B-08: Biliary Drainage

• Indications
  • Biliary obstruction
  • Choledocholithiasis
  • Failed ERCP or adverse anatomy for ERCP
• Contraindications
  • Contrast allergy (premedicate)
  • Uncontrolled coagulopathy
  • Ascites (relative)
• Patient Evaluation
  • Ability to lie still, hold breath, and cooperate during procedure
  • Consider anesthesia (MAC or general)
• Preprocedure Orders
  • Routine
  • Antibiotics should be started the night before procedure with a dose on call to radiology
• Tools
  • Accustick or Jeffery access set
  • Connecting tubing for contrast injection
  • Cope (.018"), Coons, Bentson, and Amplatz wires
  • Tegtmeyer or other 5Fr. catheter
  • 8Fr. Cope biliary drainage catheter w/ metal stiffener
  • Molnar disk, ligature (#2 silk), Tegaderm, drainage bag and tubing
• Entry site
  • Right: Mid-axillary line at 9th to 11th rib interspace
  • Left: Left subxiphoid angled toward tip of right shoulder
• Technique
  • Puncture with 21ga. needle to depth of 10-12cm. Attach connecting tubing and contrast. Withdraw needle slowly while puffing contrast under magnification fluoroscopy. Following duct entry, pass .018" Cope wire and advance until stiff part of wire is in duct. Introduce transitional dilator over wire into duct. Exchange for Coons wire. Attempt to cross obstruction with Coons, then Coons and Tegtmeyer, then Tegtmeyer and Glide. Measure distance from duct entry to duodenum with a Bentson wire and Tegtmeyer (bent wire technique). Cut additional sideholes in drainage catheter as necessary. Measure distance from proximal sidehole to catheter hub with Bentson wire. Place Coons or Amplatz wire into duodenum. Remove Tegtmeyer and insert and form drainage catheter. Position proximal sidehole using Bentson wire as a guide. Secure with Molnar disk and Tegaderm. If unable to cross obstruction in 30-45 minutes, place Cope loop or Amplatz anchor catheter for external drainage. Repeat attempt after 48 hours of decompression.
• Post-procedure Note
  • Note type and size of catheter(s) placed
  • Note if external only or internal/external drainage
  • Note ancillary procedures done (i.e., brush biopsy, balloon dilatation, stone manipulation)
• Post-procedure Orders
  1. Catheter to gravity drainage.
  2. Record output q shift
  3. Bed rest x 24 hours with BRP after 6 hours
  4. Check entry site(s) for bleeding and check and record VS (BP, HR, RR,):
     • q 15 min x 2, then
     • q 30 min x 4, then
     • q 60 min x 4, then
     • q 4 hours if stable
  5. Check and record temp q 2 hr. x 4, then q 4 hr. if stable
  6. Call H/O for any change in VS
  7. CBC at (4 hr. post procedure)_____p.m.; CBC and Chemistry profile w/ LFT at 8 a.m.
  8. Antibiotic coverage to continue for 72 hours minimum
  9. Resume other preprocedure orders
  10. H/O to review and cosign these orders

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