Chapter 6: Elimination
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Bladder irrigation
Definition
Evidence‐based approaches
Rationale
Indications
Bladder irrigation is performed to prevent the formation and retention of blood clots, for example following prostatic surgery, such as transurethral resection of bladder tumour (TURBT) or transurethral resection of prostate (TURP). Other indications include irrigation for the delivery of pharmacological agents, irrigation for candida cystitis, prevention of haematuria following chemotherapy or surgical procedures (Abt et al. [4]).
Principles of care
There are a number of risks associated with bladder irrigation (including introducing infection) and the procedure should not be undertaken lightly (Siddiq and Darouiche [222]). Prior to taking a decision to use bladder maintenance solutions, patients should be assessed. The guiding principle for effective catheter management always involves addressing the individual needs of the patient (Wilde et al. [248]). Assessment of all aspects of catheter care and irrigation should be undertaken, including:
- patient activity and mobility (catheter positioning, catheter kinking)
- diet and fluid intake
- standards of patient hygiene
- patient's and/or carer's ability to care for the catheter (EAUN [71]).
Pre‐procedural considerations
Equipment
A three‐way urinary catheter must be used for irrigation in order that fluid may simultaneously be run into, and drained out from, the bladder (Davis et al. [61]). A large‐gauge catheter (16–24 ch) is often used to accommodate any clots or debris that may be present. This catheter is commonly passed in theatre, for example after transurethral resections (Bijalwan et al. [22]). Occasionally, if a patient is admitted with a heavily contaminated bladder (e.g. by blood clots or pus), bladder irrigation may be started on the ward. If the patient has a two‐way catheter, this must be replaced with a three‐way type (Peate and Gill [195]).
It is recommended that a three‐way catheter is passed if frequent intravesical instillations of drugs or antiseptic solutions are prescribed and the risk of catheter obstruction is not considered to be very great. In such cases, the most important factor is minimizing the risk of introducing infection and maintaining a closed urinary drainage system, which the three‐way catheter allows (Figure 6.14).
Figure 6.14 Closed urinary drainage system with provision for intermittent or continuous irrigation.
Pharmacological support
The agent most commonly recommended for irrigation is 0.9% sodium chloride (RCN [208]), which should be used in every case unless an alternative solution is prescribed. 0.9% sodium chloride is isotonic so it does not affect the body's fluid or electrolyte levels, enabling large volumes of the solution to be used as necessary (Clarebrough et al. [48]). In particular, 2 L bags and bottles of 0.9% sodium chloride are available for irrigation purposes. It has been proposed that sterile water should never be used to irrigate the bladder as it can be readily absorbed via osmosis (Gupta et al. [93]). However, a study has demonstrated that sterile water is a safe irrigating fluid for TURP (Bijalwan et al. [22]). Other irrigation fluids include 3.23% and 6% citric acid used in catheter care or maintenance to dissolve or remove encrustations and crystallization in the bladder (RCN [208]).
Although not a common complication, absorption of irrigation fluid can occur during bladder irrigation. This can produce a potentially critical situation, as absorption may lead to electrolyte imbalance and circulatory overload. Absorption is most likely to occur in theatre when glycine irrigation fluid, devoid of sodium or potassium, is forced under pressure into the prostatic veins (Hermanns et al. [99]). 0.9% sodium chloride cannot be used during surgery as it contains electrolytes, which interfere with diathermy (Forristal and Maxfield [79]). However, the risk of absorption remains while irrigation continues post‐operatively. For this reason, it is important that fluid balance is monitored carefully during irrigation (Hahn [94]).
Procedure guideline 6.11
Commencing bladder irrigation
Table 6.6 Prevention and resolution (Procedure guideline 6.11)
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| Fluid retained in the bladder when the catheter is in position | Fault in drainage apparatus, e.g. kinked tubing blocking catheter | Empty the drainage bag every 2–4 hours, depending on how fast the fluid is running. |
Straighten the tubing. ‘Milk’ the tubing. Wash out the bladder with 0.9% sodium chloride using an aseptic technique. |
| Overfull drainage bag | Empty the drainage bag. | ||
| Catheter clamped off | Unclamp the catheter. | ||
| Distended abdomen related to an overfull bladder during the irrigation procedure | Irrigation fluid is infused at too rapid a rate | Monitor fluid drainage rate every 15 minutes. | Slow down the infusion rate. |
| Fault in drainage apparatus | Check the patency of the drainage apparatus. | ||
| Leakage of fluid from around the catheter |
Catheter slipping out of the bladder | Use appropriate size of catheter. | Insert the catheter further in. Decompress the balloon fully to assess the amount of water necessary. Refill the balloon until it remains in situ, taking care not to overfill beyond a safe level (see manufacturer's instructions). |
| Catheter too large or unsuitable for the patient's anatomy | If leakage is profuse or catheter is uncomfortable for the patient, replace it with one of a smaller size. | ||
| Patient experiences pain during the lavage or irrigation procedure | Volume of fluid in the bladder is too great for comfort | Titrate slowly and assess pain level frequently. | Reduce the fluid volume or rate. |
| Solution is painful to raw areas in the bladder | Inform the doctor. Administer analgesia as prescribed. | ||
| Retention of fluid with or without distended abdomen, with or without pain | Perforated bladder | Stop irrigation. Maintain in recovery position. Call for urgent medical assistance. Monitor vital signs. Monitor patient for pain or a tense abdomen. |
Box 6.1
Care of patients undergoing bladder irrigation
- Adjust the rate of infusion according to the degree of haematuria. This will be greatest in the first 12 hours following surgery (average fluid input is 6–9 L during the first 12 hours, falling to 3–6 L during the next 12 hours). The aim is to obtain a drainage fluid that is rosé in colour. Check the bags of irrigation fluid regularly and renew as required. The overall aim is to remove blood from the bladder before it clots and to minimize the risk of catheter obstruction and clot retention (Scholtes [219]).
- Check the volume in the drainage bag frequently when the infusion is in progress, and empty bags before they reach their capacity (e.g. half‐hourly or hourly, or more frequently as required). This will ensure that fluid is draining from the bladder and that blockages are detected as soon as possible; it will also prevent over‐distension of the bladder and patient discomfort.
- Annotate the fluid balance chart accurately. The fluid balance of all patients having bladder irrigation must be closely monitored so that urine output is known and any related problems, such as renal dysfunction, may be detected quickly and easily.
Post‐procedural considerations
Documentation: bladder irrigation recording chart
A bladder irrigation recording chart (see Figure 6.15) is designed to provide an accurate record of the patient's urinary output during the period of irrigation. Record the time (column A) and the fluid volume in each bag of irrigating solution (column B) as it is put up.
Figure 6.15 Example bladder irrigation chart.
When the irrigating fluid has all run from the first bag into the bladder, record the original volume in the bag in column C. Record the corresponding time in column A. Do not attempt to estimate the fluid volume run‐in while a bag is in progress as this will be inaccurate. If, however, a bag is discontinued, the volume run‐in can be calculated by measuring the volume left in the bag and deducting this from the original volume. This should be recorded in column C (Clarebrough et al. [48]).
The catheter bag should be emptied as often as is necessary; the volume should be recorded in column D and the corresponding time in column A. The catheter bag must also be emptied whenever the bag of irrigating fluid is empty, with the volume recorded in column D.
When each bag of fluid has run through, add up the total volume drained by the catheter in column D, and write this in red. Subtract from this the total volume run‐in (column C) to find the urine output (D − C = E). Write this in column E. Draw a line across the page to indicate that this calculation is complete and continue underneath for the next bag.
