B-20: Nephrostomy Catheter Placement
  • Indications
    • Urinary tract obstruction
    • Preparation for endourology
  • Contraindications
    • Contrast allergy (premedicate)
    • Uncontrolled coagulopathy
  • Patient Evaluation
    • Ability to lie prone, 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
    • 22ga. Chiba needle
    • Connecting tubing for contrast injection
    • Accustick or Jeffery access set
    • Cope (.018") and Coons wires
    • 8Fr. Cope loop catheter w/ metal stiffener (drainage), or Tegtmeyer catheter (endourology)
    • Molnar disk, #2 silk ties, Tegaderm, drainage bag and tubing, or suture if Tegtmeyer
  • Entry site
    • Antegrade pyelogram: Posterior, L1-2 level, 8-10cm lateral to midline
    • Nephrostomy: Posterolateral (medial to posterior axillary line) into a posterior calyx
  • Technique
    • Antegrade pyelogram puncture with 22ga. needle to depth of 10-12cm. Aspirate while slowly withdrawing needle until urine returns (lab specimen). Attach connecting tubing and inject contrast. In very dilated systems withdraw urine and replace with contrast in 10 ml aliquots until system is opacified.
      Nephrostomy puncture with 21ga. needle into selected posterior calyx. Pass .018" Cope wire and transitional dilator. Pass Coons wire and coil in renal pelvis. Introduce nephrostomy catheter. If endourology case, manipulate guide wire and catheter through UPJ and position catheter tip in distal 1/3 of ureter. Secure catheter and attach drainage bag (or cap Tegtmeyer catheter).
  • Post-procedure Note
    • Note type and size of catheter(s) placed, and any lab specimen sent
  • Post-procedure Orders (Nephrostomy for Drainage)
    1. Nephrostomy tube to gravity drainage
    2. Record output q shift
    3. Strict bed rest x 12 hours
    4. Check flank for bleeding or hematoma, and check VS (BP, HR, RR):
      • q 15 min x 2, then
      • q 30 min x 4, then
      • q 1 hour x 4, then
      • q 4 hours if stable
    5. Check and record temp q 2 hours x 4, then q 4 hours if stable
    6. CBC at _____p.m.; CBC and Chemistry profile at 8 a.m.
    7. H/O to write for antibiotic coverage to continue at least 48 hours
    8. Resume other preprocedure orders
    9. H/O to review and cosign these orders

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