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Suprapubic Aspirate Guideline

See also:  UTI guideline 
 Suprapubic Aspirate Parent handout
Urine test handout
References for Suprapubic Aspirate guideline

Notes

Suprapubic aspirates are the gold standard for obtaining urine specimens for culture. Any growth of pathogenic bacteria in an SPA specimen is felt to be significant. It is a simple, safe, rapid and effective technique.

Indications:

  • Any child (regardless of age) who is unable to void on request, who requires a urine specimen for the diagnosis or exclusion of UTI.

Contraindications:

  • Bleeding diathesis
  • Abdominal distension
  • Massive organomegaly

Complications:

Complications of suprapubic aspirates are uncommon (estimates of complications reported in the literature are ~0.2% (ie 1 in 500), most of which are benign). They include:

  • Macroscopic haematuria (infrequent — not usually clinically significant)
  • Bladder haematoma (rare)
  • Bladder haemorrhage (very rare)
  • Intestinal perforation (rare — not usually clinically significant)
  • Anaerobic bacteraemia or abscess formation (very rare)

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Equipment

 SPA - bladder scanner
  • One assistant to hold the infant (not parent)
  • Specimen jar for urine
  • Ultrasound gel
  • Volumetric ultrasound (BARD BladderScanTM)        
  • 23G needle (25 G for premature infants)
  • 3ml or 5 ml syringe

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Analgesia, Anaesthesia, Sedation

  • Topical anaesthetic cream (AnGELTM) should be used except where specimens are required urgently (eg prior to starting antibiotic treatment in a septic infant)
  • Oral Sucrose should be used for infants <3 months (see <a href="/clinicalguide/cpg.cfm?doc_id=5144"/>Analgesia guideline)
  • Sedation should be considered for children older than 6 months especially where several procedures are required (eg lumbar puncture, IV cannulation)
  • Non-pharmacological techniques should be used where possible, including explanation (in an older child), distraction, the presence of a parent.

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Procedure

Golden Rules:

  1. Never undo the nappy until you have a urine jar handy and someone ready to catch!

  2. Do the SPA before collecting blood or CSF  — as the child may void while having venepucture/lumbar puncture

    •  ‘Blind’ SPA has an approximately 50% chance of obtaining urine
    • the use of ultrasound increases the chance of success to 80-90%
    • Ultrasound does not tell you where to put the needle — only whether there is likely to be enough urine present.
      SPA scanner movie
      View video

A. Using the Volumetric Ultrasound (BARD BladderScanTM)      

  1. Unplug the ultrasound from the wall.
  2. Turn on the BladderScan
  3. Press ‘Scan’
  4. Select Male/female
  5. Apply ultrasound gel to suprapubic area (Keep urine jar handy!)
  6. Place probe firmly over bladder
    (make sure that it is perpendicular to the skin, with the correct
     SPA - bladder scan probe
    orientation (look at the diagram on the probe))    
  7. Press the button on the probe and hold in place until it stops vibrating
  8. Repeat
  9. See flow diagram for a guide to using bladder scan results
  10. If the bladder volume is >20 mls on three scans (with no scan results of ‘0’), the chance of obtaining urine is >90%)
SPA ultrasound flowchart

B. What to do if no bladder ultrasound is available.

  • History of no voiding in the past 30 minutes, and the presence of a dry nappy increases the chance of a successful tap
  • Prehydration increases the chance of a successful blind tap
  • If bladder is dull to percussion, there is a higher chance of successful aspiration
  • See Flow Chart  
SPA no ultrasound flowchart

SPA - position
View video of procedure

C. SPA Procedure               

  1. Ask assistant to hold infant supine with legs extended        
  2. Ask parent to be ready to catch urine if the patient voids
  3. Wipe the skin with an alcohol swab
  4. Identify insertion point      
    1. Midline
    2. Lower abdominal crease
  5. Insert needle perpendicular to the skin, aspirating gently as you advance the needle.
  6. If no success, withdraw the needle to just under the skin, and advance at an angle with the needle aimed more away from the pelvis.
  7. If urine is obtained, remove needle and squirt urine into sterile urine jar

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Post-Procedure Care

  • Place a bandaid over the puncture site (optional)
  • Warn parents that there may be a small amount of blood in the urine in the next day, but that they should re-present if there are large amounts or if they are concerned.

 

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