How do you titrate a Continuous Blood Infusion (CBI)?

Titration of Continuous Bladder Irrigation (CBI)

The optimal approach to titrating a Continuous Bladder Irrigation (CBI) is to adjust the flow rate to maintain clear or light pink urine output, typically starting at 150-200 mL/hour and adjusting based on urine color.

Initial Setup and Starting Parameters

• Initial flow rate: Start at 150-200 mL/hour of normal saline
• Equipment needed:
  • Three-way Foley catheter (usually 22-24 Fr)
  • Irrigation fluid (typically sterile normal saline)
  • Collection system with measurement markings
  • Infusion pump (recommended for precise control)

Titration Algorithm

Step 1: Assessment of Urine Color

• Clear/light pink: Maintain current rate
• Dark pink/light red: Increase rate by 50 mL/hour
• Bright red/clots present: Increase rate by 100 mL/hour and assess for clot evacuation needs

Step 2: Monitoring and Adjustment Schedule

• Check urine color every 15-30 minutes initially
• Once stabilized, check every 1-2 hours
• Document input and output hourly

Step 3: Titration Guidelines

1. Increase rate when:

   • Urine becomes more red
   • Clots are visible in drainage
   • Catheter shows signs of obstruction (decreased output)

2. Decrease rate when:

   • Urine has been clear for >2 hours
   • Decrease by 50 mL/hour increments
   • Do not reduce below 100 mL/hour until ready to discontinue

3. Maximum rate:

   • Generally not to exceed 300-400 mL/hour without physician reassessment
   • Higher rates may be needed temporarily to clear obstructing clots

Special Considerations

Monitoring Parameters

• Vital signs: Every 1-2 hours (more frequently with higher flow rates)
• Fluid balance: Calculate net fluid balance hourly (CBI input - total output)
• Bladder spasms: May indicate catheter obstruction requiring increased flow or manual irrigation

Troubleshooting

• Catheter obstruction: If output decreases despite increased flow rate:

  • Perform manual irrigation with 60 mL syringe using sterile technique
  • Use gentle pressure to avoid bladder trauma
  • If unable to clear, notify physician for possible catheter change

• Fluid overload: Monitor for:

  • Hyponatremia symptoms (confusion, headache)
  • Respiratory distress
  • Edema
  • If suspected, decrease rate and notify physician

Discontinuation

• Gradually decrease rate to 100 mL/hour when urine has been consistently clear for 24 hours
• Monitor for 4-6 hours at minimum rate before complete discontinuation
• After discontinuation, monitor urine color for 24 hours for recurrence of bleeding

Common Pitfalls to Avoid

1. Inadequate flow rate: Leads to clot formation and catheter obstruction
2. Excessive flow rate: Can cause bladder spasms, patient discomfort, and fluid overload
3. Infrequent monitoring: May miss early signs of bleeding or obstruction
4. Poor documentation: Makes it difficult to track trends in bleeding and response to treatment
5. Failure to assess total fluid balance: Can lead to unrecognized fluid overload

By following this structured approach to CBI titration, you can effectively manage hematuria while minimizing complications and optimizing patient comfort.