Nephrostomy change

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Author: Mikael Häggström [notes 1]

Main steps

Various settings of a pigtail catheter with locking string, obturator (also called stiffening cannula) and puncture needle.
A. Overview
B. Both puncture needle and obturator engaged. (not used in nephrostomy change)
C. Puncture needle retracted. Obturator engaged. In nephrostomy change, remove any puncture needle before the intervention
D. Both obturator and puncture needle retracted, when the catheter is in the renal pelvis.
E. Locking string is pulled (bottom center) and then wrapped and attach to the superficial end of the catheter.

* denotes the steps that should be done in fluoroscopy.

Preparations

  • Engage the obturator of the catheter, but loose enough so that you can remove it with one hand if needed.
  • Position the patient on the side

Removal of previous catheter

Insertion of new catheter

  • Insert the new catheter with obturator over the guidewire, keeping the same direction as the guidewire through the tissues to avoid pulling or kinking it.*
  • Enter the renal pelvis with the obturator, and then advance with only the soft catheter.*
  • If proper position of a pigtail catheter, lock the pigtail. If unsure, confirm location within the renal pelvis by injection of a few ml of contrast before fixation.*
  • Confirm functionality by injection of a few ml of contrast, two projections from different directions, looking for spontaneous dripping from the catheter when left open, as well as aspiration of the contrast.*
    Check whether there is blood or pus in the aspirate or spontaneous return.
  • Attach the outside end of the catheter to a bag.[notes 2]
  • Fixate the catheter to the skin, preferably both directly at insertion as well as enough to the side to have a soft S-shaped bend of the catheter in order to give certain room for stretching without pulling out the catheter.

Troubleshooting

Catheter in calyx

If a previous pigtail catheter is located in a calyx, push it in with a stiff guidewire (such as Amplatz). The catheter may need to be pushed from different angles, and/or be rotated.*
If this is not successful, possibly use a hydrophilic guidewire to reach the renal pelvis, on which to switch catheters.*

Cannot advance guidewire

This is probably because of kidney stones in the catheter. Possible measures:

  • Try a hydrophilic or smaller guidewire in order to get through the catheter.
  • Advance around the catheter with a larger tube
  • If the catheter has been used for weeks, it can generally be pulled out, and a new catheter inserted through the same tunnel without any guidewire.
Catheter stuck

If a previous pigtail catheter can not be pulled out after loosening of the pigtail threads, it may help to cut off the pigtail threads by the external tip, or even cutting off the entire external tip, which may loosen the threads.

Report

  • Position of the previous catheter.
  • Absence of complications, or a description thereof.
  • Type, size and position of the new catheter.
  • Color of urine. Signs of blood or pus, if suspected.

Example:

Previous/Old pigtail is located in an inferior calyx. It it pushed into the renal pelvis with an Amplatz guidewire, followed by change to a new 8 French pigtail catheter with locking string. No complications. Spontaneous return of clear urine.
See also: General notes on reporting

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
  2. Plug it only if there is a clear plan to attach a bag at a specific later time.

References