From the Guidelines
Management of a blocked nephrostomy bag in the emergency department requires prompt intervention with flushing the nephrostomy tube with 10-20 mL of sterile normal saline using aseptic technique and a small syringe (10 mL) to avoid excessive pressure, as recommended by recent studies 1. The initial assessment should include evaluating the patient for signs of infection (fever, flank pain) or obstruction (decreased urine output, pain).
- Key steps in management include:
- Flushing the nephrostomy tube with sterile normal saline
- Gentle aspiration to remove any debris
- Potential replacement of the tube by interventional radiology or urology if flushing fails
- Ensuring adequate pain control with appropriate analgesics
- Administering antibiotics if infection is suspected, such as ceftriaxone 1-2g IV or ciprofloxacin 400mg IV 1
- Monitoring should include:
- Vital signs
- Urine output
- Renal function with blood tests
- Imaging (ultrasound or CT) to evaluate for hydronephrosis or tube displacement 1
- Documentation of the color, consistency, and amount of drainage before and after intervention is crucial. Nephrostomy tube blockage commonly occurs due to blood clots, sediment, or tube kinking, and prompt management is essential to maintain kidney function and prevent complications like pyelonephritis or urosepsis, as highlighted in recent guidelines 1.
From the Research
Nephrostomy Bag Block Management in Emergency Department
- Nephrostomy tubes are commonly placed for urinary obstruction, urinary diversion, or future endourologic procedures 2.
- Complications of nephrostomy tubes may occur, including tube failure, kinking, dislodgment, or migration, which can manifest with obstructive signs and symptoms 2.
- In patients with nephrostomy tubes, asymptomatic bacteriuria is common and should not be treated, but infectious symptoms should be treated similarly to complicated cystitis or pyelonephritis 2.
- Gross hematuria is common following catheter placement, but prolonged hematuria or the return of hematuria after previous resolution should trigger investigation for hematoma formation or a delayed presentation of an intraoperative vascular injury 2.
Evaluation and Management
- Clinicians should obtain laboratory testing, advanced imaging, and specialty consultation if serious complications are suspected 2.
- The majority of minor complications can be managed at the bedside without specialty consultation, but patients with more serious complications, including dislodgement, obstruction, infection, bleeding, and pleural injury, require laboratory assessment and advanced imaging with specialty consultation 2.
- Emergency percutaneous nephrostomy is a safe procedure with a high technical success rate, and is primarily indicated for relieving an obstructed and infected renal collecting system (pyonephrosis) 3, 4.
Complications and Safety
- The overall complication rate for emergency percutaneous nephrostomy is 34%, with 6% being major and 28% being minor 4.
- Major procedure-related complications include sepsis, and hematuria requiring transfusion 4.
- Minor complications include catheter displacement or malposition, pelvic perforation, paralytic ileus, pneumonia/atelectasis, and pleural effusion 4.
- Cauterization of the access tract for nephrostomy tube-free percutaneous nephrolithotomy can diminish the possibility of postoperative bleeding 5.
- Asymptomatic bacteremia can occur after long-term drainage of the kidney, and routine nephrostomy/stent change can cause frequent, asymptomatic bacteremia in patients with colonization of bacteria in the urinary tract 6.