Chapter 32

• • Diagnostic evaluation of urine in an infant.

### Absolute

• • Neutropenia.

• Thrombocytopenia and bleeding disorders.

• Cellulitis and infection at puncture site.

• Age greater than 2 years.

### Relative

• • Urogenital anomalies.

• Recent urologic or lower abdominal surgery.

 • All equipment should be latex free. Allergy to latex is common, particularly in certain populations (such as patients with meningomyelocele.)

• • 22-gauge, 2–3-cm needle.

• 3-mL or 5-mL syringe.

• Sterile collection cup.

• 10% povidone-iodine (or equivalent).

• Sterile gloves, drapes, gauze.

• Topical anesthetic or buffered 1% lidocaine solution, or both.

• • Infection (rare).

• Intestinal perforation (very rare).

• Failure to obtain urine (success rates vary widely but less successful than catheterization).

• Psychological stress (common, as child is restrained for procedure).

• Pain (certain; can be limited somewhat with anesthesia).

• Hematuria.

• • Microscopic is very common.

• Macroscopic is uncommon.

• • Appropriate patient restraint is critical to the success of the procedure.

• More than 2 or 3 attempts do not add to success rates.

• Ultrasonography has been reported to increase success rates in some studies.

• Because spontaneous voiding may occur during skin preparation or as the procedure is initiated, have a sterile container available to collect the urine.

• • Keep the patient covered until ready to begin.

• • The child is placed supine in the frog-leg position.

• • The needle is passed through the abdominal wall just rostral to the pelvic rim in the midline.

• The bladder in an infant is located in the abdomen, which allows for direct access to the bladder lumen with a needle. (The bladder in an older child and adult is located in the pelvis.)

• Various methods to improve success have been cited and include the following:

• • Ensuring that time has passed since the last void.

• Encouraging the child to drink.

• Percussing the abdomen to ascertain bladder fullness.

• Obtaining an ultrasonogram. This can be used to ensure bladder fullness or to guide needle insertion.

• • Observe sterile procedure.

• • Wear sterile gloves.

• Use 1 hand to touch the patient if necessary, while keeping the hand with the needle clean.

• Strongly consider applying a topical anesthetic before starting the procedure.

• Leaving the topical anesthetic on for a sufficient time period provides a reasonable degree of topical anesthesia.

• Remove the topical anesthetic prior to skin preparation.

• The practice of additional injection of lidocaine varies; the injection represents a separate needle stick and is associated with pain from lidocaine infiltration.

• Apply 10% povidone-iodine solution to the skin surface of the abdomen 1–2 cm above the pubic symphysis.

• Attach the syringe to the needle.

• The provider should be ...

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