What is continuous bladder irrigation and how is it initiated?

Continuous Bladder Irrigation: Protocol and Implementation

Continuous bladder irrigation (CBI) is a procedure that uses a three-way Foley catheter to continuously flush the bladder with sterile normal saline solution to prevent blood clot formation and maintain catheter patency, primarily indicated for managing hematuria following urological procedures. 1

Indications for CBI

• Primary indication: Management of hematuria following urological procedures such as:
  • Transurethral resection of the prostate (TURP)
  • Open prostatectomy
  • Cystectomy

Required Equipment

• Three-way Foley catheter (22-24Fr size preferred)
• Sterile normal saline solution (0.9% sodium chloride)
• Irrigation bags
• IV pole
• Collection bag
• Sterile gloves and equipment

Setup Procedure

1. Catheter Insertion:

   • Insert a three-way Foley catheter (22-24Fr) using sterile technique
   • Inflate the balloon with the recommended amount of sterile water
   • Secure the catheter to prevent movement and tissue trauma

2. Irrigation System Setup:

   • Position the irrigation bag 80-100 cm above bladder level
   • Connect the irrigation tubing to the irrigation port of the three-way catheter
   • Place the drainage bag below patient level
   • Ensure all connections are secure to maintain a closed system

3. Initiation of Flow:

   • Open the irrigation clamp to begin flow
   • Start with a flow rate of 30-50 ml per hour
   • Titrate based on the color of the effluent and bleeding severity 1

Monitoring and Management

• Check effluent color every 1-2 hours
• Adjust flow rate based on:
  • Clarity of effluent (increase rate if effluent is dark red)
  • Presence of clots (increase rate if clots are present)
  • Patient comfort (decrease if causing bladder spasms)
• Monitor for:
  • Bladder spasms
  • Catheter obstruction
  • Signs of infection
  • Patient discomfort

Flow Rate Adjustment

• Clear effluent: Consider decreasing flow rate
• Pink effluent: Maintain current flow rate
• Red effluent with clots: Increase flow rate
• Completely obstructed catheter: Manual irrigation may be necessary

Complications and Prevention

• Catheter-associated UTI: Maintain closed system, avoid unnecessary disconnections 2
• Bladder spasms: May require anticholinergic medications
• Hyperchloremic metabolic acidosis: Consider Ringer's lactate as alternative irrigation solution 1
• Clot retention: May require manual irrigation or increased flow rate

Important Considerations

• Routine addition of antimicrobials to irrigation fluid is not recommended as it does not reduce catheter-associated UTIs 2, 1
• Studies show that routine CBI after procedures like TURP significantly reduces catheter obstruction rates (4.4% vs 12.9%) 3
• For severe clot retention that doesn't respond to standard irrigation, specialized solutions may be considered in consultation with a urologist 4, 5

Discontinuation

• Gradually decrease irrigation rate as bleeding subsides
• Monitor for return of hematuria after discontinuation
• Remove catheter as soon as clinically appropriate to reduce infection risk 1

Common Pitfalls to Avoid

• Using excessive pressure during irrigation (can cause bladder trauma)
• Breaking the closed drainage system unnecessarily (increases infection risk)
• Inadequate flow rate adjustment (can lead to clot formation)
• Failing to monitor for complications like bladder spasms or infection

CBI is a crucial intervention for preventing complications after urological procedures, with evidence showing it significantly reduces catheter obstruction when used routinely 3. Proper technique and vigilant monitoring are essential for successful outcomes.