2 replies to this topic

[Austyn]

I was alerted to a case here in New Zealand which involved a tetraplegic guy who died as a result of mismanagement of his supra pubic catheter in a hospital.

He attended the ED after his SPC fell out. A nurse had attempted to reinsert it at home, unsuccessfully. He then went to the local hospital and was attended to by a doctor who had never inserted a SPC into a tetraplegic. He had 4 unsuccessful attempts and eventually got it in. All this time the patient was complaining of feeling unwell and clearly had symptoms of autonomic dysreflexia with high blood pressure. At no time while attempting to insert the SPC over some considerable time did the doctor relieve the increasing bladder pressure by inserting a urethral catheter.

By the time the SPC was in the patient was feeling pretty unwell so was admitted for observation. Two days later he died and post mortem revealed a huge bloodclot in his pelvis which had broken off and gone to his lungs. This was probably caused by trauma to the area by the 4 attempts at inserting the SPC.

The expert opinion from a urologist experienced in spinal cord injury said that if an SPC comes out there should only be one attempt to reinsert it and if this fails a uretheral catheter should be inserted to prevent AD from high bladder pressures. The SPC should then be reinserted under either a spinal or general anaesthetic at some later time.

The report on the case can be read on this website: www.hdc.org.nz and the case number is 07HDC15291.

As a nurse and lawyer and partner of a C5 tetraplegic with an SPC who had it reinserted in ED the day before I read this case, I found it scary but informative and know what I will not allow to have happen should this ever occur to my partner!

[popsune]

Thanks for sharing! Is there any possibility for people with lower spinal cord injuries doing intermittent catherisation through insertion into the urethra into the bladder, with blood clots forming in the urinary tract? I am worried because I cannot feel anything in the bladder downwards till the private parts, so I may not be aware of blood clots if they form. Would there be a chance of blood clots travelling to the lungs and heart from the bladder?

[Austyn]

I shouldn't think you have anything to worry about doing intermittent catheterisations. The guy in that unfortunate scenario died because the repeated attempts at replacing the SPC caused trauma to the pelvic veins which formed clots and these travelled upwards and lodged in his pulmonary vasculature. If you cause the odd clots in your bladder you should pass these via the catheter. I guess the only problems that could arise would be if the clots blocked your urethra but it might pay to speak with your urologist or nurse just to be sure.