Pediatric bladder volume assessments

July 21, 2021

ID6833

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00:02In this video tutorial,
00:04we will review the necessary
00:07steps to obtain accurate bladder
00:09volume measurements for patients in
00:12the pediatric Ed, and we will review
00:15some cases where this pokus
00:18application can be used to help
00:20streamline your patient care.
00:25Indications to perform a diagnostic
00:28bladder scan include the following one.
00:31Prior to urine catheterization
00:33to minimize risk of a dry Cath 2.
00:37Patients with suspected ovarian torsion
00:41before radiology performed ultrasound.
00:43Tadim adequacy of bladder filling.
00:47Three patients with urine retention.
00:50Four patients were reported
00:53oliguria or anuria,
00:555 patients with incomplete bladder emptying.
00:596 patients who require suprapubic
01:02bladder aspiration procedure.
01:08Diagnostic bladder scans are
01:10to be performed with a low
01:13frequency curvilinear transducer.
01:18To maximize patient comfort and
01:20improve the quality of your study,
01:23hold the transducer like a
01:24pen with an incorrect grip.
01:26Unnecessary pressure is often applied to
01:29the patient skin with a correct grip.
01:31The ulnar side of your hand will be
01:34directly touching the patient's body.
01:36This will allow you to maneuver the
01:39probe as necessary and allow for a more
01:42comfortable experience for your patient.
01:47Please feel free to wear gloves
01:50during your ultrasound scan.
01:51Many patients will feel more relaxed
01:53and the routine use of gloves
01:55will also decrease the risk of
01:57infectious disease transmission.
02:02Before we dive into the image
02:04acquisition steps for your bladder scan,
02:06let's review a couple of
02:08important housekeeping items.
02:09Firstly, the epic order to choose from
02:12the quick list menu is Ed diagnostic
02:15flatter volume eval using this correct
02:17order will ensure that your image is
02:20captured will be transferred to EPIC,
02:22and a report of your interpretation
02:24will be generated.
02:26Secondly, it is important to fill out Q
02:29path immediately after your bladder scan.
02:31Is completed and attending signature
02:33will be required to push both the images
02:37and report over to the medical record.
02:42First you will scan through the bladder
02:45and transverse orientation with the
02:46indicator towards the patient right?
02:48Make sure you're all the way down
02:50to the pubic synthesis in order to
02:53visualize the bladder and slowly
02:54fan the probe all the way through.
02:59Next you will turn the probe
03:01clockwise 90 degrees so that the
03:03indicator is pointing towards the
03:05patients head and this view you
03:07will see the bladder in long axis.
03:09Again, you want to slowly fan
03:11the probe all the way through and
03:13keep an eye out for any abnormal
03:15lesions or masses that may
03:17be present behind the bladder.
03:21In the next step,
03:23we will review how to actually obtain
03:25your bladder volume measurements.
03:27As long as you're using a
03:29curvilinear probe utilizing the
03:31abdominal or pelvic exam mode,
03:32you'll be able to pull up
03:35the right calculator.
03:36Let's look at the buttons that
03:38are squared off in pink boxes.
03:40You will once again return to
03:43transverse orientation and find
03:44the bladder where you see it at
03:47its biggest size and hit freeze.
03:49Here you will enter.
03:50The calc button all the way on the left.
03:53This will allow you to enter
03:55your first measurement,
03:56which will be the height when
03:58you push the measure button,
04:00a caliper will appear on your screen monitor.
04:03You can use the trackpad
04:05to move the caliper from
04:06the top of the bladder to the bottom
04:09of the platter. You can then repeat these
04:11steps still in transverse orientation to
04:14obtain a width measurement and you
04:16can now save a still image of your
04:19transverse measurements by hitting the.
04:20Acquire button to obtain your
04:23bladder length measurement.
04:24You'll have to unfreeze the screen
04:26by hitting the 2D mode button.
04:29That is an orange
04:31color above the trackpad. You once
04:33again hit the CAP button and the
04:36machine will remember your prior
04:39two measurements and allow you to
04:41now obtain a third measurement.
04:43Placed the caliper on the Trigone area of
04:47the bladder and obtain the
04:49longest distance seen.
04:51Towards the bottom part of the
04:53bladder. Once you obtain this
04:56final measurement, the. Ultrasound
04:58machine will automatically
05:00generate the bladder volume using
05:02a pre designated formula that has
05:04been programmed into the system.
05:09Your final step will be to interpret
05:11your appointed Carol to sound
05:13findings related to the platter.
05:14Depending on why you're doing
05:16this study in the 1st place,
05:18you will make an assessment of
05:20whether there is sufficient or
05:21insufficient amount of urine for
05:23a catheterization procedure and
05:24likewise sufficient or insufficient
05:25amount of urine for radiology.
05:27Performed
05:27ultrasound to assess for
05:29ovarian pathology, and you
05:30will also be asked to provide a general
05:32assessment of the amount of urine in
05:35the bladder which you will correlate
05:36clinically and apply those volume
05:38measurements to expected bladder capacity.
05:40And established norms for postvoid residuals.
05:46The good news is that you will not
05:48be expected to memorize anything.
05:51All of the necessary formulas that
05:53you may need will be embedded into
05:55the queue path worksheet created for
05:57bladder volume evaluations in RED.
06:00This will help you with your
06:02interpretations as you fill out the
06:04worksheet findings in real time.
06:09So let's look at some practice cases.
06:16Case one, a 2 year old girl with
06:20Linux gesto seizure disorder.
06:21G2 dependance neurogenic bladder and
06:24global developmental delay presents
06:26with unexplained tachycardia and
06:28increase in seizure frequency.
06:30As part of her work up,
06:32urine testing is ordered.
06:33Mom opts to do a urine catheterization
06:36herself as she is routinely dusis at home,
06:39but she was unsuccessful and reports
06:41was unable to obtain any urine.
06:44She is very concerned that her daughter
06:46is dehydrated and the nursing staff
06:48does not feel comfortable performing a
06:51repeat catheterization at this time.
06:55You first recorded the bladder
06:57in transverse orientation,
06:58and although it appears less
06:59round than you usually expect,
07:01there seems to be a fair
07:04amount of urine present.
07:06You then rotate the probe 90
07:08degrees and assess the letter in
07:10longitudinal orientation where
07:11once again the bladder is seen to
07:14be filled with plenty of urine.
07:19You go back to transverse
07:21orientation and freeze the screen.
07:23Obtain a height measurement
07:25from top to bottom. Obtain
07:27a width measurement from left to right.
07:31Save that image. He then get the length
07:35of the bladder in longitudinal orientation,
07:39placing the calipers across
07:41the longest possible distance.
07:43The ultrasound machine automatically
07:46calculates the volume estimate
07:48of 82 CCS.
07:53You review these findings with mum
07:56and the nursing staff and feel that a
07:59repeat attempt at urine catheterization
08:02would be reasonable to perform.
08:07Repeat catheterization is successful
08:09and ultimately diagnostic for a
08:12urinary tract infection with greater
08:14than 100,000 colony forming units
08:17of Enterococcus arena over sound
08:19performed by diagnostic radiology.
08:21Revealed debris within the right
08:24erator which was causing obstruction
08:27and hydroureter oh nephro sis,
08:29which was managed by the
08:31inpatient urology service.
08:35So as it turns out, it does not
08:38take much urine at all to predict
08:41successful catheterization and patient
08:43under two years of age without pocus.
08:46To visualize splatter contents,
08:48the rate of successful urine catheterization
08:51in this age group was published
08:53to be 72% during the observation.
08:55ULL phase of a study published
08:58by Chen at all in 2005.
09:00However, when the investigators applied Pocus
09:02to determine whether there was at least.
09:05Two CC's of urine present in the bladder.
09:09The rate of successful catheterization
09:11when done by nursing staff was
09:15reported to be as high as 96%.
09:17Case 2 highlights the point of care
09:20ultrasound role in ovarian torsion.
09:22To expedite confirmatory testing,
09:24here we have an 18 year old female who
09:28presents with sudden onset of intense
09:30right lower quadrant pain and nausha.
09:33She reports no fever or he materia
09:36denies the possibility of pregnancy
09:39and has never had a pelvic exam.
09:42For you,
09:42she's very tearful and uncomfortable
09:45and is tender to touch to the
09:47right lower quadrant area,
09:49you need to prioritize getting a
09:52urine sample with a transabdominal
09:54ultrasound to assess.
09:55For ovarian torsion,
09:56you record her bladder and transfers
09:59orientation and notes nicely.
10:00Fluid filled structure with
10:02posterior acoustic enhancement.
10:05Upon interrogation and longitudinal access,
10:08you again see a nicely filled bladder
10:10with a normal appearing uterus behind it.
10:16He obtain your measurements and transverse.
10:19The bladder height is about 7.3 centimeters.
10:22The bladder width is about 9.7 centimeters.
10:26And in longitudinal, your bladder
10:28length is about 8.5 centimeters,
10:31which gives you a total bladder
10:33volume of about 314 CCS.
10:35This is incredibly useful information,
10:38as you would expect bladder capacity
10:40and an adult to be about 500 CC's.
10:46You determined she should be ready for
10:49radiology ultrasound without delay,
10:50but you also have a bonus finding on
10:53your bedside scan when you gently angle
10:56her probe towards her right side using
10:59her bladder as an acoustic window.
11:02You actually can't see her ovary on the
11:05right, it appears morphologically normal,
11:07and its size, shape,
11:09and appearance as small follicular
11:11structures within these findings make it
11:13incredibly unlikely that your patient.
11:15Has acute right sided ovarian torsion.
11:21On the flip side, you may have come
11:23across a case where something just
11:26doesn't look quite right deep in the
11:29pelvis in this patient who there were
11:32also some concerns for ovarian torsion,
11:34you can see a large ovoid lesion with
11:37some follicular architecture which
11:39is present behind the uterus and
11:41pushing up on the uterine fundus.
11:43The bladder here is decompressed,
11:45but even though diagnostics for
11:48ovarian torsion by ultrasound are
11:50best left for our radiology experts.
11:52To confirm any abnormal screening findings
11:55such as this one should heighten the
11:57level of urgency and should also help
12:00expedite the time it takes to get your
12:03patient to her definitive imaging study.
12:05Now back to the case of the patient
12:08with acute right lower quadrant pain.
12:11Your pocus helped determine the
12:13suitability of getting her over
12:15to radiology to have their formal
12:17diagnostic testing done at radiology.
12:19A normal right sided ovary was
12:22again it visualized.
12:24However, she had findings
12:26compatible with acute appendicitis.
12:27Luckily,
12:28you had already made the right call
12:31to obtain lab intravenous access,
12:33made her NPO,
12:35and started normal saline bolus.
12:39Case 3 is a post
12:41void residual bladder volume measurement.
12:43In this case a 10 year old circumcised
12:45male presents with mild idiopathic
12:47swelling to his penis and had an
12:49otherwise normal genito urinary exam.
12:51On review of symptoms, he
12:52says that he wakes up to go to the
12:55bathroom several times at night and
12:57for over a year the teachers had
13:00reported that he goes to the bathroom
13:02several times a day while he's
13:04at school. Your plan is to do a dose of
13:07Benadryl for the. Mild swelling
13:09and obtained a year analysis
13:11to screen for potential causes
13:12of these symptoms. However,
13:14he is only able to avoid a
13:16small amount with great difficulty.
13:23He record his bladder and
13:24transfers orientation and
13:25slowly fan all the way through.
13:33He then record his bladder
13:35and longitudinal orientation.
13:38When you obtain your
13:40measurements, his bladder
13:42volume is a 323CC's calculated,
13:45which is an abnormal postvoid
13:47residual which signifies
13:49incomplete bladder emptying.
13:54Based on your focus
13:55results, you have the patient go to
13:58radiology to have a renal ultrasound done
14:01where hydronephrosis has
14:02not found but incomplete.
14:04Bladder emptying again is confirmed,
14:06your urinalysis did not show any
14:08signs of glucose urea or signs of
14:11infection. Putting everything together,
14:12you recommend a trial of miralax
14:15with an outpatient referral
14:16to urology. Should symptoms
14:18persist, you also review the
14:20potential for you and retention
14:22secondary to anti histamine
14:24medications like Benadryl.
14:27A potential pitfall when
14:28scanning for the bladder is at
14:31your probe is actually not low enough.
14:33Note these split screens of the
14:35same patient during a scan done
14:37around the same time on the top row,
14:40the curvilinear probe is placed in
14:42the suprapubic area with the probe
14:44slightly angled towards the umbilicus.
14:46This results in only about to be
14:49present and seen on the monitor on
14:51the 2nd row of images the curvilinear
14:53probe has been placed over the pubic
14:56synthesis and slightly angled.
14:57In a caudad direction.
14:59At this point,
15:00the bladder can be seen to come
15:02into view on the screen.
15:06The other important pitfall to
15:08be aware of is that large cystic
15:10structures in the pelvis may
15:12mimic the appearance of a bladder.
15:14I would pay particular careful attention
15:17and patients who present with urine
15:19retention as a chief complaint.
15:21Here we see a 10 year old girl who
15:23complained of new onset Constipation
15:25and a sensation of incomplete
15:27bladder emptying ultrasound images
15:29by point of care and radiology.
15:31I thought the cystic structure being
15:33measured was her bladder, however.
15:35Her bladder was completely
15:37decompressed and empty during
15:39the time of the ultrasound scans.
15:41What was thought to have been a
15:44ureteral seal was actually part
15:46of a mature cystic teratoma which
15:49was diagnosed by pelvic MRI at
15:52the time of the MRI study.
15:54The bladder could be better visualized
15:56and the Mass Effect causing bladder
15:59compression was more clearly seen.
16:04In summary, we have reviewed some
16:06cases where POCUS was used as
16:08a tool to expedite patient care
16:11and help to guide procedures.
16:13Bladder scan by pocus for the
16:16assessment and interpretation of
16:17body measurements is an important
16:19skill for Penn physicians to learn.
16:22As always, with focus.
16:23If you see something unexpected
16:25that doesn't fall into the typical
16:27pattern recognition appearance,
16:29please do not hesitate