What is the purpose and protocol for continuous bladder irrigation (CBI) in patients?

Continuous Bladder Irrigation (CBI): Purpose and Protocol

Continuous bladder irrigation (CBI) is primarily used to prevent catheter obstruction from blood clots in patients with hematuria, particularly following urological procedures, and to maintain catheter patency when there is a risk of obstruction. 1

Purpose of CBI

• Primary indications:

  • Management of hematuria following urological procedures (TURP, open prostatectomy, cystectomy) 2, 1
  • Prevention of catheter obstruction from blood clots 1
  • Evacuation of existing blood clots to maintain catheter drainage 3
  • Management of hemorrhagic cystitis (including radiation-induced) 4

• Secondary uses:

  • Maintaining visualization during endourologic procedures 5
  • Preventing clot formation after transurethral resection procedures 5

Protocol for CBI Implementation

Setup and Equipment

1. Required equipment:

   • Three-way Foley catheter (larger size preferred, typically 22-24Fr)
   • Sterile normal saline solution (0.9% sodium chloride) 1, 3
   • Irrigation tubing system
   • Collection bag for drainage

2. Irrigation solution:

   • Normal saline (0.9%) is the standard solution 1
   • Avoid adding antimicrobials or antiseptics to irrigation fluid for routine CBI as they have not shown additional benefits in preventing catheter-associated UTIs 1
   • Consider Ringer's lactate as an alternative if prolonged CBI is needed to prevent hyperchloremic metabolic acidosis 3

3. Setup procedure:

   • Position irrigation bag 80-100 cm above bladder level 5
   • Connect irrigation tubing to the irrigation port of the three-way catheter
   • Ensure drainage bag is properly positioned below patient level

Administration Protocol

1. Flow rate adjustment:

   • Titrate flow rate based on the color of the effluent 6
   • Increase flow rate when effluent is heavily blood-tinged
   • Decrease flow rate when effluent becomes clearer
   • Typical initial rate: 30-50 ml per hour, adjustable based on bleeding severity 1

2. Monitoring requirements:

   • Check effluent color every 1-2 hours
   • Monitor for clot formation
   • Assess for bladder spasms or patient discomfort
   • Monitor fluid balance (input vs. output) to detect fluid absorption 3

3. Frequency and duration:

   • For severe hematuria: irrigation every 4-6 hours 1
   • Continue until effluent is clear or only slightly pink for at least 24 hours
   • Remove catheter as soon as clinically possible to reduce infection risk 1

Special Considerations

1. Complications to monitor:

   • Bladder perforation from excessive pressure 7
   • Hyperchloremic non-anion gap metabolic acidosis from absorption of saline 3
   • Fluid overload and pulmonary edema 3
   • Catheter-associated urinary tract infections 2

2. Safety precautions:

   • Avoid excessive pressure during irrigation to prevent bladder trauma 1
   • Maintain closed drainage system whenever possible to reduce infection risk 1
   • Do not use irrigation as routine prevention for catheter-associated UTIs 1
   • Consider gravity-fed systems rather than pump-driven systems to reduce risk of bladder perforation 7

3. Post-procedural management:

   • Gradually decrease irrigation rate as bleeding subsides
   • Monitor for return of hematuria after discontinuation
   • Consider intermittent catheterization instead of permanent catheterization for long-term management 1

Efficacy and Evidence

• High-pressure irrigation systems have been shown to decrease clot retention two-fold compared to traditional gravity-dependent systems 5
• CBI has not been shown to significantly reduce catheter obstructions in patients with long-term catheterization 2
• In patients undergoing urological procedures, irrigation with antiseptics has shown reduced postoperative bacteriuria rates 1

By following these protocols, CBI can effectively manage hematuria and maintain catheter patency while minimizing complications and patient discomfort.