What are the steps for managing Continuous Bladder Irrigation (CBI) and how to properly empty and measure its output?

Continuous Bladder Irrigation (CBI) Management Protocol

Continuous bladder irrigation (CBI) should be properly managed with systematic monitoring of input and output to prevent complications such as clot retention, bladder perforation, and electrolyte imbalances. 1

Indications for CBI

• CBI is primarily indicated for patients with hematuria to prevent catheter obstruction from blood clots, particularly following urological procedures or in cases of severe bladder hemorrhage 1
• CBI is essential for postoperative care after transurethral procedures to prevent clot formation and maintain catheter patency 1, 2
• Macroscopic hematuria with an indwelling catheter requires CBI to prevent clot formation and possible urinary retention 1

Equipment Setup

• Use a three-way Foley catheter (22F-24F recommended for optimal irrigation flow) 3
• Position irrigation fluid bag approximately 80 cm above the level of the bladder 4, 3
• Connect irrigation tubing to the irrigation port of the three-way catheter 3
• Use normal saline (0.9% sodium chloride) as the standard irrigation fluid 5
• Ensure drainage bag is positioned below the level of the bladder to maintain gravity drainage 3

CBI Management Steps

Initial Setup

1. Verify proper catheter placement and balloon inflation (typically 30 mL) 3
2. Connect irrigation tubing to the irrigation port of the three-way catheter 3
3. Connect drainage tubing to a collection system that allows for measurement of output 2
4. Adjust irrigation rate based on the color of the effluent - initially start at a moderate rate and adjust as needed 2

Monitoring and Adjustment

1. Assess the color of the effluent regularly - target clear or light pink fluid 1, 2
2. Increase irrigation rate if effluent appears bright red or contains clots 2
3. Decrease irrigation rate when effluent becomes clear 1
4. Document irrigation input rate and drainage output volume at least hourly 2

Measuring Output

1. Empty the drainage bag at regular intervals (typically every 1-2 hours or when 3/4 full) 2
2. Record the total volume of fluid in the drainage bag 2
3. Calculate the actual urine output by subtracting the irrigation input from the total drainage output 2
   • Formula: Actual urine output = Total drainage output - Irrigation input 2
4. Document both the total drainage and the calculated actual urine output 2

Troubleshooting Common Issues

Catheter Blockage

• If drainage suddenly decreases or stops:
  • Check for kinks in the tubing 2
  • Attempt gentle manual irrigation using a catheter-tip syringe through the irrigation port 3
  • If blockage persists, the catheter may need to be replaced 1

Bladder Spasms

• May occur due to bladder irritation from the catheter or rapid irrigation 2
• Consider reducing irrigation rate if spasms occur 1
• Anticholinergic medications may be needed for persistent spasms 6

Insufficient Irrigation

• If clots persist despite CBI, increase the height of the irrigation bag to increase flow rate 4
• Bardex 22F-24F catheters have demonstrated superior continuous irrigation flow compared to other brands 3

When to Discontinue CBI

• CBI can be discontinued when:
  • Urine is consistently clear or light pink for 24 hours 1
  • No visible clots are present in the drainage 1
  • Bleeding parameters have stabilized 1

Potential Complications

• Hyperchloremic metabolic acidosis may occur with prolonged use of normal saline irrigation 5
• Bladder perforation is a risk if excessive pressure is applied during irrigation 7
• Fluid absorption can lead to volume overload and pulmonary edema in susceptible patients 5
• Urinary tract infections may develop with prolonged catheterization 8

Documentation Requirements

• Record irrigation fluid type and rate 2
• Document color and consistency of drainage output 2
• Calculate and record actual urine output by subtracting irrigation input from total output 2
• Note any clots, tissue, or unusual characteristics of the drainage 2
• Document any interventions performed to maintain catheter patency 2

Cautions

• Avoid using automated pumps for CBI in settings where precise pressure control is not available, as this can increase risk of bladder perforation 7
• Monitor for signs of fluid absorption (hyponatremia, pulmonary edema) in patients receiving prolonged CBI 5
• Consider alternative irrigation fluids (e.g., Ringer's lactate) in patients at risk for electrolyte imbalances 5