Indications in ED

• Children less than six months of age need a urine culture.

<1% contamination rate with SPA, compared to about 10% with a catheter sample and 25% with a clean catch

• Children under one-year-old need to repeat urine cultures because the previous urine culture is contaminated.

Contraindications

• Passed urine in the previous 1 hour
• Distended abdomen
• Coagulopathy
• Skin infection over the puncture site
• Urogenital abnormality

Equipment

• 23g needle (or smaller for a preemie)
• 3ml or 5ml syringe
• Specimen jar
• Skin prep
• Sterile gloves
• Dressing

Pre-procedure

• Check the bladder size/volume using one of the following: Curvilinear ultrasound probe to check bladder volume:
• Transverse view, depth (D) 2-3 cm or Transverse diameter (T) 3.5 cm
• The use of ultrasound increases the success rate of SPA from 50% to >80%
• Bladder scanner (minimum 20mL) – scan three times to confirm,
• Give sucrose to the child

Positioning

• An assistant should hold the infant down with the legs together and extended.
• Identify the site of entry.
• Find the intersection between the suprapubic crease and a line drawn between the umbilicus and pubic symphysis.

Procedure

• Open sterile equipment onto sterile field trolley
• Perform hand hygiene and don sterile gloves.
• Clean the skin from the pubis to the umbilicus in a circular motion 5 cm diameter with an alcohol wipe.
• Insert the needle (attached to the syringe) perpendicular to the skin at 1-2 cm superior to the pubic symphysis (the suprapubic crease level) in the midline:

• Aspirate gently after the needle pierces the skin. Aspirate as you advance, as well as when you withdraw the needle.
• Advance the needle 2-3 cm deep if needed (i.e., the whole length of the 23G needle). Stop advancing the needle once urine is aspirated.
• If urine is not obtained, partially withdraw the needle to just below the subcutaneous layer and redirect it slightly cephalad while aspirating. If still unable to obtain urine, partially withdraw and redirect slightly caudally while aspirating.
• o The procedure should be abandoned if still unsuccessful, and an alternative method of urine collection should be considered.
• Further attempts at SPA should be at the discretion of the Senior Doctor on duty.
• Withdraw the needle when adequate volume is obtained, or no further urine can be aspirated.
• Place dressing over the puncture site.
• Transfer urine from the syringe to the yellow top specimen jar. If an adequate urine volume is obtained, save 0.5 mL for urine dipstick analysis.
• Remove gloves and perform hand hygiene.

Post-procedure

• Routine observations and care.
• Label specimen jar with patient details and time of specimen collection and send for MC&S

Complications

• Complications of SPA are rare but may include:
• Transient, gross or microscopic haematuria
• Intestinal perforation (rarely leads to peritonitis)
• Bladder haematuria
• Abdominal wall abscess