Clinical Urodynamics Guide
Contents
1. The purpose of this guide is not to describe the clinical reasons for urodynamic diagnostic testing but to give a general outline of the mechanics of the test The actual sequences and methods utilised may vary from lab to lab References to equipment and their operation are clarified in later revisions Document No NSO1875D Revised 17 07 99 This document contains clinical diagrams for pressure transducer and catheter setup Please contact Neomedix Systems if you have any problems or suggestions regarding this document or require more detailed information for system setup Tel 612 9913 8044 Fax 612 9913 7818 eMail sales neomedix com netSite http neomedix com Clinical Urodynamics Guide Document NSO18 5D R i I i Ch ch a ce _ ug acaguiamplifier top amp acquiprocessor bottom filling volume sensor li FN ne ee ia SS receiving chamber flow sensor Clinical Urodynamics Guide Document NSO18 5D a mount MX848 sterilised E disposable dome to MX860 transducer attach transducer assembly on to mounting plate which is then attached to patient pole not shown Clinical Urodynamics Guide Document NSO1875D UD 004 bladder pressure monitoring catheter UD 003 abdominal pressure balloon catheter Sc ee UD 005 bladder filling catheter Bi MX634L 4 way stopcock e UD O2. be the Puc value displayed if that catheter is inserted into the burette and all three pres sure Pura Pves and Puc are monitored EMG To test the EMG sensitivity calibration a sig nal must be injected into the NT462F active headstage This can only be performed ade quately by a qualified service person with adequate specialist test calibrator However to quick check that a signal is being record ed can be done Note This does not necessarily A ensure correct operation of the EMG system Prior to testing ensure the Uromac software is running with the correct settings file selected allowing an EMG chan nel display usually on channel or H 7 or 8 on older AcguiAmplifier models e Connect the NT462F headstage and plug in the three leadwires e Ensure that the appropriate channel G or H or channel 7 or 8 on older systems to which EMG has been display selected has its AcguiAmplifier mounted toggle mode switch rear panel left side when viewed from the rear selected to direct e Select an appropriate range on the AcquiAmplifier front panel range gain switch such as 0 5mV Clinical Urodynamics Guide 28 Document NSO18 5D e select the forward rotation push button e push the power on rocker switch and check that the green power on lamp in the switch illumi nates e turn the speed switch clockwise and ensure that the head rotates in the correct clockwise viewed from above direction and that the speed c
3. stopcock Clinical Urodynamics Guide 8 Document NSO18 5D closeup view of a single sensor 5F polyurethane MTC view of a dual sensor SF polyurethane MTC iy 3 co 5 T o m D o 3 o o 3 m a o o a e this page to be revised Clinical Urodynamics Guide Document NSO18 5D withdrawal speed spring biased securing clip catheter guide selector switch y NN catheter introduced into the bladder via the urethra prior to starting withdrawal operation withdrawal unit UPPO1 A f N fi A a y OO a ee ee ee ee ee ee ee ee eee ae ee ee ee ee ee ee EEE eee eee ee eee ee footswitch cable to withdrawal unit power module E adjustable arm footswitch pads for insertion or withdrawal ee e this page to be revised Clinical Urodynamics Guide 10 Document NSO18 5D Operating Procedure Connect the audio output to the remote speaker Connect the patient electrode and interconnect with the leadwires connectors to the active head stage input NT462F Select the range switch to a suitable setting which in most cases will be approximately 1mV or greater sensitivity Monitor the quality of the audio signal aurally until the recording electrodes are correctly positioned and recording the urethral electromyographic activity synchronous with patient voiding Select Integrated EMG using the rear panel switch on the AcquiAmplifi
4. voiding com mences the respective screen traces will move from right to left as they would on a paper chart recorder Should an inappropri ate display range have been selected the range can be altered by selecting a new range from the Range menu the small down arrow to the left of each channel title on the right side of each waveform trace A greater value will increase the display range reducing sensitivity Selecting a value either side of the default setting will typically double or half the display range Larger changes are rarely required If the range needs to be altered by a smaller amount usually for screen cosmetics the actual display range can be set using the Set Scale menu select the small down arrow to the left of each of the waveform trace displays Do not alter the range more than 30 of the default value using this technigue Zero Balancing Three methods are available to zero the transducers either globally by pressing the Balance push button on the AcquiAmplifier front panel or using the F15 key on the key board Alternatively all or any one of each each parameter can be balanced using the Uromac software This is done through the Uromac Zero menu Individually balancing one transducer channel is useful when only that transducer channel needs to be reset for example if the volume reduires resetting prior to a second bladder filling Operating any of the these balancing mecha nisms wil
5. 4 Document NSO18 5D Pressure Recording external fluid coupled transducers Female Testing Q Pves sensing lumen port O Pura sensing port for perfused lumen Distance A to B is usually 5 to 6cm 9 Pabd active measuring site using a special balloon or sensing sheath liquid filled catheter Multi lumen UPP Catheter Several catheter options can be employed some with a third larger lumen for bladder filling 2nd Stopcock Note The separate larger filling catheter is used to fill the bladder After filling it is withdrawn from the bladder urethra as shown under the system setup UTRAZ urethral lumen perfusing pump electrically operated Rate 5mL mint Volume 50mL Syringe 50mL Perfusate Sterile Water Three MX860 transducers employing replaceable sterile domes 4 way stopcock utilised between dome and flushing syringe Transducer plugs connect to AcguiAmplifier inputs Overview of a Urodynamics test Clinical Urodynamics Guide 15 Document NSO18 5D Pressure Recording external fluid coupled transducers Male Testing Q Pves measuring site using small 3F liquid filled catheter 3 Pabd active measuring site using a special balloon or sensing sheath liquid filled catheter Note The separate larger filling catheter is used to fill the bladder After filling it is withdrawn from the bladder urethra as shown under system setup Two MX860 transducers employing repl
6. O5 in 14F size is supplied in kit UD OO1 e UD OO5 in 10F size is supplied in kit UD OO2 e this page to be revised Clinical Urodynamics Guide Document NSO18 5D connect the vesical pressure catheter to this port on the transducer dome attach 4 way stopcock this luer port of the transducer dome fill syringe with sterile saline or water and connect to luer port of 4 way stopcock Clinical Urodynamics Guide Document NSO18 5D e The perfused liguid is supplied by the mechani cal compression pump e Fill the 10mL or 30mL syringe with sterile water e Operate the pump by turning to on the switch on the pump body until all the air has been flushed through the urethral catheter lumen and intercon nect tube e Turn off the pump Vesical Channel InfuPress mechanical compression pump i Urethral Channel Flowrate constant ym TT ynau O 0OSmL sec 3 Volume 10 or SOmL syringe Perfusate Sterile water or saline i R MX860 transducers employing replaceable sterile domes 4 way stopcock utilised between dome and flushing syringe Hydraulic resister tubing e this page to be revised Clinical Urodynamics Guide Document NSO18 5D connect the abdominal pressure catheter to this port on the transducer dome attach 4 way stopcock this luer port of the transducer dome fill syringe with sterile saline or water and connect FR o to luer port of Away
7. aceable sterile domes 4 way stopcock utilised between dome and flushing syringe Transducer plugs connect to AcquiAmplifier inputs Overview of a Urodynamics test Pressure Recording micro transducer tipped pressure sensing catheters MTC n filling lumen f i A ir Mm N j i J U Transducer plugs connect to AcquiAmplifer Insertion length Spacing to be revised Insertion length Kb SETO Sg Clinical Urodynamics Guide Document NSO1875D Female Testing 2 Pves active sensing site O Pura active sensing site Distance A to B is usually 5 to 6cm 9 Pabd active sensing site using 5F single sensor MTC Optional large bore Note 1 A B and Filling is through a 7F or 8F dual sensor with filling lumen polyurethane or silicone catheter Note 2 This system requires no lumen flushing urethral lumen perfusion or re adjustment of channel zero with patients repositioning An Overview of a Urodynamics test Clinical Urodynamics Guide 17 Document NSO18 5D Pressure Recording micro transducer tipped pressure sensing Male Testing catheters MTC Q Pves active measuring site using 3F or 5F single sensor MTC can be sup plied with a second filling lumen O Pabd active measuring site using 5F single sensor MTC Transducer plugs connect to Note 1 This system AcquiAmplifer requires no liquid flushing ____ Insertion length t I
8. al and cleaning area Lift the funnel assembly off the container Empty the urine and rinse out the receiving chamber Rinse the funnel assembly Reassemble and replace the airflow head At the end of the recording session sanitise the receiving chamber and funnel assembly The receiving chamber can be cleaned with warm soapy water or be soaked in a weak gluteraldehyde CIDEX solution or similar overnight for sanitising The funnel and flange plate assembly may be cleaned with a standard domestic cleaning powder or liquid Do not use acetone based agents The metal receiving chamber holding platform if supplied with the Acquidata systems should be cleaned with a cloth dampened in warm soapy water then wiped over by a cloth moistened with a mild sanitising agent if the transducer has been contaminated with urine or saline to be revised
9. ce about 6 8 ml of liquid into the balloon Hold balloon upwards as shown in Figure 2 hold ing your thumb over and gently pushing down on the balloon to hold the trapped internal air bubble over the end of the catheter inside the balloon Pull back on the syringe withdrawing the air bub ble back down the catheter into the syringe Close the stopcock off to the transducer dome Push down on the syringe to expel the air in the syringe Refill syringe if reguired Repeat the balloon filling and air aspiration until most of the air is out of the balloon catheter The syringe dome stopcock balloon catheter should be a closed fluid filled system Fit the dome to the transducer with syringe and catheter still connected Withdraw all but about 2 3ml of saline from the balloon into the syringe With about 2 3 ml of saline in the balloon intro duce the balloon catheter into the rectum with a gloved index finger using sterile lubricant if required When correctly located operate the stopcock to return 5 to 6ml of saline into the balloon The bal loon should contain enough saline to loosely 3 4 fill the balloon before a volume where the balloon material starts to stretch Note air bubble saline Some the later rectal catheter kits utilise an open slit balloon simplifying the de bubbling process Flush these as explained for the vesical pressure catheter Overview of a Urodynamics test Clinical Urodynamics Guide 1
10. e infusion bag on the fill volume trans ducer hook e start the Uromac acquiring data e zero balance the flow Ovoid and Fill Volume Vfill channels e drain the bag via a normally used giving set direct ly into the Urine Void Receiving Chamber at approx 25mL sec e When the bag has emptied stop the chart e Move the marker lower left side of the screen to a point on the Vfill tracing where it becomes arti fact free just after starting the delivery of saline or water Then move the cursor to a point on the same tracing just prior to the fill waveform end point Ensure that the section of the Vfill waveform between the marker and cursor looks linear Clinical Urodynamics Guide Document NSO18 5D e Do the same for each pressure channel 4 With multiple sensor MTC catheters each sensor calibration will have to be individually checked The derived subtracted pressure values Pdet and Puc can be checked by applying a different known pressures to the primary channels in each case say 5OcmH20 by applying 100cmH20 to Pves and 50 cmH20 to Pabd to achieve Pdet say 50cmH20 by applying 100cmH20 to Pura and 50cmH20 to Pves to achieve Puc insert important point finger icon If an equal pressure is applied to both primary channels then the subtracted pres sure of Pdet or Puc should be zero LcmH20 With dual sensor MTC devices with fixed distances of either 5cm or 6cm between the two sensors this difference will
11. er This optional inte grated EMG will now be displayed if a smoothed envelope display is preferred A suggested sampling rate of 100 samples divi sion will give a more detailed raw data display Electrodes 1 The ability to selectively record from the desired muscle is best when carried out with needle elec trodes and least when using surface electrodes Suitable electrode systems are available from Neomedix Systems or your Acquidata distributor Any of the following electrode systems can be used with this system Needle electrodes dual concentric Bipolar Surface electrodes preferably of the silver silver chloride type which are generally situated over the perineum Biologically inert stable recording wires connected to a urethral catheter Usually these wires are made of nichrome or medical grade stainless steel or alternatively an anal plug with conductive ring electrodes Detailed Neurohysiological Investigation For carrying out EMG recordings in the Neurophysiological investigation high speed sweep mode when monitoring single fibre responses or pudendal nerve conduction veloci ties requiring a current stimulator refer to the the separate scope mode EMG option Information on the EMG NCV option for the Acguidata system is available from your supplier Clinical Urodynamics Guide Document NSO18 5D Recording Press start bottom right of screen or F13 on the keyboard As filling and or
12. l offset any recorded input value on that transducer channel and force the trace for that channel to the zero position on the screen Clinical Urodynamics Guide Document NSO18 5D After the patient has emptied their bladder the technician or doctor may record the residual bladder volume by ultrasound or by introducing a Foley drainage catheter into the bladder to drain the residual urine into a measuring container and the volume noted No computer measurement is needed at this point a ee flow oume Catheterisation At this point the patient will have the relevant catheters placed by the technician or the doctor For the male patient this is generally limited to a Vesical bladder and Abdominal rectal catheter to record pressures and a larger diameter Vesical catheter introduced for bladder filling If appropriate for the patient symptoms urethral pressures may also be measured although this measure ment is more frequently made on female patients this can be a second sensor in a micro transducer tipped catheter or an addi tional lumen in a fluid filled pressure sensing catheter note no patient connections Please review the following pages describing both the catheterisation site and connection of the catheters to the transducers Clinical Urodynamics Guide Document NSO18 5D Abdominal Pressure Connect the sterile rectal balloon catheter to the other port of the transducer dome and introdu
13. nated the dome completely entraps the pressure catheter liguid and the whole dome assembly can be discarded without disposing of a more expensive transducer assembly Note these domes are labeled for one patient use only e As the disposable domes utilise a flexible membrane between the liquid filled patient catheter and the pressure sensing diaphragm of the transducer the corrosive effects of saline are prevented from acting upon the diaphragm Clinical Urodynamics Guide Document NSO18 75D e Additional fail safe Class CF electrical isolation for the patient is afforded when using disposable domes by virtue of the silicone isolating mem brane Micro transducer tipped pressure catheters MTC Supplied optionally with the Uromac The major advantages of this type of transducer are e in situ recording e No need to flush the system e Greater signal fidelity e No need for transducer zero balancing with patient repositioning e Test time is also reduced due to the convenience afforded e A filling lumina as well as pressure sensors for Pves and Pura can be supplied as a single catheter The pressure transducers themselves have no calibration adjustment If the transducers are replaced then a check of the system must be made by connecting a calibrating pressure to the transducer Any necessary adjustment is made through the units con version dialogue box refer to the Uromac User s Guide It is recommended calibrati
14. on checks are carried out weekly as a matter of good laboratory practice Clinical Urodynamics Guide Document NSO18 5D i my Y r Cam Nu Fill Volume transducer to measures the Vesical blad der volume during filling with water saline or radiopaque liquids This measures voiding volume and voiding flow rate using two separate transducers in the same hous ing Uromac Major The Uromac Median and Petite utilise only a voiding flowrate sensor and volume is derived by integration e this page to be revised Clinical Urodynamics Guide Document NSO18 5D Urine flow sensor located on urine receiving chamber Clinical Urodynamics Guide 24 Document NSO18 5D ar i i UPPO1 Urethral _ pressure profilometer Las neomedix systems 2 NL InfuPress urethral lumen perfusing syringe pump HPFP cart mount multi speed peristaltic pump AcquiVes Pump compression powered cuff amp controller System Accessory Options Video recording options AcquiVideo allows high quality digital acquisi tion and display on screen of live video images Sources of the video signal can be from fluoroscopy l l or ultrasound Any image frame or sequence of frames selectable from 1 to 25 can be captured and saved to disk inside the urodynamics file An optional composite video output signal can record the test to S VHS VCR Acquilog Ambulatory two channel pressure recorder f
15. ontrol knob causes appropriate speed changes Note the software in the Uromac application carries our on line calcu i lation of filling rate by computing the actual rate of liquid loss from the bladder filling bag during bladder filling Using the standard Neomedix 600 364 2P8FLU dual sensor 8F MITC device with integral filling lumen filling rates from 10 to 180 ml min can be achieved Clinical Urodynamics Guide 29 Document NSO18 5D Responsibility for effective destruction of micro organisms Do Not clean any part of the system i to which electrical power is connected a without first removing the power from the system or item by disconnecting the power cable It is the responsibility of the end user to ensure that the technique adopted for steril isation complies with the hospitals local infection control requirements and that all recommended processes set by the manu facturer of the sterilising process or Do Not wet any electrical connectors chemical agent are met In the case of Sterrad the end user should seek assurances as to the suitability of Sterrad in destroying micro organisms and to seek procedural protocols to this extent from the manufacturer Johnson and Johnson Void Transducers To empty and clean the receiving chamber first gently pull the airflow transducer out of the receiving socket on the flange plate on the funnel assembly lift up the complete receiving chamber and carry to the urine dis pos
16. or 12 to 24 hour urodynamics monitoring utilising micro tipped pressure transducer catheters Output downloads to a standard Uromac recording screen for off line analysis 20g Clinical Urodynamics Guide Document NSO18 5D Pe Eai Setup Commands Windores Piarre Video Sale Ey Woo nice HIT es l gt s Acquilag ele S AcquiVideo window juiLog bulatory order e this page to be revised Document NSO18 5D e start the Uromac acquiring data Clinical Urodynamics Guide 26 e zero balance both Fill volume and Void volume channels e drain the bag via a normally used giving set direct ly into the Urine Void Receiving Chamber the Fill and Void volume trace excursions and displayed values should each register 500ml 2 if either channel shows a discrepancy recal iorate the channel in error using the Units Conversion operation within Uromac refer to the Uromac User s Guide if the correct calibration cannot be achieved contact your Acquidata Uromac supplier or Neomedix Systems pty Itd Voided Flow Rate Prior to flow channel calibration ensure the Uromac software is running and the system has been prepared to record the voiding flow The receiving chamber must be primed with sufficient fluid to cover the bottom of the inner filling tube the flowhead must be clean See Uromac User Manual and correctly inserted in the receptor plate e hang a salin
17. quidata Median cart system TTT conn Alin Patient Transducer Function General The information contained in this section is to inform the operator of the purpose of the indi vidual parts of the Uromac system give an elementary understanding of how the parts are constructed and the control functions that are available Operation of the system soft ware is described fully in the Uromac User s Guide Transducers A transducer is a device which converts one form of energy to another For example a loud speaker in an audio system converts electrical energy to mechanical displacement the dis placement generating an audio pressure sound wave Physiological Pressure Transducers These are used for measuring Vesical blad der Urethral and Abdominal rectal pressures Three transducer sensing sites may be used if simultaneous Urethral closing pressure measurement is also reguired These transducers may be in the form of solid state micro transducer tipped pressure catheters or extracorporeal pressure transduc ers connected to the measurement site with saline or water filled pressure conducting catheters Extracorporeal Pressure Transducers These transducers have been chosen for their high stability and the facility to accept sterile closed envelope replaceable domes There are three major reasons for using disposable replaceable domes e f there is any risk of the patient s catheter becoming infected contami
18. t I EO d t d d oei eii loSi Ac to be revised Document NSO18 5D Vesical Filling Clinical Urodynamics Guide 18 The patient is placed supine lying on back on an examination couch The patient filling catheter is connected to the fluid source and the bladder filling usually between 50 and 100 ml per minute and event associated with patient sensations comments annotat ed at the various points during filling When the technician or doctor has decided that the patients bladder is full the filling is stopped and the filling catheter removed The clinical interest during filling is to ascertain the patients sensory perception of different vol umes and as to whether the bladder exhibits unstable detrusor pressure contractions dur ing filling At the end of filling the patient may be asked to stand and or cough to further test whether these provocation pressures to the bladder mediate unstable detrusor contractions Optional Above vesical filling using fluid X bag and gravity i g Insert vesical filling using fluid bag and perfusion pump Lee eee eee eee ee Above vesical filling using fluid bag and AcquiVes compression cuff Clinical Urodynamics Guide 19 Document NSO18 75D Optional Clinical Urodynamics Guide 20 Document NSO18 5D L Eib 5 L See AcguiAmplifier amp AcguiProcessor Above 8ch system Below 4ch system Right Sch Acguidata Petite system Left Sch Ac
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