. 85 No. 5 May 1990

REFERENCES

1. Gaisie G, Bender TM. Knotting of urethral catheter within bladder: An unusual complication in cystourethrography.

Urol Radiol. 1983;5:271-272

2. Klein EA, Wood DP, Kay R. Retained straight catheter: complication of clean intermittent catheterization. J Urol. 1986;135:780-781

3. Sugar EC, Firlit CF. Knot in urethral catheter due to

im-proper catheterization technique. Urology. 1983;22:673-674

4. Harris VJ, Ramilo J. Guide wire manipulation of knot in a

catheter used for cystourethrography. J Urol. 1976;116:529

5. Lipp H, O’Donoghue K, Resnekov L. Intracardiac knotting

of a flow-directed catheter. N Engi J Med. 1971;284:220 6. Mond HG, Clark DW, Nesbitt SJ, et al. A technique for

unknotting an intracardiac flow-directed balloon catheter. Chest. 1975;67:731-732

7. Edward LE, Lock R, Powell C, et al. Post-catheterization

urethral strictures. A clinical and experimental study. Br J Urol. 1983;55:53-56

8. Hughes JP, Gambee J, Edwards C. Perforation of the

blad-der: A complication of long dwelling Foley catheters. J Urol. 1973:109:237

Evaluation

of an Infrared

Tympanic

Membrane

Thermometer

in Pediatric

Patients

Body temperature measurement provides

impor-tant information for evaluation of pediatric

pa-tients. Because of the role that central nervous

system thermoreceptors play in temperature

ho-meostasis, accurate measurement at core body sites

has long been sought.’ Rectal temperature, often

considered

the “gold standard”

for clinical

use, does

not correlate well with deep measurements.2’ 3

Pub-monary artery catheters and deep rectal probes

measure core temperature accurately4 but are not

practical

for clinical

use.

The tympanic membrane shares the same

vas-cular supply that perfuses the hypothalamus and is

an excellent, readily accessible site for core

temper-ature measurement.’ Although indwelling

contact-type tympanic membrane temperature probes

pro-vide accurate data, patient discomfort and

compli-cations such as perforation have restricted their

45 More recently, a tympanic membrane

ther-mometer that measures emitted infrared energy

offers instantaneous readings without membrane

contact

and correlates

accurately

with pulmonary

artery thermistor measurements.4 Pediatric clinical

evaluation of this instrument has not been

per-formed, however. To examine the usefulness of this

thermometer in a pediatric clinic population, we

Received for publication Mar 10, 1989; accepted Jun 23, 1989.

Reprint requests to (R.D.K.) Charlotte Memorial Hospital and Medical Center, P0 Box 32861, Dept of Pediatrics, Charlotte,

NC 28232.

PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the

American Academy of Pediatrics.

compared its measurements with oral and rectal

temperatures in children of various ages with and

without acute suppurative otitis media.

METHODS

Patients/Setting

All patients seen in the General Pediatric Clinic

during a 2-month period between January and

March 1988 were eligible for the study. The General Pediatric Clinic, situated in a community teaching hospital, serves an urban population of ill children

(60% black, 40% white, <1% Southeast Asian) from newborn to 18 years of age.

Measurement

All

patients had temperature measured using

both the standard glass-mercury thermometer and

the tympanic membrane thermometer. Nursing

staff not involved in the study first took a

glass-mercury thermometer temperature6 and recorded

the result on a sheet given to the examining

resi-dent. In children less than 48 months of age, rectal

temperatures were obtained; in children older than

48 months of age, oral temperatures were taken. A

febrile temperature was defined as an oral temper-ature >37#{176}C,or rectal temperature >37.6#{176}C.A reg-istered nurse who was unaware of the glass-mercury

thermometer measurement then took bilateral

tym-panic membrane temperatures and recorded them

on a separate sheet unavailable to the examining

resident.

Tympanic membrane temperatures were

meas-ured with a noncontact infrared tympanic

mem-brane thermometer (First Temp; Intelligent

Medi-cal Systems, Inc, Carlsbad, CA). The instrument

consists of an ear probe containing infrared sensing equipment in a handle connected to a liquid crystal

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

1990;85;852

Pediatrics

MARY H. ANDERSON

Urethral Catheter Knots

Services

Updated Information &

http://pediatrics.aappublications.org/content/85/5/852

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

1990;85;852

Pediatrics

MARY H. ANDERSON

Urethral Catheter Knots

http://pediatrics.aappublications.org/content/85/5/852

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1990 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news