狠狠撸

Indwelling Urinary Catheter
東京慈恵会医科?学葛飾医療センター?酔部
福島東浩
1
2021年12?14?慈恵医?ICU勉強会
適応について真剣に考える

今回のテーマ
? はじめに
? abbreviation
? 歴史
? 尿道カテーテル留置の現状
? ガイドライン上の適応
? 尿量モニタリング
? AKIの診断
? 循環評価
? 尿排出
? ?分バランスの調整
? 術後尿閉
2
? 合併症
? CA-UTI
? ?感染性合併症
? 代替?法
? 超?波診断装置
? 体重測定
? 尿道カテーテル留置は減らせるか?
? 最後に

Abbreviations
AHRQ: Agency for Healthcare Research and Quality
AKI: Acute Kidney Injury
BS: Bladder Scanner
CAH: Critical-access hospital
CAUTI: Catheter Associated Urinary Tract Infection
CDC: Centers for Disease Control and Prevention
HICPAC: Health Infection Control Practice Advisory
Committee
ISC: Intermittent Straight Catheter
4
IUC: Indwelling Urinary Catheter
POUR: Postoperative urinary retention
QI: Quality Improvement
SCr: serum creatinine
UO: Urinary Output
US: Ultrasound
UTI: Urinary Tract Infection
UVol: Urine Volume

Indwelling Urinary (Urethral) Catheter
?本語訳は? ○○カテーテル留置
○○留置カテーテル
○○ à 尿路、尿道、膀胱
「尿カテ」と省略していることも多々あります
表現に?定の決まりがなく、所々変わることをご了承下さい
5

歴史
6
Feneley RC et al. J Med Eng Technol. 2015;39(8):459-70.
Erratum in: J Med Eng Technol. 2016;40(2):59. PMID: 26383168
? 1500BC エジプト
パピルスに銅管, 葦, 藁, 巻いた椰?の葉での尿閉治療の記述
? 400BC ヒポクラテスが鉛の管を使?
? 18世紀頃からゴム製のカテーテルが開発
? 1933 Frederic Foley博?の開発した尿道カテーテルがBARD社から発売

尿道カテーテル留置の現状
ガイドライン上の適応
7

集中治療室でのIUC
8
Kuriyama A et al.
Clin Infect Dis. 2017 May 15;64(suppl_2): S127-S130. PMID: 28475778.
観察研究, ?本の3次救急病院, 7ICU. Observer; 医師、看護師. IUCの適応の評価基準; 2009 CDC HICPAC guidelines criteria
FOLEY CATHETER
INDICATIONS*
Bedside
Nurse, N(%)
Objective
Observer, N(%)
Appropriate 846 (65.6%) 691 (53.5%)
Inappropriate 443 (34.4%) 598 (46.5%)
Location of IUC
(N=1287)
N, (%)
ICU 242 (18.8%)
Emergency ICU 26 (2.0%)
Emergency Room 698 (54.2%)
Operating Room 212 (16.5%)
Inpatient Unit 63 (4.9%)
High Care Unit 15 (1.2%)
Other Hospital 18 (1.4%)
Other 13 (1.0%)
不適切な尿カテは3-4割
10％は?解に相違あり 5割以上救急室
2割弱がICU
15％強が?術室

9
Kuriyama A et al.
Clin Infect Dis. 2017 May 15;64(suppl_2): S127-S130. PMID: 28475778.
観察研究, ?本の3次救急病院, 7ICU. Observer; 医師、看護師. IUCの適応の評価基準; 2009 CDC guidelines HICPAC criteria
FOLEY
CATHETER
INDICATIONS*
Bedside
Nurse, N(%)
Objective
Observer, N(%)
Appropriate 846 (65.6%) 691 (53.5%)
Inappropriate 443 (34.4%) 598 (46.5%)
FOLEY CATHETER
INDICATIONS
Bedside
Nurse, N(%)
Objective
Observer, N(%)
Appropriate
尿閉 31(2.4%) 33(2.5%)
重症患者の水分出納管理 642(49.8%) 469(36.4%)
周術期 59(4.6%) 68(5.3%)
疾患/外傷による長期臥床 46(3.6%) 47(3.6%)
終末期の緩和 21(1.6%) 29(2.2%)
Inappropriate
失禁 2(0.2%) 0(0.0%)
動けない 189(14.6%) 99(7.7%)
非重症患者の水分出納管理 204(15.8%) 247(19.1%)
患者の要望 2(0.2%) 1(0.1%)
看護師の負担軽減 8(0.6%) 28(2.2%)
せん妄 2(0.2%) 2(0.2%)
理由なし 36(2.8%) 221(17.2%)
看護師?医師で
適応の?解に相違ありそう

10
Saint S, et al. N Engl J Med. 2016 Jun 2;374(22):2111-9. PMID:27248619.
多施設コホート研究
32か国, 603施設, 926箇所 (non-ICUs; 59.7%, ICUs; 40.3%)
UTI減少プログラムによるIUC適応の厳格化, プログラム導?前後でのUTIとIUC率評価
Study Period Catheter Utilization Units with Zero CAUTI
Non-ICU
Baseline1 20.60% 77.40%
Baseline2 20.20% 79.40%
Baseline3 19.80% 77.90%
ICU
Baseline1 59.80% 73.10%
Baseline2 60.80% 70.80%
Baseline3 61.10% 72.80%
IUC頻度
Non-ICU 約2割
ICU 約6割

救急室でのIUC
11
Greene MT, et al. Infect Control Hosp Epidemiol. 2018 Jan;39(1):77-84. PMID: 29249212.
Prospective observational study, 13,215 patients, 救急室での尿道カテーテル挿?改善計画
?営利組織(Acscension)が経営する18施設; System-based, 16施設; ミシガン州によるState-based intervention
I: CDCガイドラインを基にした尿カテ挿?基準を策定, C/O: 介?前後でのappropriate IUCの割合の変化
Intervention
Phase
UC Utilization,
%
P Valuea
Appropriate UC,
%
P Valuea
System-based hospitals Baseline 9.1 Ref 73.1 Ref
Intervention 6.1 < .001 91 < .001
Sustainability 5.3 < .001 92.4 < .001
State-based hospitals Baseline 6.6 Ref 70.9 Ref
Intervention 4.9 0.03 82 0.05
Sustainability 6.4 0.97 87.3 0.05
QI介?前
適正使?は7割程
QI介?後
適正使?は8-9割

救急室でのIUC
12
Fakih MG, et al. Acad Emerg Med. 2010 Mar;17(3):337-40. PMID: 20370769..
救急室での尿道カテーテル減少プロジェクトを検証 before-after, single center, 769 tertiatry care hospital, 2517 patients
Compliant with guidelines, n = 203 (63.0%) N (%)
Non?intensive care 6 L /min oxygen 40 (12.4)
Output monitoring in intensive care 39 (12.1)
Emergent pelvic ultrasound 33 (10.2)
Intubated 32 (9.9)
Neurogenic bladder 14 (4.3)
Emergency surgery 12 (3.7)
Urinary obstruction 10 (3.1)
Unresponsive 7 (2.2)
Acute hip fracture 6 (1.9)
Urologic procedures 4 (1.2)
Acute mental status changes with agitation 4 (1.2)
Stage 3 or 4 sacral decubitus ulcers with
incontinence
1 (0.3)
Hospice or palliative care 1 (0.3)
Noncompliant with guidelines, n = 119 (37.0%)
No clear reason 64 (19.9)
Oxygen supplementation <6 L ? min 26 (8.1)
Dementia 16 (5.0)
Urine specimen collection 5 (1.6)
Incontinence 3 (0.9)
Patient request 3 (0.9)
Output monitoring outside intensive care 2 (0.6)
ガイドライン非遵守IUCの理由
理由なしが約20%

尿道留置カテーテル
2-3割は使わなくてすむ？
13

尿道カテーテル留置の現状
ガイドライン上の適応
14

Guideline for prevention of
catheter-associated urinary tract infections 2009
15
https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
1981年CDCよりUTI予防についてのガイドラインが発効
2009年に改訂
2017年に?部修正

Guideline for prevention of
catheter-associated urinary tract infections 2009
16
https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
https://www.info-cdcwatch.jp/views/pdf/CDC_guideline2009.pdf
A. 尿道留置カテーテルの適切な使?例
患者に急性の尿閉または膀胱出?部閉塞がある
重篤な患者の尿量の正確な測定が必要である
特定の外科?技のための周術期使?
● 泌尿?殖器の周辺構造で泌尿器科?術または他の?術を受ける患者
● ?時間の?術が予測される患者（このために挿?されるカテーテルは?酔後回復室（PACU：post-anesthesia
care unit）で抜去する）
● 術中に?量の点滴または利尿剤が投与されることが予測される患者
● 尿量の術中モニタリングが必要な患者
尿失禁患者の仙椎部または会陰部にある開放創の治癒を促すため
患者を?期に固定する必要がある（例：胸椎または腰椎が潜在的に不安定、?盤?折のような多発外傷）
必要に応じて終末期ケアの快適さを改善するため
B. 尿道留置カテーテルの不適切な使?例
尿失禁のある患者または居住者の看護ケアの代わりとしての使?
患者が?発排尿をできるときに、培養その他の診断検査のために採尿する?段としての使?
適切な適応が認められない場合の術後?期間の使?（例：尿道または周辺構造の修復、硬膜外?酔の作?遷延など）

17
AHRQ Safety Program for Reducing CAUTI in Hospitals https://www.ahrq.gov/hai/cauti-tools/impl-guide/index.htmL

AHRQ Safety Program for Reducing CAUTI in Hospitals
18
https://www.ahrq.gov/hai/cauti-tools/impl-guide/index.htmL
Appropriate IUC
1. Acute urinary retention or obstruction
2. Accurate measurement of urinary output in critically ill patients
3. Perioperative use in selected surgeries
4. Assistance with healing of stage III or IV perineal and sacral wounds in
incontinent patients
5. Hospice/comfort/palliative care
6. Required immobilization for trauma or surgery
尿閉
尿量測定
周術期
失禁/褥瘡がある
緩和
安静

19
Inappropriate IUC
1. Urine output monitoring that can be obtained by means other than an
indwelling urinary catheter
2. Incontinence without a sacral or perineal pressure sore
3. Prolonged postoperative use
4. Other potentially inappropriate uses of urinary catheters include the following:
① Patients who are being transferred within or from an acute care facility
② Morbid obesity or immobility
③ Confusion or dementia
④ Patient and or family request
AHRQ Safety Program for Reducing CAUTI in Hospitals
替わりがある
失禁/褥瘡がない
術後?期
搬送時
肥満などで動けないだけ
せん妄/認知機能低下
要望

救急室でのIUC
20
https://viaaerearcp.files.wordpress.com/2018/02/atls-2018.pdf
Advanced Trauma Life Support ATLS 10th edition
Initial Assessment and Management
Urinary Catheter
Urinary output is a sensitive indicator of the
patient’s volume status and reflects renal perfusion.
Monitoring of urinary output is best accomplished
by insertion of an indwelling bladder catheter. In
addition, a urine specimen should be submitted for
routine laboratory analysis. Transurethral bladder
catheterization is contraindicated for patients who
may have urethral injury. Suspect a urethral injury in
the presence of either blood at the urethral meatus or
perineal ecchymosis.
Accordingly, do not insert a urinary catheter before
examining the perineum and genitalia. When urethral
injury is suspected, confirm urethral integrity by
performing a retrograde urethrogram before the
catheter is inserted.
At times anatomic abnormalities (e.g., urethral
stricture or prostatic hypertrophy) preclude placement
of indwelling bladder catheters, despite appropriate
technique. Nonspecialists should avoid excessive
manipulation of the urethra and the use of specialized
instrumentation. Consult a urologist early.
尿量モニタリングは尿道カテーテル留置が最も適切

救急室でのIUC
21
https://www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.htmL
アメリカ医療研究品質機構 Agency for Healthcare Research and Quality
救急室での不適切な尿カテについて?及

数値目標や対象が不明確
22

適応を再検証しましょう
23

診断
n 尿量モニタリング
n 尿の性状確認
n 腹腔内圧
n 逆行造影など
治療
n 尿排出
n 術後処置
n 尿による汚染防止

尿量モニタリング
n AKI診断
n 循環評価
尿排出
n 水分バランス調整
n 術後尿閉
n 脊髄損傷/疾患

救急外傷患者でのIUC
?盤外傷時のIUC
出?性ショックで尿量モニタリングが必要になる
膀胱内への??注? à 圧迫??
?盤外傷の約20％尿路損傷合併といわれる
ATLS 10th edition
When urethral injury is suspected, confirm urethral integrity by performing a retrograde urethrogram
before the catheter is inserted.
衝動損傷が疑われる場合は尿カテ挿?前に逆?尿路造影
?盤外傷の話になってくるので今回は割愛
29
?Coccolini F et al. World J Emerg Surg. 2019 Dec 2;14:54. PMID: 31827593.
?https://viaaerearcp.files.wordpress.com/2018/02/atls-2018.pdf

AKI CRITERIA
33
RIFLE Creatinine criteria Urine Output criteria
Risk ↑ SCr x1.5 <0.5mL/kg/h x6h
Injury ↑ SCr x2 <0.5mL/kg/h x12h
Failure
↑ SCr x3 or ≧4.0 mg/dl
(Acute rise of ≥0.5 mg/dl)
<0.3mL/kg/h x24h
Anuria x24h (oliguria)
Loss
Persistence ARF?
Complete loss of renal function >4weeks
ESKD End stage Renal disease
KDIGO Creatinine criteria Urine Output criteria
Stage 1
1.5-1.9 times baseline
or ≥0.3mg/dL ↑
<0.5mL/kg/h for 6-12h
Stage 2 2.0-2.9 times baseline <0.5mL/kg/h for ≥12h
Stage 3
↑SCr to ≧4.0 mg/dL
or Initiation of RRT
or ↓ eGFR to <35mL/min/1.73m2
<0.3mL/kg/h for ≥24h
or Anuria for ≥24h
AKIN Creatinine criteria Urine Output criteria
Stage 1
↑ SCr ≥0.3 mg/dL
or
↑SCr ≥1.5 to 2× from baseline
<0.5 mL/kg/h (>6 h)
Stage 2 ↑ SCr >2 to 3× from baseline <0.5 mL/kg/h (>12 h)
Stage 3
↑ SCr >3× from baseline
or
if baseline SCr ≥4 mg/dL,
↑SCr ≥0.5 mg/dL
<0.3 mL/kg/h (24 h)
or
anuria (12 h)

AKIKI study
N Engl J Med. 2016;375:122-33.
Setting/Design 31 ICU, France, N=619
Patients AKI KDIGO stage 3
group Early Delayed p
Mortality 49.5% 49.7% .79
Oliguria/ Anuria 65% 62%
34
RRTのRCT
ELAIN trial
JAMA. 2016;315:2190-9.
Setting/Design Single center, Germany , N=231
Patients AKI KDIGO stage 2
Mortality 39.3% 54.7% .03
Oliguria/ Anuria 69.9% 68.1%
IDEAL-ICU
N Engl J Med. 2018;379:1431-42.
Setting/Design 29 ICU, France, N=488
Patients RIFLE Failure stage
Mortality 58% 54% 0.38
Oliguria/ Anuria 69% 69%
Urine output criteria only 28% 31%
STARRT-AKI
N Engl J Med 2020; 383:240-251
Setting/Design 168ICU, 15 country, N=3019
Patients AKI KDIGO stage 2 or 3
group Early Delayed Relative Risk (95%CI)
Mortality 58% 58% 1.00 (0.93-1.09)
Oliguria/ Anuria 45.7% 43.5%

尿量モニタリングと死亡リスク
35
Jin K, et al. Chest. 2017 Nov;152(5):972-979. PMID: 28527880.
ICUデータベースを?いて尿量モニタリング厳密さとAKI発症予後の関連を評価 , 8 ICU, retrospective cohort study 15,724 adults, AKI diagnosis; KDIGO criteria
UO Intensive monitoring
死亡リスクが低かった
Intensive monitoring: UO intensive monitoring, hourly recordings; no gaps of > 3 hours for the initial 48 hours
SC intensive monitoring, 3 calendar days of SC data
Less Intensive monitoring: not meeting intensive monitoring criteria in the 7 days
Intensive Monitoring by UO
SC Only UO Only Both SC and UO
AKI 166 (4.1%) 1,795 (44.3%) 568 (14%)
No AKI 1,520 (37.5%)
TOTAL 4,049
Non-intensive Monitoring by UO
SC Only UO Only Both SC and UO
AKI 693 (5.9%) 4,432(38%) 2337(20%)
No AKI 4,214 (36.1%)
TOTAL 11,675
Outcome: 30-Day Mortality HR (95% CI) P Value
Model 1: UO Monitoringa AKI
Monitoring–/AKI+ Reference
Monitoring+/AKI+ 0.90 (0.81-0.99) < .04
Monitoring–/AKI– 0.63 (0.56-0.70) < .001
Monitoring+/AKI– 0.57 (0.48-0.68) < .001
Age by 5 y 1.12 (1.11-1.14) < .001
APS-III score by 10 units 1.20 (1.18-1.21) < .001

36
Kellum JA, et al. J Am Soc Nephrol. 2015 Sep;26(9):2231-8. PMID: 25568178
Retrospective cohort, Multiple ICU (mixed), one large academic medical center, 2000-2008, 32,045 patients, AKI diagnosis; KDIGO criteria
UO, SCr単独よりもUO＋SCrの?がより?存予後予測できる
SC: serum creatinine
No AKI Stage 1 Stage 2 Stage 3 P Value
Surgical Admission 6,202 (60.3) 2,903 (59.4) 6,800 (63.2) 2,441 (59.5) <0.001
Vasopressors, 034(18.4) 1,276(24.5) 3,040(26.5) 1,929(44.7) <0.001
Mechanical Ventilation 403(0.5) 3,068(58.8) 7,551(65.9) 3,043(70.6) <0.001
Suspected sepsis 774(7) 564(10.8) 1,540(13.4) 978(22.7) <0.001
KDIGO Stage UO Only
No AKI Stage 1 Stage 2 Stage 3 Total
No AKI 8,179 3,158 5,421 440 17,198
Dead 4.30% 5.30% 7.90% 17.70% 5.90%
RRT 0.00% 0.00% 0.10% 1.10% 0.10%
Stage 1 1,889 1,262 3,485 842 7,478
Dead 8.00% 11.30% 13.00% 32.10% 13.60%
RRT 0.30% 0.70% 0.60% 10.90% 1.70%
SC Only Stage 2 618 476 1,533 831 3,458
Dead 11.30% 23.90% 21.50% 44.20% 25.50%
RRT 1.00% 1.30% 1.70% 21.70% 6.30%
Stage 3 371 321 1,019 2,200 3,911
Dead 11.60% 38.60% 28.00% 51.10% 40.30%
RRT 3.20% 17.80% 14.20% 55.30% 36.60%
Total 11,057 5,217 11,458 4,313 32,045
Dead 5.60% 10.50% 13.00% 42.60% 14.00%
RRT 0.30% 1.40% 1.70% 34.60% 5.60%
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6

37
Bianchi NA, et al. JAMA Netw Open. 2021 Nov 1;4(11):e2133094. PMID: 34735011..
Retrospective cohort, single center, tertiary ICU, 15,620 patients, ≥18 years, admitted for more than 6 hours,, January 1, 2010, to June 15, 2020
SCrとUOの?致率は低い
weighted κ coefficient, 0.36 [0.35-0.37; P < .001]
全体の比率
UO 低下à死亡リスク増加
Characteristic All No AKI AKI, sCr plus UO AKI, UO only AKI, sCr only
(N = 15 620) (n = 3477) (n = 5524) (n = 5630) (n = 989)
Septic shock 1762 (11.6) 181 (5.3) 1044 (19.5) 297 (5.4) 240 (25.0)
Neurological 1615 (10.6) 456 (13.4) 380 (7.1) 667 (12.1) 112 (11.7)
Surgical 8724 (57.2) 1923 (56.6) 2888 (53.7) 3488 (63.3) 425 (44.0)
Medical 6536 (42.8) 1476 (43.4) 2492 (46.3) 2026 (36.7) 542 (56.0)
Elective admission 4524 (29.6) 1187 (34.9) 978 (18.2) 2242 (40.7) 117 (12.1)

AKIの診断
尿量 + SCr
↓
予後予測の精度が高い
38
慈恵医?ICU勉強会 2017年6?6?AKIの診断における尿量の意義参照

周術期の尿量と術後AKI (??臓?術)
39
Myles PS, et al. Br J Anaesth. 2019 Feb 15. [Epub ahead of print] PMID: 30916001
RCT, RELIEF trialのpost hoc, 術中乏尿と術後AKIとの関連を検証
腹部?術症例 (?腸約50％, ?道?泌尿器?婦?科各々約10％, 緊急?術約8%)
Oliguria (N=889) vs. No_oliguria (N=1528), oliguria: urine output <0.5 mL/kg/h for at least 1hr
術後AKIリスク
術中乏尿 OR: 1.29 [1.14 ? 1.45, p<0.001]
Factor AKI RR (95% CI) P-value
Treatment group
interaction
All patients (n=2354)
Any oliguria
Yes (n=864) 220 (26) 1.29 (1.14-1.45) <0.001 <0.001
No (n=1490) 274 (18) reference
Urine output (mL/kg/h) 0.006* <0.001
≥0.5 (n=1880) ) 366 (20) reference - -
0.40-0.49 (n=143) 39 (27) 1.50 (1.05-2.13) 0.025 0.5
0.30-0.39 (n=128) 36 (28) 1.56 (1.08-2.26) 0.018 0.14
0.20-0.29 (n=102) 33 (32) 1.90 (1.27-2.82) 0.002 0.077
0.10-0.19 (n=71) 14 (20) 1.02 (0.57-1.80) 0.96 0.84
<0.10 (n=31) 7 (23) 1.20 (0.52-2.77) 0.67 0.81
AUC 0.54 [0.51 ? 0.56]
Positive predictive value: 25.5%
Negative predictive value: 81.6%

周術期の尿量と術後AKI (??臓?術)
40
Shiba A, Uchino S, Fujii T, Takinami M, Uezono S.
Anesth Analg. 2018 Nov;127(5):1229-1235. PMID: 29933276.
Retrospective cohort (慈恵医?附属病院), ??臓外科5,894症例, 2時間以上の?術, 術中尿量と術後AKIの関連を検証
消化器20％、整形外科15％、婦?科15％、?管外科12％
術後AKI 37%(Risk; 5.1%, Injury; 1.4%, Failure; 0.9%)
術中乏尿 (UO<0.5 mL/kg/hr)の時間が?いと
術後AKIリスクが増加
Table 3. Multivariable Logistic Regression Model for
Association Between Oliguria and Postoperative
Acute Kidney Injury
Factor: Age (5 per years), Sex (male), ASA PS≥3, Emergency surgery, Department, Blood
loss (100 g), Crystalloid infusion (100 mL), Hydroxyethyl starch infusion, RCC transfusion,
Furosemide, Mannitol, Atrial natriuretic peptide, NSAIDs
Odds Ratio 95% CI P Value
Model 1, primary exposure
Oliguria ≥120 min 2.104 1.593–2.778 <.001
Model 2, secondary exposure
Duration of oliguria (min) <.001
None 1 — —
>0, <60 0.827 0.59–1.16 0.272
≥60, <120 1.542 1.185–2.007 0.001
≥120, <180 1.896 1.35–2.663 <.001
≥180, <240 3.54 2.377–5.273 <.001
≥240, <300 6.5 4.027–10.493 <.001
≥300 12.353 7.145–21.357 <.001

周術期の尿量と術後AKI (?臓?術)
41
Song Y, et al. Medicine (Baltimore). 2016 May;95(22):e3757. PMID: 27258505 .
Retrospective cohort, ?臓外科696症例 (術後AKI 37%), CPB中の尿量と術後AKIの関連を検証
CPB中UO< 4 mL/kg/hr
術後AKIリスクが増加
CPB UO< 4 mL/kg/hr CPB UO ≥4 mL/kg/hr
UO 4 mL/kg/hr
CPB Urine Output mL/kg/hr
Variables No AKI (n=439) AKI (n=257) P
Type of surgery
Mitral valve surgery only 201 (46) 136 (53) 0.69
Aortic valve surgery only 141 (32) 89 (35) 0.497
Double valve operation 42 (10) 52 (20) <.001
Coronary valve
operation
31 (7) 27 (11) 0.113
Aorta surgery 17 (4) 15 (6) 0.448
Adult congenital 21 (5) 15 (6) 0.545
Transplantation 1 (0) 3 (1) 0.145
Others 28 (6) 24 (9) 0.152
CPB time, min 105 [80–135] 127 [91–161] <0.001

周術期の尿量と術後AKI (?臓?術)
42
Pet?j? L, et al. J Cardiothorac Vasc Anesth. 2017 Jun;31(3):827-836. PMID: 27856153 .
Single-center, prospective cohort, ?臓外科術後638症例, 術後AKIと予後を検証
AKI: 28.7% (KDIGO: 1; 18.8%, 2;6.1%, 3; 3.8%), No AKI: 71.3%
術後AKI
UO+SCrで診断された?が死亡リスク?い HR: 4.9 [2.4-9.9]
術後AKIリスクファクター
Multivariable
Odds Ratio (95% CI)
p Value
Age,years 1.02(1.00-1.04) 0.027
Body mass index 430 kg/m2, yes/no 2.99 (1.87-4.78) 0.001
Chronic kidney disease, yes/no 4.08 (2.22-7.50) 0.001
Peripheralvascular disease, yes/no 1.95 (1.10-3.45) 0.023
Urgent/emergency versus elective surgery 1.76 (1.11-2.78) 0.017
Lowest hematocrit, % 0.95(0.92-0.99) 0.009
Vasopressor load, ?g/kg/min 3.72 (1.50-9.25) 0.005
Inodilator therapy, yes/no 2.49 (1.54-4.02) 0.001
Furosemide in intensive care unit, yes/no 3.84(2.47-5.99) 0.001
Multivariable Regression Analysis of Covariates Predicting AKI During First 5 Postoperative Days

周術期尿量測定
術後AKIを予測
43

AKIリスク低ければ
尿量測定必要ない？
44

尿量をターゲットにした循環管理
46
van der Zee EN, et al. BMC Anesthesiol. 2017 Feb 10;17(1):22.
Systematic Review. PMID: 28187752
尿量をターゲットにした循環管理が死亡割合に関連するかを検証, Systematic review, 36 RCT
CFM: Conventional Fluid Therapy
Mortality risk OR [95% CI] I2
Not Targeting UO in both protocol (13 RCT) 0.87 [0.59 - 1.27, p=0.94] 20%
Targeting UO only in CFM (7 RCT) 1.09 [0.59 – 2.00, p=0.91] 4.7%
Targeting UO in both protocol (16 RCT) 0.77 [0.59 - 1.01, p=0.47] 35.6%
Total (36 RCT) 0.825 [0.684 - 0.995, p=0.95] 28%
7RCTでGDT群で尿量を指標にしていなかったが、
死亡リスクは変わらなかった
尿量測定の30?死亡リスク
死亡との関連は?せず
尿量を輸液管理の指標として死亡割合との関連を直接検証した
研究はなかった
GDT vs. CFMの研究
尿量測定と30?死亡割合を提?している研究を選択

尿量を基にした循環管理
研究はほとんどない
47

?分バランスの調整
術後尿閉
49

術後尿閉
50

Prospective worldwide audit, 84countries, 730ICU, total 10,069 patients à 1,808 sepsis patients, 1,098(60.7%) had septic shock
72時間後の積算バランスで4分位毎の群に分け?較
Sakr Y, et al.Crit Care Med. 2017 Mar;45(3):386-394. PMID: 27922878.
Hazard of death,
Fluid Balance within 72hr
P=.003
Cumulative Fluid Balance, mL
72hrバランスが多い程で死亡リスク増加 51
敗?症患者の?分バランス
Hazard Ratio (95% CI) p
1st
quartile Ref
2nd
quartile 1.36 (1.03–1.80) 0.035
3rd
quartile 1.47 (1.12–1.92) 0.005
4th
quartile 1.63 (1.25–2.12) < 0.001

Prospective worldwide audit, 84countries, 730ICU, total 10,069 patients à 1,808 sepsis patients
72時間後の積算バランスで4分位毎の群に分け?較
Sakr Y, et al.Crit Care Med. 2017 Mar;45(3):386-394. PMID: 27922878.
52
敗?症患者の?分バランス
0
2000
4000
6000
8000
10000
12000
14000
First 24 h At 3 days At 7 days
Output, median (mL)
Survivors Non-survivors
0
1000
2000
3000
4000
5000
First 24 h At 3 days At 7 days
Fluid Balance, median (mL)
Survivors Non-survivors
尿量 Non-Survivor
1500-2500mL/day 程度
尿量 Survivors
2000-2500mL/day 程度

?臓?管外科術後?分バランス
53
Kuo G, et al. Ann Thorac Surg. 2020 May;109(5):1343-1349. PMID: 31734247.
Single center, prospective cohort, cardiovascular surgery, 1063 patients. Primary Outcome, AKI.
?臓外科術後患者の輸液バランスとAKI発?リスクについて検証
Age, y 59.1 ? 13.7
BMI, kg/m2 24.8 ? 4.1
Surgery type
Aortic 282 (26.5)
CABG 344 (32.4)
Valve 437 (41.1)
Surgical detail
Emergent surgery 411 (38.7)
APACHE III 43.5 ? 22.3
SOFA 6.5 ? 2.2
In-Out バランスで3群に分割
G1, negative
G2, slightly positive
G3, progressively positive
AKI risk OR (95%CI)
G1: negative Reference
G2: slightly positive 2.43 (1.74-3.38)
G3: progressively positive 8.45 (3.77-18.91)
In-Out Balance
プラスバランス
à AKIリスク?い
In-Out Balance
G1
G2
G3

?臓?管外科術後?分バランス
54
Kuo G, et al. Ann Thorac Surg. 2020 May;109(5):1343-1349. PMID: 31734247.
Single center, prospective cohort, cardiovascular surgery, 1063 patients. Primary Outcome, AKI.
2144
1688
2378
1762
1410
2031
1017
931
1534
0
500
1000
1500
2000
2500
3000
3500
4000
UO at 0-24 hrs., mL UO at 24-48 hrs., mL UO at 48-72 hrs., mL
尿量
術後72時間の尿量変化
術後尿量
1000-2000mL/day 程度必要
3000mL/day以上必要な場合もある

排出路の確保
2000mL/day程度の尿排出能力は必要そう
55

術後尿閉
56

Postoperative urinary retention, POUR
57
Brouwer TA, et al. Anesthesiology. 2015 Jan;122(1):46-54. PMID: 25371036.
膀胱内尿量増加による膀胱壁の過伸展
ウサギの尿路を閉塞
その後膀胱を電気刺激
閉塞の?数と電気刺激による反応を検証
閉塞期間と共に膀胱容量増加
排尿筋機能障害の可能性
膀胱容量過多
↓
膀胱収縮?の低下
閉塞の?数
閉塞の?数
平滑筋の反応

膀胱内容量の限界は?
58

術後の尿排出
59
術後患者の術後尿閉予防とIUCの?安を検証, single center RCT
Control Group: 膀胱容量500mLと設定した群, USスキャンで膀胱容量≥500mL, ?尿促しだめならカテ挿?
Index Group: 膀胱容量を事前に評価した群, 事前に算出した容量を閾値として，容量に達したらカテ挿?
Primary outcome: IUCの頻度
Control Group
n = 909
Index Group
n = 931 Relative Risk P Value
Catheterization 11.8% 8.6% 0.73 (0.55-0.96) 0.025
66% 以上の患者が MBC 500 mL以上
500
Control Group
n = 909
Index Group
n = 931
最?膀胱容量, mean (SD), mL 582 (199) 611 (209)
残尿, mean (SD), mL 33 (61) 33 (53)
輸液量, mean (SD), mL 1,475 (580) 1,492 (647)
?術時間, mean (SD), 分 61 (37) 61 (40)

術後の尿排出
60
術後患者の術後尿閉予防とIUCの?安を検証したRCT
Control群: 膀胱容量500mLと設定した群, USスキャンで膀胱容量≥500mL, ?尿促しだめなら尿カテ挿?
Index treatment 群: 膀胱容量を事前に評価した群, ?宅で事前に算出した容量を閾値として，容量に達したら尿カテ挿?
Primary outcome: IUCの頻度
Control Group Index Group RR (95% CI)
n = 883 n = 909
Voiding less than threshold 505 (56.8) 611 (67)
Catheterized less than threshold 2 (0.2) 10 (1)
Reaching volume threshold (=POUR) 376 (43) 288 (32)
Spontaneous voiding 273 (72.6) 223 (77.4)
Catheterization 103 (27.4) 65 (22.6) 0.82 (0.63 to 1.08, P = 0.160)
7割は??で尿排出
4分の1で尿カテ挿?
膀胱容量に達した患者の

残尿量の許容
600mL程度
61

硬膜外カテーテルの影響は?
62

硬膜外カテーテルとIUC
63
Zaouter C, Kaneva P, Carli F. Less urinary tract infection by earlier removal of bladder
catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain
Med. 2009 Nov-Dec;34(6):542-8. PMID: 19916208.
Single center RCT, 硬膜外カテーテル使?した腹部外科患者215例
IUC早期抜去群, ?術翌朝に尿カテ抜去，標準治療群, 硬膜外カテ挿?抜去まで尿カテ留置
硬膜外カテーテル挿?患者の尿カテ早期抜去
術後UTI少ない
尿カテ再挿?に有意差なし
ICU早期抜去
N=105
標準治療群
N=110
p-value
Age, y (SD) 57 (15) 63 (11) 0.002
Age ≥65 y. % (n) 34 (36) 41(45) 0.32
Men, % 52 62 0.1 24
Type of Surgery
Thoracic, % 47 51 0.53
Abdominal, % 53 50
Duration of surgery, min (SD) 236 (95) 271 (111) 0.02
ICU早期抜去
N=105
標準治療群
N=110 P-value
UTI, N 2 15 0.004
尿カテ再留置, N 8 2 0.09
間欠的導尿, N 3 0 0.229

Early Removal Control Group P-value
Total number 101 210
Epidural duration (days) 4 (3-5) 4 (3-5) 0.983
Urinary catheter
Catheter duration (days) 1.8 (1.1-2.1) 3 (2-5) <0.001
Recatheterization 27 (26.7) 26 (12.4) 0.003
Urinary tract infection 1 (1.0) 8 (3.8) 0.28
64
Hu Y, et al. Early removal of urinary catheter after surgery requiring thoracic epidural: a prospective trial.
J Cardiothorac Vasc Anesth. 2014 Oct;28(5):1302-6. PMID: 25281046.
Prospective cohort study, 術後2?内に尿カテ抜去, 硬膜外カテ挿?患者尿カテ抜去後の尿閉を検証
Urinary retention: bladder volume >400mL
早期抜去群の26.7%で尿カテ再挿入
Table 1. Patient Characteristics and Outcomes across Study Groups
n (%), Median (IQR)
POUR (+) POUR (–) P-value
Total number 53 258
Age 62 (48-70) 60 (51-68) 0.724
Epidural level 0.964
T5-6 0 2 (0.8)
T6-7 6 (11.3) 25 (9.7)
T7-8 24 (45.3) 109 (42.2)
T8-9 20 (37.7) 95 (36.8)
T9-10 3 (5.7) 25 (9.7)
T10-11 0 2 (0.8)
Decatheterization 10 (5-10) 5 (0-11.9) 0.255
Epidural duration (days) 4 (3-5) 4 (3-5) 0.668
Catheter duration (days) 2 (1.8-2.3) 2.7 (1.8-4) 0.002
Table 2. Characteristics of Patients With Postoperative Urinary Retention
硬膜外カテ挿?部位に関わらず
尿閉発生頻度変わらず

65
Young J, et al. J Thorac Cardiovasc Surg. 2018 Jul;156(1):430-435. PMID: 29609886.
Retrospective cohort, 胸部硬膜外カテーテル挿?した胸部?術患者275症例
SCIP9に則ってUC抜去?多変量解析で再挿?リスクを検証
48時間以内のUC再挿?; あり (21.6%) vs. なし(78.4%)
尿カテ再挿?リスク因?：?道?術, BPH
Factors P value OR (95% CI)
Esophageal resection
(vs pulmonary)
<.001 4.16 (2.05-8.43)
Presence of BPH*
Female 0.056 0.49 (0.24-1.02)
Male without BPH reference
Male with BPH 0.049 2.73 (1.00-7.45)
Lower BMI 0.029 0.93 (0.87-0.99)
Age 0.07 1.03 (0.99-1.06)

硬膜外脊髄くも膜下併??酔とIUC
66
Thiengwittayaporn S, et al. Arch Orthop Trauma Surg. 2021 Mar;141(3):469-476. PMID: 33180187.
Design: single center RCT. Patient: TKA, CSEA. 硬膜外カテーテルは24時間以内に抜去
retained UC群 (UC, N=113), non-retained UC群 (non-UC, N=113) groups
Outcome: incidences of postoperative urinary retention (POUR, <400mL)
Clinical outcomes UC (N = 113) Non-UC (N = 113) p value
POUR, n 3 6 0.4
Mean intraoperative intravenous fluid, ml (range) 1054.0 (350–1300) 978.8 (300–1500) 0.07
Mean duration of the surgery, min (range) 89.5 (54–149) 89.8 (60–140) 0.8
UTI, n 2 0 0.4
Mean length of stay, day (range) 4.8 (3–10) 4.5 (2–9) 0.08
硬膜外脊髄くも膜下併??酔患者
術中輸液1000mL程度
à
術後に尿カテがなくても
術後尿閉有意差なし
?術時間90分程度

硬膜外カテーテル
尿閉を起こすのは2-3割
67

感染症発?率
CR-UTI
4.1/ 1000 urinary catheter-days
(95% CI 3.7-4.6)
ICUでの医療関連感染発?率(WHO報告)
http://apps .who .int/ iris/ bitstream/ 10665/80135/ 1/ 9789241501507_eng .pdf
VAP
7.9/1000 ventilator-days
(95% CI 5.7-10.1)
CR-BSI
3.5/1000 catheter-days
(95% CI 2.8-4.1)

IUC合併症
73
Saint S, et al. JAMA Intern Med. 2018 Aug 1;178(8):1078-1085. PMID: 29971436;
PMCID: PMC6143107.
Infectious Complication
Non-Infectious
Complication
Variable IRR (95% CI) P Value IRR (95% CI) P Value
Urinary Catheter Duration
3 days or Less 1 [Reference] 1 [Reference]
More than 3 days 1.38 (1.03-1.84) 0.03 1.27 (1.17-1.37) <.001
Other Factor, Sex; Reason; AUA Symptom Index Score; Age
Percentage of 2076 Patients Reporting Complications After IUC
Multivariable Linear Regression Model to Predict Infectious and Noninfectious Urethral
Catheter Complications
3?以上の尿カテ挿?は
合併症のリスク
?感染性合併症
感染症の5倍以上
Total [55.4%]
Woman [47.3%]
Men [58.6%] P < .001
Total [10.5%]
Women [15.5%]
Men [ 8.6%] P < .001

?感染性IUC合併症
74
Hollingsworth JM, et al. Meta-analysis,37studies, 2868 patients
合併症頻度 95% CI
尿漏れ 10.6% [2.4 to 17.7]
尿道狭窄(Higher quality studies) 16.7% [13.0 to 20.8]
(Low quality studies) 3.4% [1.0 to 7.0]
血尿 4.7% [0.0 to 10.0]
事故抜去 4.0% [0.0 to 8.6]
留置中 !"#$%&' (
感染性合併症 15.3%
?感染性合併症 70.2%
痛み?は不快感 54.5%
切迫感や膀胱の痙攣 34.7%
?尿 27.4%
?膚障害 19.4%
その他の合併症
社会活動の制限 43.9％
?常?活の制限 39.5%
抜去後 (N=2034) %
尿漏れ 20.3%
排尿開始または尿?め困難 19.5%
排尿時痛または灼熱感 17.4%
排尿困難 12.1%
尿の噴き出し 9.2%
?膚障害 6.6%
挿?部の出? 4.6%
Saint S, et al. Prospective cohort, 4 US Hospital, 2076 patients with IUC.内科/外科急性期病棟, ICU
18歳以上、参加者に聴取し3?以内に尿カテ留置した患者、留置から14??と30??詳細聴取
?感染性合併症約7割
Hollingsworth JM, et al. Ann Intern Med. 2013 Sep 17;159(6):401-10. PMID: 24042368.
Saint S, et al. JAMA Intern Med. 2018 Aug 1;178(8):1078-1085. PMID: 29971436; PMCID: PMC6143107.

IUCによる尿道損傷
75
Kashefi C, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008
Jun;179(6):2254-7; discussion 2257-8. PMID: 18423712.
prospective cohort, identified urethral catheter injuries 4,310 cases
1) difficult catheter placement with subsequent poor catheter drainage
2) inability to place a catheter
3) At least of 1 certain condition - urethral and/or perineal pain, blood at the urethral meatus, a nondraining catheter that could not be irrigated,
cystoscopic evidence of urethral injury or retrograde urethrogram demonstrating urethral extravasation
Intervention: 看護師へのIUC適正使?の教育
Before and After Intervention
Injuries (N) Admissions (N)
Before Intervention 14 4,310
Hematuria, pain 12
Pain 2
After Intervention 3 4,523
Hematuria, pain 2
Hematuria, pain,
urinary retention
1
3.2 injuries
/1,000 male patients

IUCによる尿道損傷
76
Davis NF, Quinlan MR, Bhatt NR, Browne C, MacCraith E, Manecksha R, Walsh MT, Thornhill JA, Mulvin
D. Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A
Prospective Multi-Institutional Study. J Urol. 2016 Nov;196(5):1473-1477. PMID: 27317985.
A prospective study at 2 tertiary university hospitals in a 6-month period
There are 1,000 inpatient beds between both institutions with 11,000 catheter insertions performed per year.
尿カテによる尿道損傷 6.7 /1,000 catheters
在院?数の延?
9.4±10 days (range 2 to 53)
Table 3. Clinical outcomes after traumatic UC No.
Indwelling suprapubic catheter 9
Indwelling urethral catheter 8
Intermittent self-catheterization 9
Urethral dilation/direct vision internal urethrotomy 4
Outpatient uroflow post-void residual measurement 7
Total 37
Table 2. Short-term complications and relevant Clavien-Dindo
No.
Urosepsis (requiring ICU management) 10 (2)
Acute renal failure (requiring ICU management) 3 (1)
Hematuria requiring continuous bladder irrigation 6
Repeat cystoscopy to catheterize bladder 4
Epididymo-orchitis requiring intravenous 2
antibiotics
Blood transfusion 2

IUCとせん妄
77
Eide LS et al. BMJ Open. 2018 Nov 1;8(11):e021708. PMID: 30389757
Eide LS, et al. Am J Cardiol. 2015 Mar 15;115(6):802-9. PMID: 25644851.
Observational Prospective cohort study, post-hoc, SAVR or TAVI in a tertiary university hospital, ≥80 years old, 尿カテ挿?時間とせん妄の関係を検証
尿カテ挿?時間が?くなる程
せん妄リスク上昇
Other factors: Sex, Barthel Index, Atrial fibrillation, Charlson Comorbidity Index, MMSE score,
Postoperative infections
Adjusted OR 95% CI P value
Length IUC use (hours) 1.01 0.99 to 1.03 0.54
Treatment 0.003
SAVR (ref.)
TAVI 0.06 0.01 to 0.35
Length IUC use × treatment type 1.04 1.00 to 1.08 0.04
Characteristic Delirium No delirium P values
SAVR, n = 73 n=25 n=48
Age (years) 81.6±1.4 82.7±2.3 0.01
Length of time of IUC use (hours) 59±27 66.1±29.3 0.31
TAVI n=63 n=28 n=35
Age (years) 84.9±2.8 84.7±2.8 0.74
Length of time of IUC use (hours) 58.5±38.2 31.6±15.1 0.001
Count/ mean±SD or (%)
Odds
Ratio

Retrospective cohort, 慈恵医?葛飾医療センター, 低侵襲?術患者5112例, 術後の意識変容を解析。診察記録からせん妄と思われる状態を抽出。
Inverse Probability Weightingで調整
意識変容リスク
Fukushima T, et al. Ann Med Surg (Lond). 2021 Mar 6;64:102186. PMID: 33747493
IUCとせん妄
All Patients Inverse Propensity-Weighted Patients
Control IUC ASD Control IUC ASD
Number of patients, N (%) 2,249 2,863 3,080.94 2,863.00
Age, y 48 [36 - 63] 60 [44 - 72] 0.477 60 [47 - 71] 60 [44 - 72] 0.024
Surgery type, N (%) 0.498 0.089
General surgery*
, N (%) 633 (28.1) 1,283 (44.8) 1,393.3 (45.2) 1,283.0 (44.8)
ENT surgery?
, N (%) 820 (36.5) 498 (17.4) 457.3 (14.8) 498.0 (17.4)
Orthopedic surgery?
, N (%) 724 (32.2) 896 (31.3) 979.3 (31.8) 896.0 (31.3)
Others, N (%) 72 (3.2) 186 (6.5) 251.1 (8.1) 186.0 (6.5)
Age >65 y, Male,BMI >30 kg/m2,Surgery type, Nerve block, Fentanyl use
Odds ratio [95% CI]
All patients P-value IPW P-value
Urinary catheter 2.08[1.44 - 3.03] <0.001 1.97 [1.50 - 2.59] <0.001
Inverse Propensity-Weighted Patients
Control IUC ASD P-value
N 3,080.94 2,863.00
AMS or UTI 98.3 (3.2) 143.0 (5.0) 0.091 0.397
AMS, Altered Mental Status
尿カテ挿?
↓
意識変容のリスク因?

IUCによる尿道狭窄
79
Prospective cohort, 尿道狭窄形成術を?った268症例の解析
治療対象の11.2 % がIUCによる影響
Lumen N, et al. J Urol. 2009 Sep;182(3):983-7. PMID: 19616805.
Retrospective cohort, DVIUを?った医原性尿道狭窄224症例の解析
(DVIU: direct vision internal urethrotomy, 経尿道的内尿道切開術)
IUCによる尿道狭窄は31.7%, そのうち再発は26.5%
K?z?lay F, et al. Turk J Med Sci. 2017 Nov 13;47(5):1543-1548. PMID: 29151330.

尿道狭窄ガイドライン
80
Lumen N et al. Eur Urol. 2021 Aug;80(2):190-200. PMID: 34059397.
Campos-Juanatey F, et al. Eur Urol. 2021 Aug;80(2):201-212. PMID: 34103180.
European Association of Urology Guidelines on Urethral Stricture Disease
Recommendations Strength rating
Advise safe sexual practices, recognise symptoms of sexually
transmitted infections, and provide access to prompt investigation and
treatment for men with urethritis.
Strong
Avoid unnecessary urethral catheterisation. Strong
Implement training programmes for physicians and nurses performing
urinary catheterisation.
Strong
Do not use catheters larger than 18 Fr if urinary drainage only is the
purpose
Weak
Avoid using noncoated latex catheters Strong
Do not perform urethrotomy routinely when there is no pre-existent
urethral stricture
Strong

Immobilization
IUC
↓↑
Immobilization
81

Indwelling vs. Intermitted
82
Kidd EA, et al. Cochrane Database Syst Rev. 2015 Dec 10;(12):CD004203.
PMID: 26661940.

Indwelling vs. Intermitted
83
Kidd EA, et al. Cochrane Database Syst Rev. 2015 Dec 10;(12):CD004203.
PMID: 26661940.

尿道カテーテルによる合併症
尿カテ挿入患者の半数
合併症の約7割非感染性
84

超?波診断装置
体重測定
86

超?波診断装置
体重測定
87

膀胱専?超?波診断装置による測定
88
周術期IUCの必要な患者、超?波内容量測定した後、尿カテ挿?し尿量測定
Brouwer TA, et al. J Clin Monit Comput. 2018 Dec;32(6):1117-1126. PMID: 29516310
Verathon Medical BVI 9400?
BVI 9400 (n = 105)
Estimated volume, mean (SD) (mL) 288 (237.0)
Actual volume, mean (SD) (mL) 266 (241.9)
Difference estimated–actual volume, mean (SD) (mL) 21.8 (59.9)
Preoperative measurement, no (%) 89 (84.8)
Actual volumes > 400 mL, no (%) 26 (24.8)
Volumes ≤400mL Volumes >400 mL
N Bias LOA N Bias LOA
BVI 9400 79 25.7 ? 69 to 121 26 10 ? 159 to 179
400 mL 500 mL 600 mL
True negatives True positives True negatives True positives True negatives True positives
BVI 9400 100 (1.00–1.00) 89.7 (0.79–1.00) 100 (1.00–1.00) 90.9 (0.79–1.00) 98.9 (0.97–1.00) 80.0 (0.60–1.00)
LOA; Limit of Agreement (±1.96SD)

膀胱専?超?波診断機
89
Brouwer TA, et al. J Clin Monit Comput. 2018 Dec;32(6):1117-1126. PMID: 29516310
Daurat A, et al. Anesth Analg. 2015 May;120(5):1033-1038. PMID: 25642660.
Cho MK, et al. Int Urogynecol J. 2017 Jul;28(7):1057-1061. PMID: 27942791.
Verathon Medical Bladderscan Prime plus?
Verathon Medical Bladderscan BVI 3000? Biocon-700, Mcube Technology

膀胱専?超?波診断機 Cho MK, et al. Int Urogynecol J. 2017 Jul;28(7):1057-1061. PMID: 27942791.
超?波と実測による尿量の差異をBrand-Altman法で検証125例の残尿を測定
Biocon-700, Mcube Technology
Residual N Catheterized volume Bladder scan volume Scan error Absolute scan error
0–50 93 10.16 ± 11.54 15.94 ± 33.66 5.77 ± 32.69 15.37 ± 29.38
51–100 17 70.59 ± 15.60 63.82 ± 42.48 ?6.76 ± 43.80 31.35 ± 30.38
100–200 9 147.56 ± 30.39 178.33 ± 86.43 30.78 ± 67.25 59.22 ± 40.53
>201 6 230.0 ± 25.29 300.33 ± 99.15 70.33 ± 83.70 75.67 ± 77.92 Mean ± standard deviation (mL)
Pearson’s correlation coefficient 0.872 mL
(R2 = 0.76).
The mean difference 23.59 ± 37.32 mL
(95%confidence interval, 17.5–30.65 mL)

?般超?波診断装置による測定
91
Sullivan R, et al. Ann Am Thorac Soc. 2019 Dec;16(12):1582-1584. PMID: 31774326.
Point-of-care bladder ultrasound with measurement for volume assessment.
The urinary bladder volume = 7.73cm(w)?×?9.08cm(l)?×?5.77cm(d)?×?0.52*?=?211 mL.
*係数は0.5とすることもある
腹?が圧場合誤認することがあるので注意
Transverse section Sagittal section

膀胱エコーと尿量 Prentice DM, et al. J Intensive Care Soc. 2018 May;19(2):122-126. PMID: 29796068;
超?波と実測による尿量の差異を検証
All patients (n=13), 51 measurements
US:
Sonosite M-turbo
Zonare Ultra version 4.8
BS: BVI 9400,Verathon
US BS UVol,
US-Uvol
Difference
BS-Uvol
Difference
US-BS
All patients (n = 13), 51 measurements
72.1
±127
117
±131
237.5
±339
-11.5
!158
-48.8
!406
-44.7
!162
Dialysis patients only (n=11), 49 measurements
50.4±66 119±133 100 ±144 0.5 ±37.8 132 ±167 -68.7 !110
BS: bladder scanner; US: ultrasound; UVol: urine volume, mean ±SD

超?波診断装置
体重測定
93

輸液バランスと体重
94
Testani JM, et al. Am J Med. 2015 Jul;128(7):776-83.e4 PMID: 25595470
急性?不全(ADHF)に対する利尿薬、尿量と体重変化の?致の程度を検証
A: DOSE (N Engl J Med. 2011;364:797-805.), B: ESCAPE (JAMA. 2005;294:1625-1633.), C: Penn (Circ Heart Fail. 2014;7:261-270.)
データを?いたpost-hoc解析 (N=254)
DOSE, Inpatient randomized trial of loop diuretic strategies in acute decompensated heart failure
ESCAPE, Inpatient randomized trial of pulmonary artery catheters in acute decompensated heart failure
Penn, Inpatient retrospective observational acute decompensated heart failure cohort
A: DOSE B: ESCAPE C: Penn
Correlation between net fluid and weight loss r=0.55, P < .001 r=0.48, P < .001 r=0.51, P < .001
95% limits of agreement (kg-L) -6.4 to 7.9 -7.5 to 11.6 -11.4 to 14.5
Mean bias (kg-L) 0.74±3.8 2.1±4.9 1.6±6.6
Mean of Change in Weight (Kg) and Net Fluid Loss (L)
Change
in
Weight
(Kg)
-
Net
Fluid
Loss
(L)
尿量と体重変化
相関関係はあり
誤差は?きそう

体重測定と予後
Taiwan, multicenter, prospective cohort, adult cardiac surgery 188 patients with postoperative AKI requiring renal replacement therapy
(Survivors, N = 124; Non- Survivors, N = 64)
体重変化と予後を検証 (体重変化: ?院時から?臓外科術後ICU?室時, ICU?室時とRRT導?前)
95
Shiao CC, et al. PLoS One. 2017 Nov 17;12(11):e0187280. PMID: 29149189
HR 95% CI p-value
Peri-op BW change 1.07 1.03–1.12 0.001
Post-RRT BW
change
1.06 1.04–1.08 <0.001
Independent predictors of 30-day postoperative mortality using
multivariate Cox proportional hazards model.
Other factor: Peri-op PRBC transfusion, CAVH (with ECMO), HR at RRT, MAP at RRT, SOFA
Score at RRT
2%以上の体重変化
死亡リスク

体重測定と予後
96
Shiao CC, et al. PLoS One. 2017 Nov 17;12(11):e0187280. PMID: 29149189
ICU?室時からRRT導?前までの体重変化と術後死亡予測
2% 15%
体重変化 %
Probability
of
postoperative
mortality

超音波?体重測定
尿量測定と相関関係あり
予後との関連もありそう
ばらつきは大きい
97

尿道カテーテル留置は減らせるか？
98

改善?法
n ガイドライン/プロトコール作成
n スタッフの再教育
n チェックリスト
n 包括院内システムの導入
n 行政制度?保険制度の導入

100
多施設コホート研究
32か国, 603施設, 926箇所 (non-ICUs; 59.7%, ICUs; 40.3%)
UTI減少プログラムによるIUC適応の厳格化
UTI減少プロジェクト

101
プログラムによりUTI, IUC減少
UTI: 2.40 à 2.05 infections/1000 catheter-days, incidence rate ratio (IRR), 0.86 [0.76 to 0.96; P = 0.009]
Non-ICU (N=553)
UTI Catheter Use
Time 0.68 (0.56–0.82) <0.001 0.93 (0.90–0.96) <0.001
Teaching hospital 1.76 (1.03–3.01) 0.04 0.96 (0.73–1.26) 0.77
Rural hospital 0.90 (0.66–1.23) 0.51 0.89 (0.78–1.01) 0.07
CAH 2.36 (1.65–3.37) <0.001 0.95 (0.82–1.10) 0.47
Hospital size
(per 100-bed increase)
0.97 (0.90–1.05) 0.45 0.98 (0.95–1.02) 0.38
UTI
2.28 à 1.54 infections/1000
catheter-days,
IRR, 0.68 [0.56-0.82, P<0.001]
IUC
20.1 à 18.8%
IRR, 0.93 [0.90-0.96, P<0.001]
全体でUTI, 尿カテ使?率減少

102
UTI
2.48 à 2.50 infections/1000 catheter-days,
IRR, 1.01 [0.87-1.17, P=0.90]
IUC
62.8 à 61.9%
IRR, 0.98 [0.96-1.01; P=0.15]
プログラムによりUTI, IUC減少
UTI: 2.40 à 2.05 infections/1000 catheter-days, incidence rate ratio (IRR), 0.86 [0.76 to 0.96; P = 0.009]
ICU (N=373)
UTI Catheter Use
Time 1.01 (0.87–1.17) 0.9 0.98 (0.96–1.01) 0.15
Teaching hospital 1.92 (1.32–2.80) 0.001 0.96 (0.88–1.06) 0.45
Rural hospital 0.83 (0.58–1.18) 0.3 0.85 (0.78–0.91) <0.001
CAH 2.60 (0.94–7.20) 0.07 0.81 (0.67–0.98) 0.03
Hospital size
(per 100-bed increase)
1.09 (1.02–1.16) 0.01 1.02 (1.01–1.04) 0.01
Rural Hospital, CAH à 尿カテ使?率減少

CAUTI教育プログラムの導?
103
Menegueti MG, et al. Medicine (Baltimore). 2019 Feb;98(8):e14417. PMID: 30813142
ブラジル南東部にある公?3次医療機関の9床の?般集中治療室, CAUTI予防プログラム導?後のCAUTI発?率とIUC使?率を検証
1st ; 2005–2006, CAUTIがアウトブレイク, プロトコール導?期 2nd ; 2007–2010, CDCガイドラインに基づく年２回のトレーニング
3rd ; 2011–2014, チェックリスト導? + 年２回トレーニング 4th ; 2015–2016 年２回のトレーニングを年1回新?トレーニングに変更
1st 2nd 3rd 4th
Mean patient-days using an IUC/month
(SD)
169
(25)
186
(30)
131
(31)
108
(19)
Utilization:
mean % catheter-days/patient-days /month
(SD)
73.1
(9.9)
74.1
(10.2)
54.9
(11.5)
45.6
(7.3)
尿カテ使?率
導?前の 6割程度まで減少

CAUTI教育プログラムの導?
104
Menegueti MG, et al. Medicine (Baltimore). 2019 Feb;98(8):e14417. PMID: 30813142
ブラジル南東部にある公?3次医療機関の9床の?般集中治療室, CAUTI予防プログラム導?後のCAUTI発?率とIUC使?率を検証
1st ; 2005–2006, CAUTIがアウトブレイク, プロトコール導?期 2nd ; 2007–2010, CDCガイドラインに基づく年２回のトレーニング
3rd ; 2011–2014, チェックリスト導? + 年２回トレーニング 4th ; 2015–2016 年２回のトレーニングを年1回新?トレーニングに変更
1st 2nd 3rd 4th
CAUTI mean incidence rate,
entire phase
(No. of episodes/1000 catheter-days [SD])
14.9
(7.5)
7.3
(5.0)
3. 8
(5.7)
1.1
(3.0)
CAUTI
導?前の 7% 程度まで減少

Value-based incentive programの導?
105
Hsu HE, et al. JAMA. 2019 Feb 5;321(5):509-511. PMID: 30721286
Value-based incentive program (VBIP)の効果, ICUのCAUTIで評価, 49州592病院, 22,572,494 patient-days, 13,607,240 indwelling urinary catheter-days
VBIP: the Hospital Value-Based Purchasing (VBP) Program, the Hospital-Acquired Condition Reduction Program (HACRP)
Comparing: the hospitals with intensive care services subject to the inpatient prospective payment system
Value-based incentive program導?によりCAUTIが減少
device use declined
2% /quarter
device use declined
2% /quarter
介?前介?後
介?前
介?後
declined
by 1% per quarter
Stable
Device-associated CAUTI Indwelling urinary catheter devise use ratio

施設ガイドライン作成と救急室でのIUC
106
Fakih MG, et al. Acad Emerg Med. 2010 Mar;17(3):337-40. PMID: 20370769..
before-after, single center, 769 tertiatry care hospital, 2517 patients
施設ガイドライン作成による救急室でのIUC減少頻度を評価
Compliant with guidelines, n = 203 (63.0%) N (%)
Non?intensive care 6 L /min oxygen 40 (12.4)
Output monitoring in intensive care 39 (12.1)
Emergent pelvic ultrasound 33 (10.2)
Intubated 32 (9.9)
Neurogenic bladder 14 (4.3)
Emergency surgery 12 (3.7)
Urinary obstruction 10 (3.1)
Unresponsive 7 (2.2)
Acute hip fracture 6 (1.9)
Urologic procedures 4 (1.2)
Acute mental status changes with agitation 4 (1.2)
Stage 3 or 4 sacral decubitus ulcers with incontinence 1 (0.3)
Hospice or palliative care 1 (0.3)
Noncompliant with guidelines, n = 119 (37.0%)
No clear reason 64 (19.9)
Oxygen supplementation <6 L ? min 26 (8.1)
Dementia 16 (5.0)
Urine specimen collection 5 (1.6)
Incontinence 3 (0.9)
Patient request 3 (0.9)
Output monitoring outside intensive care 2 (0.6)
UC utilization 14.9% à 10.6% OR = 1.48, [95% CI 1.16-1.90, p = 0.002]
ガイドライン非遵守IUCの理由
理由なしが約20%

救急室でのIUC改善計画
107
Greene MT, et al. Infect Control Hosp Epidemiol. 2018 Jan;39(1):77-84. PMID: 29249212.
Prospective observational study, 13,215 patients, 救急室での尿道カテーテル挿?改善計画
?営利組織(Acscension)が経営する18施設; System-based, 16施設; ミシガン州によるState-based intervention
I: CDCガイドラインを基にした尿カテ挿?基準を策定, C/O: 介?前後でのappropriate IUCの割合の変化
Intervention
Phase
UC Utilization,
%
P Valuea
Appropriate UC,
%
P Valuea
System-based hospitals Baseline 9.1 Ref 73.1 Ref
Intervention 6.1 < .001 91 < .001
Sustainability 5.3 < .001 92.4 < .001
State-based hospitals Baseline 6.6 Ref 70.9 Ref
Intervention 4.9 0.03 82 0.05
Sustainability 6.4 0.97 87.3 0.05
QI介?前
適正使?は7割程
QI介?後
適正使?は8-9割

制度の導入
尿道カテーテル留置を減らせそう
108

110
Appropriate Urinary Catheter Use
Need for accurate measurements of urinary output in critically ill patients.
尿道カテーテル留置のカイゼン活動の基準のほとんどはCDCガイドライン

111
Appropriate Urinary Catheter Use
Need for accurate measurements of urinary output in critically ill patients.
尿道カテーテル留置のカイゼン活動の基準のほとんどはCDCガイドライン
タイミングは？
指標は？
対象症例は？
具体的な提示はない

SSCG 2021
Mean arterial pressure
Recommendation
9. For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure
(MAP) of 65 mm Hg over higher MAP targets
Strong recommendation, moderate-quality evidence
Monitoring and intravenous access
Recommendations
43. For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over
non-invasive monitoring, as soon as practical and if resources are available
Weak recommendation, very low quality of evidence
44. For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather
than delaying initiation until a central venous access is secured
112

SSCG 2021
Mean arterial pressure
Recommendation
9. For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure
(MAP) of 65 mm Hg over higher MAP targets
Strong recommendation, moderate-quality evidence
Monitoring and intravenous access
Recommendations
43. For adults with septic shock, we suggest using invasive monitoring of arterial blood pressure over
non-invasive monitoring, as soon as practical and if resources are available
44. For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather
than delaying initiation until a central venous access is secured
113
尿量?尿道カテーテル
言及なし

ProCESS
Protocolized Care for Early Septic Shock
(United States, U.S.)
ARISE
Australasian Resuscitation In Sepsis Evaluation
(Australia and New Zealand, ANZ)
ProMISe
Protocolised Management In Sepsis
(United Kingdom, U.K)
CVP, MAP, ScvO2を?いたEGDTを検証
114

ProCESS
Protocolized Care for Early Septic Shock
(United States, U.S.)
ARISE
Australasian Resuscitation In Sepsis Evaluation
(Australia and New Zealand, ANZ)
ProMISe
Protocolised Management In Sepsis
(United Kingdom, U.K)
CVP, MAP, ScvO2を?いたEGDTを検証
115
尿量?尿道カテーテル
強固なエビデンスがない

116
UTI
尿道損傷
せん妄
合併症は多い
尿道狭窄動きづらい

117
適応について真剣に考える

118
適応について真剣に考えている？

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