Case Study: Demented 72 Year Old with Distended Abdomen

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“I need a breath of fresh air,” your senior resident states. He has had a pretty rough night. He missed an LP on a rather robust woman with “the worst headache of her life” and then the trauma team swooped in and “stole” his thoracotomy on a GSW that was dropped off at the ambulance door. You tell him to take all the time he needs as you turn your attention to the intern that has been patiently awaiting your emergence from the critical care bay.

Jealous that she hasn’t had a single procedure yet during the shift, your intern is eager to tell you about the next patient she saw. It sounds like a relatively straightforward case: a 72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation.

“What should we be worried about?” you ask. Your intern rattles off a differential diagnosis straight out of Tintinalli. Without missing a beat, she continues to explain how she plans to rule-out the scary etiologies such as acute intraperitoneal hemorrhage or ascites, AAA, mesenteric ischemia, perforated bowel, acute cholecystitis, appendicitis, and SBO. Her initial orders are spot-on, and before you can utter another syllable, she grabs the ultrasound machine and wheels it over to the patient’s bedside. You follow a few steps behind her, and observe with pride as she performs a scan of Morrison’s pouch, followed by a quick look at the gallbladder, aorta, splenorenal space and right-lower quadrant. She gently calms the agitated patient as she slides the probe down towards his suprapubic region.

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Her ultrasound image is depicted here. What do you see? What does this patient need?  Conclusion in the following

 

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Dx: Ultrasound-Guided Catheter Placement

Easy enough, right? The patient has a large, distended bladder that requires a Foley for decompression. Unfortunately, once you pull down the patient’s diaper to examine his genitals, you realize that the case isn’t going to be as straightforward as you thought. His urethral stricture is covered with a crusting cellulitis and all attempts to pass a catheter are met with resistance, bleeding, and a slew of cursing (mostly from the patient).

You have your intern call the urologist on call, while you head over to the supply closet to gather the equipment you know you will need. As anticipated, your intern tells you that the Urologist wants you to get everything set up for a suprapubic catheter and to page him when you are ready to go. Once he arrives, you use your bargaining power to get the urologist to let your intern do the procedure. You know your team has only one shot to do it right, so you show your intern how she can use bedside ultrasound to guide the catheter placement. Like a pro, she anesthetizes the patient, inserts a needle under direct ultrasound guidance, and then places a suprapubic catheter into the bladder via the Seldinger technique. You beam with pride as you see the catheter on ultrasound entering the bladder lumen (Image 1).

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You drain 1500 mL of urine and watch as your patient’s demeanor and vital signs normalize. To your surprise, the urologist thanks you for the consult and for showing him a “neat ultrasound trick” that he plans to use the next time he places a suprapubic catheter. After your senior resident’s run of bad luck with procedures, it was nice to see your intern nail one on the first try.

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Tips & Tricks for Performing Bladder Ultrasonography

01 Ultrasound can be used to assess bladder volume prior to performing a suprapubic aspiration or placement of a suprapubic catheter. The formula to estimate bladder volume is (A)(B)(C)/2, where A, B and C are the height, depth and width of the bladder measured with the ultrasound calipers.

02 Bladder scans should be performed with a low frequency curvilinear or phased array transducer. Remember that lower frequency transducers allow you to visualize deeper structures at the expense of resolution.

03 Obtain both longitudinal and transverse views of the bladder, and map out surrounding structures.

04 Use ultrasound to determine how deep the bladder lies below the skin’s surface. Ensure that you have a needle long enough to puncture through the anterior bladder wall.

05 Ultrasound can be used to guide needle insertion during the placement of a suprapubic catheter.

06 Once the needle has been visualized entering the bladder lumen, withdraw a sufficient amount of urine to relieve some of the intraluminal pressure. Leaving a small amount of urine within the bladder can make it easier to pass a suprapubic catheter.

07 In order to avoid creating a false passage, use ultrasound to guide the suprapubic catheter into the bladder lumen. The catheter will appear as a hyperechoic structure within the anechoic bladder lumen.

08 With bedside ultrasound, there is no substitute for experience. The more scans you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is. An image library of normal and abnormal ultrasounds helps immensely, and you can find out in the ultrasound section of www.epmonthly.com.

09 For more information on how ultrasound can save your day, check out the ultrasound app “SonoSupport”. Available now for smartphones and tablets.

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