‘A step change in action is key to tackling the staffing crisis’

Steve Scholtes, BSc, RGN, is a charge nurse, gastrointestinal and urology oncology unit, Royal Marsden Hospital, London

Clot retention is a possible complication following urological surgery, involving the prostate gland and bladder, which is prevented or rectified with the use of bladder irrigation and, when necessary, bladder washouts (lavage). It may also occur as a result of bladder and prostatic cancers and chemotherapy agents, such as ifosfamide.

Clot retention manifests itself with suprapubic distension, severe discomfort in the lower abdomen and, if the patient is catheterised, bypassing of fluid around the catheter.

Bladder irrigation is a procedure in which sterile fluid is used to prevent clot retention by continuously irrigating the bladder via a three-way catheter (Gilbert and Gobbi, 1989). Bladder irrigation is required due to the vascular nature of the prostate, and to a lesser extent the bladder, and the potential for this gland and organ to bleed in the postoperative period (Forristal and Maxwell, 1997). Bleeding can be due to the surgeons’ inability to obtain haemostasis because of difficulty in visualising small bleeding vessels.

Sodium chloride 0.9% is recommended in the clearance and prevention of clots (Macaulay, 1997; Getliffe, 1996). It is recognised that it is the mechanical action of irrigation that removes and dislodges the clots rather than the sodium chloride itself (Flack, 1993).

Water is not used for irrigation, as it may be absorbed via the process of osmosis from the bladder, and this may cause dilution of electrolytes in the circulatory system (Blannin and Hobden, 1980).

Bladder irrigation will normally have been started in theatre. However, it may occasionally need to be started on the ward. The irrigation system consists of two irrigation bottles or bags of sodium chloride 0.9% (2-3 litres each) which are connected to a Y-shaped giving set which is, in turn, connected to the irrigation port on the patient’s three-way catheter (Fig 1). A giving set with roller ball clamps is preferable to one with an on/off clamp, as the roller ball clamp enables the nurse to regulate the infusion rate according to blood loss.

The three-way irrigation catheter (Fig 2) is a large indwelling urinary catheter which has three lumens - for inflating the balloon which retains the catheter in the bladder, urine drainage and irrigation.

The catheter simultaneously allows fluid to run into and drain out of the bladder. It tends to be of a large size (16-24ch) to accommodate the passage of clots from the bladder. Patients can experience discomfort from these catheters due to their size, but this can be reduced with the use of prescribed topical anaesthetic gel.

As with any other procedure, an explanation should be given to the patient and consent obtained. The equipment required for the procedure should be prepared in advance and includes:

The patient should be positioned comfortably in a supine position, so that there is easy assess to the catheter. The nurse should wash hands and, using aseptic technique, open the equipment, cleanse hands with antibacterial gel and put gloves on.

The protective caps from the irrigation bottles should be removed and, after closing the clamps A,B,C the irrigation set can be connected (Fig 1). The irrigation set should be primed by opening clamp A and C. Clamp B must remain closed as fluid can run from one bottle into the other if clamps A and B are open at the same time. Once the irrigation set is primed, close clamps A and C.

A sterile towel should be placed under the catheter/catheter bag connection and the catheter clamped. The spigot in the irrigation port of the catheter is then removed and the port cleaned with antiseptic solution. Connect the irrigation set to the catheter port and unclamp the catheter. Start the irrigation by opening clamps A and C (Baxter, 2000).

When the first bag of irrigation fluid is completed, close clamp A on the Y connection and open clamp B to the second bag. This system allows the irrigation to run continuously while the empty infusion bag is changed. It is important to make the patient comfortable once irrigation has been started.

The rate of administration of irrigation fluid is dependent on the colour of the drainage from the catheter. If it is heavily bloodstained (claret-coloured) the irrigation should be run quickly, as the likelihood of clot formation is increased due to the presence of a large amount of blood. If the drainage is lightly blood stained (rose-coloured) the irrigation can be allowed to run at a slower rate. Irrigation is normally discontinued when the urine has been only lightly bloodstained for 24-48 hours.

Occasionally a clot can lodge itself within the catheter tip, bringing on the symptoms of acute urinary retention. If this should occur the irrigation should be ceased immediately to prevent further discomfort for the patient. The clot may be dislodged by either squeezing the catheter tubing or ‘milking’ it with rubber-covered milking tongs (Lowthian, 1991). This causes pressure within the catheter lumen, which in turn expels the clot. If this is unsuccessful a bladder washout will need to be performed.

A bladder washout can be defined as the instillation of fluid into the bladder via a catheter using a bladder syringe or prepacked solution to flush away debris or dissolve encrustation (Rew, 1999).

Several authors have written about the need to use washouts sparingly, as they can cause urinary tract infections by the violation of the closed catheter system (Jenner 1983, Getliffe 1997), and for this reason the use of aseptic technique and sterile equipment is important. However, bladder washout is necessary and unavoidable when there is a large amount of clot present in the postoperative period.

Before starting the procedure, a full explanation should be given to the patient and consent received. Equipment required includes: 

The patient should be positioned so that there is easy access to the catheter. The nurse should wash hands using aseptic technique, open the sterile packages and pour the sterile fluid into the jug, then wash hands with bactericidal alcohol hand rub and put on gloves.

A sterile field should be placed under the catheter junction and the catheter clamped. Then disconnect the irrigation set. The port of the catheter should be cleaned with antiseptic solution; 40ml of the washout solution should be drawn up in a 60ml bladder syringe, the syringe connected to the irrigation port and the catheter clamp released. The syringe plunger should be depressed slowly until the fluid is instilled, after which the syringe should be removed and the catheter allowed to drain.

If no drainage occurs, gentle suction should be applied via the catheter syringe. This must be performed gently, as it is possible to suck part of the bladder wall (urothelium) into the eye of the catheter, causing pain for the patient and trauma to the bladder, which in turn may cause infection (Macaulay, 1997). The washout can then be repeated until the fluid from the catheter becomes clear (Baxter, 2000).

An oral intake of three litres of fluid a day is recommended to dilute the urine and assist in flushing out clots. Accurate measurement of fluid balance is important to determine the patient’s urine output in the postoperative period, but also to observe for the onset of transurethral resection syndrome.

TUR syndrome occurs very rarely. It happens when there are open vessels present during prostatic surgery and when the pressure within the vessels is lower than that within the bladder. This facilitates the absorption of irrigation fluid into the circulatory system, causing fluid overload and low plasma potassium and sodium, which can lead to cardiac arrest. Patients with TUR syndrome may present with confusion and disorientation due to electrolyte imbalance (Pengelly, 1985; Forrestal and Maxwell, 1997).

Maintenance of fluid balance charts during irrigation is important. Once an irrigation container is empty all the drainage from the catheter during the time that the container has been running should be added together. The volume of the irrigation container should then be subtracted from this total and the remaining volume of fluid recorded as urine (Table 1).

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Panel discussions shaped this consensus document on transforming leg ulcer care. Its purpose is to capture nurses’ insights, raise awareness in nursing and beyond, highlight problems and suggest solutions. At the end of the document, 10 recommendations for change are outlined.