AHFS Class:

• Irrigating Solutions 40:36

Generic Name(s):

• Acetic Acid

• Glycine

• Ringer's

• Sodium Chloride

• Sterile Water

Irrigating solutions are sterile, nonpyrogenic solutions that may be used for sterile irrigation, washing, rinsing, and/or diluting purposes.

Acetic Acid

Acetic acid irrigation is used for constant or intermittent irrigation of the urinary bladder to help prevent the growth and proliferation of susceptible urinary pathogens (especially ammonia-forming bacteria) in the management of patients who require prolonged use of an indwelling urethral catheter. Acetic acid irrigation is also used for periodic irrigation of an indwelling urethral catheter to help maintain patency by reducing the formation of calcium encrustations.

Acetic acid irrigation is not used for irrigation during transurethral surgical procedures.

Glycine

Glycine irrigation is used as an irrigating solution during transurethral prostatic resection and other transurethral surgical procedures. Glycine irrigation is useful for urologic irrigation during electrosurgical procedures.

Ringer's, Sodium Chloride, and Sterile Water

Ringer's and sodium chloride irrigations are used for all general irrigation (e.g., irrigation of body cavities, tissues or wounds, indwelling urethral catheters, surgical drainage tubes), washing, and rinsing purposes that allow use of a sterile, nonpyrogenic electrolyte solution; sodium chloride irrigation may also be used for all general dilution purposes that allow use of a sterile, nonpyrogenic electrolyte solution. Ringer's and sodium chloride irrigations may also be used for soaking surgical dressings, instruments, and laboratory specimens. The hypotonic 0.45% sodium chloride irrigation may be used alone or with appropriate additives when 0.9% sodium chloride irrigation is considered too irritating for wounds or other altered structures. Ringer's and sodium chloride irrigations are not used for irrigation during electrosurgical procedures.

Sterile water for irrigation is used for all general irrigation, washing, rinsing, and dilution purposes that allow use of sterile, nonpyrogenic, solute-free water. Sterile water for irrigation is also used as a pharmaceutic aid and as an adjunct in the preparation of nutrient mixtures that are not administered IV. Since sterile water for irrigation is solute-free and will cause hemolysis if absorbed systemically, its use is not recommended in conditions (e.g., surgical procedures) in which it may be readily absorbed.

Irrigating solutions are administered topically or, during urologic irrigation, via an administration set connected to an indwelling urethral catheter designed for continuous or intermittent 2-way flow. For periodic irrigation of an indwelling catheter to maintain patency, irrigating solutions may be administered using a bulb or piston syringe. Irrigating solutions must not be administered by parenteral injection.

The use of aseptic technique is essential when irrigating solutions are used for irrigation of body cavities, wounds, and urethral catheters or for wetting dressings that come in contact with body tissues. Irrigating solutions should not be used unless they are clear and the container is undamaged with seal intact. After an irrigating solution container is opened, the solution should be used promptly to minimize the possibility of bacterial growth or pyrogen formation. Unused portions of irrigating solutions should be discarded.

Dosage of an irrigating solution depends on the capacity or surface area of the structure to be irrigated and the nature of the procedure. When an irrigating solution is used as a diluent or vehicle for other drugs, the manufacturer's recommendations should be followed. Specialized references should be consulted for specific information on the compatibility of additives.

Acetic Acid

For continuous or intermittent irrigation of the urinary bladder with 0.25% acetic acid irrigation, the rate of administration will approximate the rate of urine flow and should be adjusted to maintain a urinary effluent pH of 4.5-5. Nitrazine or other pH paper may be used to monitor pH, preferably at least 4 times daily. Generally, a volume of 500-1500 mL per 24 hours is required.

For periodic irrigation of an indwelling urinary catheter to maintain patency, about 50 mL of 0.25% acetic acid irrigation is required for each irrigation.

Adverse Effects

Adverse effects resulting from irrigation of body cavities, tissues, or indwelling catheters and tubes are usually avoidable when appropriate procedures are followed. Displaced catheters or drainage tubes can lead to irrigation or infiltration of unintended structures or cavities. Excessive volume or pressure during irrigation of closed cavities may result in distension or disruption of tissues. Inadvertent contamination from careless technique may transmit infection.

Acetic Acid

Systemic acidosis, urologic pain, and hematuria have occurred in patients receiving 0.25% acetic acid irrigation.

Glycine

Systemic absorption of glycine irrigating solutions may result in fluid and electrolyte disturbances such as acidosis, electrolyte loss, marked diuresis, urinary retention, edema, dryness of the mouth, thirst, and dehydration and cardiovascular/pulmonary disorders such as pulmonary congestion, hypertension, hypotension, tachycardia, angina-like pain, and thrombophlebitis. Shift of sodium-free intracellular fluid into the extracellular compartment following systemic absorption of glycine irrigating solutions may decrease serum sodium concentration and aggravate preexisting hyponatremia. Other adverse effects such as blurred vision, seizures, nausea, vomiting, chills, rhinitis, vertigo, urticaria, and backache may also occur following systemic absorption of glycine irrigating solutions.

Precautions and Contraindications

Systemic absorption of irrigating solutions may cause fluid and/or solute overload resulting in dilution of serum electrolytes, overhydration, congestive conditions, or pulmonary edema. The risk of dilutional conditions is inversely proportional to the electrolyte concentration administered, and the risk of solute overload and resultant congestive conditions with peripheral and/or pulmonary edema is directly proportional to the electrolyte concentration administered. Entry of hypotonic solutions into the systemic circulation may result in hemolysis. Irrigating solutions should generally not be used in conditions in which systemic absorption may result. Solutions for urologic irrigation should be used with caution in patients with severe cardiopulmonary or renal dysfunction, since systemic absorption of large amounts of the solutions may substantially alter cardiopulmonary or renal function. If adverse effects, overhydration, or solute overload occurs with an irrigating solution, the irrigating solution should be discontinued, the patient closely evaluated, and appropriate corrective therapy instituted if necessary.

Solutions containing electrolytes should not be used for irrigation during electrosurgical procedures.

Acetic Acid

Use of acetic acid irrigation in patients with mucosal lesions of the urinary bladder may cause irritation of the lesions and systemic acidosis may result from systemic absorption of the solution via the lesions. If pain or hematuria occurs during irrigation with acetic acid, the irrigation should be discontinued and the patient reevaluated. Use of acetic acid irrigation is contraindicated during transurethral surgical procedures.

Glycine

Glycine irrigation should be used with caution in patients with known or suspected hepatic impairment, since absorption and resultant metabolism of glycine may result in increased blood concentrations of ammonia in such patients. Glycine irrigation is contraindicated in patients with anuria.

Sterile Water

Since sterile water is hypotonic and will cause hemolysis, its use during surgical procedures is not recommended.

Pharmacology

Acetic Acid

Irrigation of the urinary bladder with acetic acid 0.25% solution exerts an antimicrobial action against a variety of microorganisms (particularly ammonia-forming bacteria) that often gain access to the urinary bladder in patients requiring prolonged indwelling urethral catheterization. The antimicrobial activity depends on administration of the solution via an indwelling catheter at a rate sufficient to maintain an effluent pH of at least 5. Maintenance of a low pH of bladder urine with acetic acid irrigation also helps reduce formation of calcium encrustations in the indwelling catheter.

Glycine

Glycine irrigation is nonhemolytic and nonconductive and has a refractive index close to that of water, making it useful as a urologic irrigating solution, particularly during transurethral surgical procedures where the irrigant may be absorbed systemically through cut venous sinuses. Because of its nonconductive property, glycine irrigation may be useful as a urologic irrigant during electrosurgical procedures.

In the absence of accompanying calorie substrate, systemically absorbed glycine is metabolized mainly by deamination to ammonia and transamination to other amino acids, principally serine. In individuals with normal hepatic function, an increase in blood ammonia concentration does not occur.

Ringer's, Sodium Chloride, and Sterile Water

Ringer's, sodium chloride, and sterile water irrigating solutions exert a mechanical cleansing action for sterile irrigation of body cavities, tissues or wounds, indwelling urethral catheters, and surgical drainage tubes and for washing, rinsing, or soaking surgical dressings, instruments, and laboratory specimens. These irrigating solutions also act as diluents or vehicles for drugs used for irrigation or other pharmaceutical preparations.

Sterile water for irrigation is solute-free and its entry into systemic circulation causes hemolysis; 0.45% sodium chloride irrigation is hypotonic and its entry into systemic circulation may also cause hemolysis.

Chemistry and Stability

Chemistry

Irrigating solutions are sterile, nonpyrogenic solutions that may be used for sterile irrigation, washing, rinsing, and/or diluting purposes.

Acetic Acid

Acetic acid irrigation is a sterile, 0.25% solution of glacial acetic acid in water for injection. Acetic acid irrigation has a pH of 2.8-3.4 and a calculated osmolarity of 42 mOsm/L. Acetic acid irrigation should not be confused with Acetic Acid NF which contains 36-37% of the acid or with Diluted Acetic Acid NF which contains 5.7-6.3% of the acid.

Glycine

Glycine (aminoacetic acid) irrigation is a sterile solution of glycine in water for injection. Glycine irrigation has a pH of 4.5-6.5 and the 1.5% irrigation has a calculated osmolarity of approximately 200 mOsm/L.

Ringer's

Ringer's irrigation is a sterile solution of sodium chloride, potassium chloride, and calcium chloride in water for injection. Ringer's irrigation contains sodium chloride 8.6 g/L, potassium chloride 0.3 g/L, and calcium chloride 0.33 g/L; the solution contains sodium 147.5 mEq/L, potassium 4 mEq/L, calcium 4.5 mEq/L, and chloride 156 mEq/L. Ringer's irrigation has a pH of 5-7.5 and a calculated osmolarity of 309 mOsm/L.

Sodium Chloride

Sodium chloride irrigation is a sterile solution of sodium chloride in water for injection. Sodium chloride irrigation contains 77 or 154 mEq/L each of sodium and chloride in the 0.45 or 0.9% solution, respectively. Sodium chloride irrigation has a pH of approximately 5.3, and the 0.45 or 0.9% solutions have a calculated osmolarity of 154 or 308 mOsm/L, respectively.

Sterile Water

Sterile water for irrigation is water for injection that has been sterilized and suitably packaged. Sterile water for irrigation has a pH of 5-7.

Stability

Acetic Acid

Acetic acid irrigation should be stored at a temperature of 40°C or less; freezing and exposure to extreme heat should be avoided. Acetic acid irrigation should not be heated to temperatures greater than 66°C.

Glycine

Glycine irrigation should be stored at a temperature of 40°C or less; freezing should be avoided. Glycine irrigation should not be heated to temperatures greater than 66°C.

Ringer's

Ringer's irrigation solution should be stored at a temperature of 40°C or less; freezing and exposure to extreme heat should be avoided. Ringer's irrigation should not be heated to temperatures greater than 66°C.

Sodium Chloride

Sodium chloride irrigation should be stored at a temperature of 40°C or less; freezing and exposure to extreme heat should be avoided. Sodium chloride irrigation should not be heated to temperatures greater than 66°C.

Sterile Water

Sterile water for irrigation should be stored at a temperature of 40°C or less; freezing and exposure to extreme heat should be avoided. Sterile water for irrigation should not be heated to temperatures greater than 66°C.

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.