Catheter maintenance solutions

• A full patient assessment is essential in establishing whether a catheter maintenance solution is required. Catheters block for a number of reasons, therefore staff should ensure that these problems are eliminated prior to instillation. i.e. constipation, patients position in bed or chair, bladder spasm or “kinking” of the catheter drainage system. (Refer to appendix 3). 
• Encrustation occurs when the pH is alkaline, therefore, in these cases a maintenance solution maybe recommended. (Refer to appendix 4). 
• Catheter changes should be recorded in the care plan in the patient’s notes, identifying the reasons why the change is required. In doing this, patterns of blockage will be identified; therefore, action will be taken to ensure the catheter remains patent. 

• To minimise encrustation of catheter.
• To prevent catheter blockage and encrustation.
• To maintain the life of the catheter by keeping patent and preventing blockage.
• To alleviate trauma caused by encrustation on catheter removal.  

• Lack of patient consent (verbal or implied) 
• Medical instruction not to undertake bladder washout.

• Undiagnosed haematuria.
• History of carcinoma of the lower urinary tract.
• Fistula or radiotherapy to the lower urinary tract. 
• Recent urological surgery. 
• Patients with spinal injury (autonomic dysreflexia) 
• Patient has a proven urinary tract infection.

Remember: Chlorhexidine solution is not advocated for use within NHS Ayrshire & Arran.

There are three main catheter maintenance solutions which can be prescribed. They come in two types of containers; these are the gravity fed and the agitation type container. At present, research literature suggests that gravity fed instillation is best practice. Instillation by gravity alone results in the least amount of bladder trauma¹⁸.

• Normal saline solution.

This solution is recommended to flush out debris and mucous, it has purely a mechanical action. 

         Dosage – available in 100ml bags as required. 

• Polihexanide (PHMB 0.02%) 

This solution is recommended to help aid removal of debris, mucus, light haematuria and provide bacterial decolinisation of the catheter.  

Dosage – available in 100ml bags as required.

Up to 1-2 irrigations per day may be indicated. 

• Solution G (3.2% citric acid) (also known as Suby G)  

This solution dissolves the crystals formed by urease producing bacteria. Solution G contains magnesium oxide which has been incorporated to prevent bladder irritation due to the acidic nature of the solution. This solution is used for encrustation, blockage or as part of a management regime to prevent recurrent blockage. The urotainer twin was developed based on research delivering two washouts one after the other without needing to break the closed system. Each chamber of the urotainer twin holds 30mls of solution which is more comfortable for the patient to tolerate. 

Dosage - maximum up to twice daily, if irritation experienced discontinue treatment.

• Solution R (6% citric acid)

This solution dissolves severe encrustation. It should only be used after solution G has been tried and not been effective. It is most useful prior to catheter removal if external encrustation on the catheter tip and balloon cause pain and tissue trauma when the catheter is removed.

Dosage - maximum up to twice daily, if irritation experienced discontinue treatment. 

Refer to guidance from BBraun. Uro-Tainer Catheter maintenance Solutions- A guide to best practice. Catheter Maintenance and Bladder Irrigation (bbraun.co.uk)

The nurse/carer administering a catheter maintenance solution should use an aseptic technique. If undertaken by a patient a clean technique is acceptable. 

Equipment

• Apron
• Nitrile examination gloves
• Prescribed catheter maintenance solution checking expiry date and the package is intact and sterile.
• Patient's selected sterile urine drainage bag.
• Clinical waste bag as per waste management.
• PPE.
• Maintain a closed system by using a bladder infusion kit (BIK)

Procedure

1. Explain procedure to patient.
2. a. Assist the patient into a supine position
   b. Ensure comfort privacy and modesty.
3. Decontaminate hands as per the WHO 5 moments for hand hygiene.
4. Put on PPE.
5. The Uro-tainer is supplied sterile. If desired bring solution to body temperature by immersing the wrapped sachet into luke-warm water.
6. Open outer packaging to expose inner sterile solution container.
7. Remove inner sterile solution container.
8. Close the clip to prevent solution loss.
9. Remove the security ring on the solution container.
10. Disconnect urine bag from catheter or use BIK.
11. Twist and withdraw cap without touching connector.
12. Open the clip and allow a few drops of the solution to flow into the catheter to remove any air locks.
13. Insert connector into the catheter and allow solution to flow into the bladder by gravity and ensure that the solution is higher than the bladder (Do not apply force to instil solution)
14. If the solution is to be retained in the bladder close the clip for the specified period, cover the exposed area of the patient and dispose of the old urine drainage bag.
15. If you leave the patient, remove PPE and decontaminate hands as per the WHO 5 moments for hand hygiene. Before resuming the procedure decontaminate hands, apply alcohol hand rub and put on PPE.
16. When the solution is to be removed, lower the bag below the level of the bladder, open the clip and allow the solution to drain back into the bag.
17. Close the clip and disconnect the solution bag and connect the appropriate sterile drainage bag. 
18. Empty solution from bag as per waste management policy.
19. Dispose of bag /receptacle as advised within the local Waste Management Policy. 
20. Dispose of PPE and decontaminate hands as per the WHO 5 moments for hand hygiene.
21. Document solution administered and any complications encountered in the nursing records. 

Procedure

1. Explain procedure to patient.
2. Assist the patient into a supine position.
3. Ensure comfort, privacy and modesty.
4. The Twin Uro-tainer is supplied sterile. Bring solution to body temperature by immersing the wrapped sachet into luke-warm water.
5. Decontaminate hands as per the WHO 5 moments for hand hygiene.
6. Open outer packaging to expose inner sterile solution container.
7. Decontaminate hands as per the WHO 5 moments for hand hygiene.
8. Put on PPE.
9. Close both tubes with green and white clamps.
10. Remove the security ring on the solution container.
11. Disconnect urine bag from catheter or use bladder infusion kit (BIK)
12. Twist and withdraw cap without touching connector.
13. Open white clamp and allow a few drops of the solution to flow into the catheter to remove any air locks.
14. Insert connector into the catheter and allow solution to flow into the bladder by gravity and ensure that the solution is higher than the bladder. You may find that you will not be able to instil the full 30mls therefore do not apply force to instil solution. The solution should remain in the bladder for 5 minutes, closing the clamp for the specified period, cover the exposed area of the patient and dispose of the old urine drainage bag.
15. If you leave the patient:

    Remove PPE and  Decontaminate hands as per the WHO 5 moments for hand hygiene.

    Before resuming the procedure:

    Decontaminate hands as per the WHO 5 moments for hand hygiene and put on PPE.
16. After 5 minutes release white clamp and hold bag below the level of the bladder and drain solution back into the compartment. Do not worry if 30mls is not returned.
17. Now repeat the process using the second chamber of solution.
18. Ensure both clamps are closed and disconnect the solution bag and connect the appropriate sterile drainage bag.
19. Remove PPE.
20. Decontaminate hands as per the WHO 5 moments for hand hygiene.
21. Dispose of all equipment as per Local Waste Management Policy.
22. Document solution administered and any complications encountered in the nursing records.