A brief literature search and clinical audit of postoperative urinary retention following total joint replacement

Summary

This search highlights the limited evidence and some of the associated factors which may cause postoperative urinary retention to develop. Supporting some of the evidence reviewed are local audit figures carried out to establish the incidence of catheterisation within a 9-month period in patients following primary total hip and knee replacements. Over this period 13 (1.5%) total knee replacement patients and 23 (3%). of total hip replacement were catheterised. The potential use of bladder scanners is explored. There this is a need for further research into all associated factors in postoperative urinary retention to be explored in greater depth.

Introduction

Postoperative urinary retention is a frequent problem associated with major joint replacement surgery. There are many contributing factors which, when combined, may influence why patients experience this distressing postoperative complication. The main factors influencing its occurrence appear to be age, sex, past medical history and fluid management before and during surgery. The type of anaesthetic and drugs used for other medical conditions and analgesia are also issues. These factors increase the potential for patients to be catheterised, thus increasing the risk of developing a catheter associated urinary tract infection.

To identify the evidence on which nurses may base their clinical practice and care provision a literature review was conducted to identify the available research and other evidence related to the contributing factors associated with postoperative urine retention. The results of an audit will be used to support the literature and consideration given to the use of bladder examination and reducing the incidents of catheterisation through the introduction of portable bladder ultrasound.

Postoperative urinary retention is the inability to void with a full bladder during the postoperative period despite the urge to do so (Tammela et al., 1986, Osbourne, 2000). It can present in a variety of ways, which vary from patient to patient. Some patients may suddenly be unable to void at all and others may have some ability to pass urine but an elevated residual volume prevents complete voiding. This leads to an increased risk of acute retention of urine. If this is not well managed it may result in chronic retention, which often takes months to resolve (Gary, 2000). In many instances urine retention is managed through the insertion of an urinary catheter to drain the bladder either through short-term continuous or intermittent catheterisation. This often results in patients developing an urinary tract infection (UTI), which may result in bacteraemic seeding and metastatic infection around a joint prosthesis in major orthopaedic surgery (Resnick, 1995, Butwick et al., 2003). However, the statistical significance of this remains controversial (Wilson et al., 1990). UTI is seen as the single most common hospital-acquired infection (HAI) with more than one-third (30–40%) of infections acquired whilst in hospital (Stamm, 1991). The risk of catheter associated UTI’s thus relates to the period of catheterisation and rises from 1% to 2% for a single act of catheterisation to 100% with longer term use (more than 30 days) (Parkin and Keeley, 2002). Nurses therefore need to reduce the incidence of catheterisation of the orthopaedic patient.

There is some confusion within the literature of what constitutes a normal bladder volume, which is defined as a palpable mass in the suprapubic region without spontaneous voiding (Gonulla et al., 1993). This ranges from 400 ml to 600 ml (Osbourne, 2000, Weatherall and Harwood, 2002), with retention being suggested as anything over 600–1000 ml (Kemp and Tabaka, 1990, Gary, 2000).

The postoperative period is defined as the period up to 24–48 h postsurgery (Michelson et al., 1988, Kemp and Tabaka, 1990, Knight and Pellegrini, 1996, Butwick et al., 2003).

Evidence-based practice is a method of problem solving which involves identifying the clinical problem, searching the literature; evaluating the research evidence and deciding on the best intervention (White, 1997). This is to allow clinical decisions to be made about providing best practice, through the use of research or by creating evidence within practice. Through this nurses need take into account patient’s needs and preferences using the best resources available (Flemming and Cullum, 1997).

There is increased pressure on orthopaedic nurses to base practice and decision making on evidence and not just on individual personal opinion (NMC, 2002). Nurses have a professional responsibility to provide the most effective care based on the best available evidence. With help from supporting bodies, where evidence is lacking in practice, nurses now need to create an evidence base through research and audit. This in turn will allow the profession to do the right things in the right way (Muir Gray, 1997). Although there are many issues associated with why nurses do not create evidence, such as time, knowledge, understanding and resources, there is a need for a change within the nursing culture, whereby nurses are encouraged to undertake research within clinical practice to provide the evidence.