How long can a patient go without urinating after receiving a Duramorph spinal?

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    I had a patient come back from a TKA at 1500. I'm a new grad, and this was my first fresh ortho surgical that I've had. He received a Duramorph spinal as well as general anesthesia. The patient did not have a foley. I asked if the patient peed in recovery, the surgical nurse stated no. He had 2400 mL of fluids in during the surgery and he was a very large gentleman and had peed before they took him in at 1200, which the surgical nurse told me it was fine if he didn't pee for awhile. I had the patient try to pee at about 1830, even though he couldn't feel like he had to pee. The patient had full sensation back from his spinal (another story all together). The doctor came in at 1845 and was furious he hadn't peed yet. How long is it OK to wait for a patient to pee after getting a spinal?? Any thoughts? I felt terrible!
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  3. 19 Comments so far...

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    I work out patient surgery. So I do not deal with the same situation.

    We do not require our patients to urinate after surgery (except for some hernia and uro/genital surgeries). Even when the surgeon writes patient must void prior to discharge they don't put a specific number of hours. Since it is out patient surgery, after 2 - 3 hours we notify the surgeon. We don't do spinal anesthesia at my current job.

    Where I worked before spinal patients had to urinate before they went home. I can't remember any problems, I also can't remember if we had protocol about how long we waited for them to urinate? Call the surgeon? Call anesthesia? I can't remember.

    At my current job our protocol for any patient, regardless of type of anesthesia they received, is pre-printed orders on our one size fits all discharge form. We tell patients to call their surgeon if they haven't urinated six hours after their surgery.

    I would guess it is not unreasonable to go by six hours? Be sure to assess the patients lungs in case they are fluid overloaded before the six hour guideline is reached. Of course how long you wait varies with the patients age, health, type of surgery, lung sounds, how much IV fluid they received, etc.

    Please don't kick yourself over this. Lessons taught in the school of hard knocks are learnt better than what you learn in a classroom. You will continue to get these lessons until you retire. I'm at retirement age and am still getting these lessons!!!!! The patient wasn't harmed.
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    I work on an ortho floor and if a patient doesn't void in 6 hours, we bladder scan and do a straight cath. Lots of times I'll even scan @ 5 hours just to see how much is in there. I always tell the patient around hour 4 or 5 ( if I haven't already) what interventions will take place at hour 6. Sometimes hearing about a catheter really motivates people to void on their own. Especially men. LOL
    DeBerham likes this.
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    Quote from beauty912
    I work on an ortho floor and if a patient doesn't void in 6 hours, we bladder scan and do a straight cath. Lots of times I'll even scan @ 5 hours just to see how much is in there. I always tell the patient around hour 4 or 5 ( if I haven't already) what interventions will take place at hour 6. Sometimes hearing about a catheter really motivates people to void on their own. Especially men. LOL
    We have a similar policy on our ortho floor. No pee by 4-6 hours? Bladder scan. Scan shows over 200-300mL (depends on MD)? Foley. I'd rather do a straight cath to relieve the patient temporarily, since the foley usually ends up staying in for at least 24 hours. But alas, an order for a foley is an order for a foley.
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    I agree with six hours post op being the normal cut off time.

    I'm about to ask a stupid question - isn't 2400 mL of IVF a lot over three hours? I used to take care of post and pre op orthopedic patients (before I joined the evil ranks of Adult Medicine!) but that seems like an awful lot fluid to me.

    How were his vitals?
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    I had a similar situation recently on our ortho floor. I had a male pt come up at 1500 with bilat TKAs with no foley, which is unusual. I asked him if he peed before surgery, he said yes. Then I asked what time that was, and he said 0645. I was like... YOU NEED TO PEE! He tried to pee in the urinal three times, no success. He didn't feel like he had to pee, and when I bladder scanned him it was ~500 ml. So we put a foley in.

    Anyway, our Duramorph order sheets say (if they don't already have a foley) they have 6 hours to void. After we pull foleys, we give them 8 hours to void.
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    We give them six hours too, then bladder scan and call the doc for orders for straight cath or foley.
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    Remember that as the spinal wears off (assuming local anesthetic was used as well as the Duramorph) the bladder and genitals are one of the last regions to recover.

    2400 ml of fluid in a big guy for a big case like a TKA isn't all that much unless he's unhealthy with CHF and such. Remember that he was NPO for quite some time (without a maintenance fluid like you'd see in someone who's already inpatient), lost some blood, lost more than usual through insensible losses due to his skin being opened up. Then add in the fact that he had a spinal, which quite frequently causes hypotension necessitating fluids to keep a decent pressure (and maybe a little pressor, at least in the short term).

    At the 8 hr point since last void (or roughly 6 hours post-op) it is a good idea to perform a bladder scan & if needed do a cath. Don't forget your low-tech assessments, too. Look for abnormal BP or HR caused by the distended bladder, and gently palpate the bladder area to see if it's full.

    Or maybe if it's a hip and you do an X-ray post-op the radiology tech will call you and say the bladder's ready to burst. That was only like 30 min post-op, too. I got a liter out of that poor dude when I straight cathed him. He actually had a general, but was nonverbal.
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    Look at the whole intraop I & O. A lot of stuff is sucked out. But I wouldn't go over say 3 hours. Before that make sure you have a cath order.....never wait til end of shift and wake a doctor for something you could have handled earlier and especially one he should have covered in the post op orders. If they do void you still want at LEAST 30cc an hour. MINIMUM. US Bladderscan will usually lead you to the right decision. but learn how to palpate with and without listening to an echo with your steth. Kinda sounds boing slush.
    Last edit by P_RN on Feb 26, '12
    NRSKarenRN likes this.
  12. 0
    Why not bladder scan the pt? Then there'd be no doubt. That's what we do where I work(ambulatory surg) A call is placed to MD if 250cc or greater.Pt is usually straight cath'd.


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