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Catheter Irrigation in the Management of the Urinary Tract in Spinal Cord Injury

That is the general definition of catheter irrigation. However, in this case, we will be discussing about catheter irrigation performed to drain urine from the bladder.

“Irrigation is a procedure to open a plugged urinary catheter. Normal saline (NS) is inserted into the catheter to remove the plug, so that the urine can drain from the bladder.”1

There are two main reasons for catheter irrigation

  1. To assess the patency of the catheter
  2. In an effort to prevent the formation of urine stones. If need be, acetic acid, renacidin or Solution G (which contains citric acid, anhydrous sodium carbonate, and magnesium oxide) are used for this purpose.

“Urinary bladder irrigation is done in cases of both hematuria and as a part of any intervention in bladder and prostate such as transurethral prostatic resection and mensa irrigation. This is done using a 3-way irrigation urethral catheter. Usually, the size available is 16-Fr and above; however, in cases of stricture, smaller size is required. We describe a technique for this situation.”2

“The literature indicates that IUCs (intermittent irrigation of indwelling urinary catheters) should only be irrigated if there is evidence of a blood clot. Blood clots may be present after bladder, kidney, or prostate surgery, or with encrustation of long-term catheters. Routine intermittent irrigation of an IUC, especially if the IUC is disconnected from the drainage bag, is thought to increase the possibility of introducing microorganisms into the bladder, resulting in an infection. According to experts, even if biofilm (bacterial colonies) are suspected to have caused encrustation on the IUC sides, and are causing blockage, routine irrigation is not effective and could even increase the risk of infection.5 In addition, the IUC itself may be part of the problem causing the obstruction and should then be replaced rather than irrigated.”3

Necessary items for catheter irrigation

  • A syringe with a tip that fits into a catheter
  • Alcohol swabs
  • Disposable paper towels
  • Catheter clamp if using renacidin
  • A sterile urine receiving container
  • Solution for irrigation
  • Alcohol wipes for keeping the drainage tube end sterile in case it needs to be used again.

Catheter irrigation procedure

“Irrigate through the catheter every four hours during the day using Normal Saline (do not use tap water). It is important to irrigate more frequently if the urine output has diminished or if the Blake drain or Penrose drain seems to have a significant increase in the amount of output. No need to wake up overnight to irrigate, last irrigation should be before you go to bed, and then upon waking in the morning. It is important to irrigate in order to keep the catheter free of mucous plugs, or blood clots so that urine is able to drain out and not back up into the kidneys.”4

  • Have the aforementioned supplies at the ready.
  • Use towelettes or soap and water to wash your hands
  • Place disposable paper towels under the catheter system
  • By touching the outside part of the glass only, pick up the irrigating solution; measure 2 ounces and pour it into the container.
  • Arrange the urine receiving container under the open catheter end for draining purposes.
  • Swab the catheter-drainage tube connection with the alcohol-infused cotton swabs.
  • Disconnect the catheter from the tube and put the tube away after covering its end while ensuring the catheter end does not come into contact with the urine receiving tray.
  • Withdraw just one ounce of the irrigating solution into the syringe, making sure to push out any residual out of it.
  • Insert the syringe into the end of the catheter. Apply gentle pressure on the syringe plunger and push the irrigation solution into the catheter and up into the bladder. If resistance is encountered during insertion, the catheter should be changed. Always avoid suction to the catheter while it is inserted as this may cause physical trauma to the bladder.
  • Grasp the catheter end with 2 fingers in a pinching position and gently apply pressure to pull out the syringe.

“Catheter irrigation should be on schedule. This erroneous concept presupposes that irrigation of the bladder is a cleansing process and beneficial to maintaining physiology. The error in this concept is that any interruption of the closed drainage system, especially by careless personnel or poor technique, can introduce bacteria and infection. Naturally, there is no benefit to be gained by irrigating the catheter for any purpose unless it is to prevent encrustations by using Renacidin, or to medicate the bladder for specific purposes known to the attending physician.

Since the advent of closed drainage systems and appropriate antibacterials, there is absolutely no indication on a regular basis for scheduled bladder irrigations. Primary indication for catheter irrigation is poor or obstructed drainage. This can be determined by noting the presence or absence of fluctuation of the urine in the catheter tubing. Absence of fluctuation suggests obstruction and therefore the need for aspiration or irrigation (aspiration preferred).”5

If using renacidin as the irrigating solution

“Renacidin (Citric Acid, Glucono delta-lactone, and Magnesium Carbonate) is a sterile, non-pyrogenic irrigation solution for use within the lower urinary tract in the dissolution of bladder calculi of the struvite or apatite variety, and prevention of encrustations of urethral catheters and cystostomy tubes.”6

  • Ensure sterility of the solution
  • Drip the second ounce of the solution into the catheter and clamp it.
  • Un-clamp the catheter and allow to drain after 10 minutes
  • Drain the urine into the receptacle
  • Repeat the process with the unused solution.
  • Swab the connector with cotton alcohol swabs and attach it back to the urine bag tubing.
  • Do away with the disposable items and wash the remaining supplies.
  • Thoroughly wash your hands.

“Renacidin use should be stopped immediately if the patient develops fever, urinary tract infection, signs and symptoms consistent with urinary tract infection, or persistent flank pain. Irrigation should be stopped if elevated serum creatinine develops. The contents of individual Renacidin containers should not be combined for use as continuous irrigation of the urinary tract because of complications that may arise from inadequate aseptic technique. Terminal sterilization processes that are not adequate may result in sepsis and/or injury to product handlers (e.g., irritation to exposed, unprotected areas of the skin). Serious adverse reactions, including sepsis and hypermagnesemia, have been reported to occur when Renacidin was used for continuous irrigation of the upper urinary tract. Renacidin is not indicated for continuous irrigation of the upper urinary tract.“7

Suggestions

“Urinary catheter/bladder irrigation requires a prescriber’s order. The order must include type and amount of irrigating solution and frequency of irrigation. The following assessment and troubleshooting steps should be taken prior to the decision to irrigate catheter:  No urine output x 1 hour  Patient complaints of urinary retention (abdominal discomfort, urge to void)  Palpate for distended bladder  Site-to-source check (system intact, kinks, clamps, etc.)  Reposition patient to optimize drainage  Scan bladder  Discuss assessment findings with the team and obtain order.”8

  • Perform irrigation at the time of changing from a leg bag to a drainage bag. This is usually during bedtime and upon waking up in the morning.
  • If you do your catheter irrigation twice in a day, sterilize 2 irrigation sets at the same time.
  • It is much more affordable to prepare the irrigation solution on your own.
  • If you notice blood in urine, avoid irrigation solutions containing acetic acid. These include:
  1. Renacidin
  2. Solution G

Even during the catheter irrigation procedure, a high degree of hygiene must be observed. It is also important to actively prevent introducing air into the bladder inadvertently.

“It is not uncommon to enter a patient’s room and find irrigation equipment on the bedside stand. This is to be prohibited at all times. Such irrigation equipment is to be always sterile and by leaving it at the bedside, patients, relatives, visitors, have access to this equipment, may handle it, may curiously examine it, may drop cigarette ashes into it, or any other ill-advised activity which cannot be monitored from the nurses’ station. It may be convenient for the nurse or personnel to have the sterile equipment at the bedside but it is poor public policy, poor patient policy, and poor infection control to have this condition exist. The sterile equipment should be kept at the nursing station under careful control and supervision. In addition to this, bladder irrigation is not a casual activity and should be ordered only in a rational manner. Drainage, a continuous process, should be uninterrupted, and the only rationale for irrigation is to restore patency to the drainage system, if in fact drainage is impeded by a condition correctable by irrigation.”9

“It is important to stay hydrated. You should drink at least 2 liters of decaffeinated liquids per day. There may be some incidental light bleeding during or after irrigation. This is normal as things are healing.”10

“To maintain a closed urinary system when irrigating, it has become a widely accepted practice in many hospitals to use the sampling port, rather than disconnecting the IUCs from the drainage bag. Since the sampling port was designed for obtaining a specimen and not for irrigation, most likely it would not be effective in removing the catheter blockage and is not a recommended routine practice. Other methods for intermittent irrigation of an IUC are using a 3-way catheter and disconnecting the tubing, which requires a good technique to avoid allowing organisms to enter the catheter. It is notable that some nursing textbooks state that the closed system should be maintained and intermittent irrigation might sometimes be necessary.”11

References:

(1) Urinary catheter irrigation. Children’s Hospitals and Clinics of Minnesota. 2010. https://www.childrensmn.org/references/pfs/homecare/urinary-catheter-irrigation.pdf

(2) Improvised Urinary Bladder Irrigation System. Agarwal, A., Bora, A., & Banerjee, A. Annals: The Royal College of Surgeons of England. 2008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728318/

(3, 11) Standardizing Practice for Intermittent Irrigation of Indwelling Urinary Catheters. Weber, J., Purvis, S., Van Den Bergb, S., & Stevens, L. Journal Of Nursing Care Quality. 2017. https://nursing.ceconnection.com/ovidfiles/00001786-201707000-00004.pdf

(4) Hematuria Catheter Irrigation Procedure. Keck Medicine of USC Urology. 2016.https://urology.keckmedicine.org/wp-content/uploads/sites/30/2016/12/Hematuria-Catheter-Irrigation-Procedure.pdf

(5, 11) Basics of Catheterization and Catheter Care. Becker, L. Journal Of The National Medical Association. 1980. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552415/pdf/jnma00036-0087.pdf

(6, 7) Renacidin (Citric Acid, Glucono Delta-Lactone, and Magnesium Carbonate) Irrigation Solution. Smith Medical ASD. Guardian Laboratories. 2015. https://www.google.com.mx/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=2ahUKEwj1j-GQ_47jAhWFAWMBHelRC8wQFjABegQIARAC&url=https%3A%2F%2Fdailymed.nlm.nih.gov%2Fdailymed%2FgetFile.cfm%3Fsetid%3D13a9bbba-db21-4cba-991c-5d8afaf2ed74%26type%3Dpdf%26name%3D13a9bbba-db21-4cba-991c-5d8afaf2ed74&usg=AOvVaw1p1XBJ9Ymd9UiGR091Nhhe

(8) Catheter/ Bladder Irrigation. BC Children’s Hospital. BC Children’s Hospital Child & Youth Health Policy and Procedure Manual. 2016. http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children%27s%20Hospital/CC.15.06%20Catheter-Bladder%20Irrigation%20-%20Syringe%20Method.pdf

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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