What are the guidelines for managing a patient with a nephrostomy tube?

Management of Patients with Nephrostomy Tubes

For patients with nephrostomy tubes, proper management includes regular catheter care, monitoring for complications, and consideration of tube removal or replacement when appropriate, with the primary goal of maintaining adequate renal drainage while minimizing infection risk.

General Nephrostomy Tube Care

Daily Care Requirements

• Clean the peristomal area daily with soap and water
• Keep the skin around the tube clean and dry
• Inspect the site daily for signs of infection, leakage, or skin breakdown
• Secure the tube properly to prevent accidental dislodgement
• Maintain closed drainage system to prevent infection

Monitoring Parameters

• Monitor urine output (color, clarity, volume)
• Check for fever, flank pain, or other signs of infection
• Assess renal function periodically through laboratory tests
• Evaluate tube patency regularly

Managing Common Complications

Tube Obstruction

• Signs: decreased or absent drainage, flank pain, fever
• Management:
  • Gentle irrigation with 5-10 mL sterile normal saline if permitted
  • If irrigation fails, urgent intervention radiology or urology consultation
  • Never forcefully irrigate an obstructed nephrostomy tube 1

Infection Management

• For suspected infection (fever, cloudy urine, flank pain):
  • Obtain urine culture from the nephrostomy tube
  • Start empiric antibiotics covering gram-negative organisms
  • For fluconazole-susceptible fungal infections, use oral fluconazole 200-400 mg daily for 2 weeks 1
  • For fluconazole-resistant Candida species, consider amphotericin B deoxycholate 1
  • In cases of fungal balls, irrigation through nephrostomy tubes with amphotericin B deoxycholate (25-50 mg in 200-500 mL sterile water) is recommended 1

Tube Dislodgement

• If dislodgement occurs within 1-2 weeks of placement:
  • Cover site with sterile dressing
  • Immediate urology/interventional radiology consultation
  • Do not attempt replacement without imaging guidance
• If tract is mature (>2-4 weeks):
  • Replacement may be possible by experienced clinicians 2
  • Maintain safety wire during complex manipulations 3

Bleeding

• Minor bleeding or hematuria is common after placement (28.6% in minimal hydronephrosis, 4.9% in severe hydronephrosis) 4
• For significant bleeding:
  • Monitor hemoglobin/hematocrit
  • Consider tract tamponade with balloon catheter if active bleeding
  • Arteriography and selective embolization may be needed for persistent bleeding 3

Special Considerations

Patients with Cancer

• Higher risk of nephrostomy-related pyelonephritis (19% within 90 days) 5
• Risk factors include:
  • Prior urinary tract infection
  • Neutropenia
• Consider prophylactic antibiotics in high-risk patients 5

Timing of Tube Exchange/Removal

• Allow 1-2 weeks for initial nephrostomy tract to mature before conversion to internal drainage 2
• Consider tube exchange every 4-12 weeks depending on:
  • Tube material
  • Urine characteristics (presence of sediment, infection)
  • Underlying condition

Conversion to Internal Drainage

• For patients with benign obstruction, consider conversion to internal ureteral stent after tract maturation
• Contraindications for immediate conversion include 2:
  • Pyonephrosis or sepsis
  • Complete ureteral transection
  • Complex anatomy requiring specialized planning
  • Patient instability

Prevention of Complications

Infection Prevention

• Maintain closed drainage system
• Use aseptic technique when manipulating the tube
• Consider antibiotic prophylaxis before tube manipulation in high-risk patients
• Ensure adequate hydration to maintain good urine flow

Preventing Dislodgement

• Secure tube properly with appropriate anchoring device
• Educate patient about movement restrictions
• Consider using self-retaining drainage catheters to minimize risk of dislodgment 3

Technical Considerations for Placement

• Optimal approach includes:
  • Adequate visualization of calices
  • Puncture below the 11th rib when possible
  • Puncture at the tip of a posterior calix from a 20-30° posterolateral oblique approach
  • Single-wall puncture of the calix 3

Follow-up Care

• Regular outpatient follow-up every 1-3 months
• Periodic imaging to assess for resolution of underlying condition
• Evaluate for possible removal when obstruction resolves
• Monitor renal function with regular laboratory tests

By following these guidelines, healthcare providers can effectively manage patients with nephrostomy tubes while minimizing complications and optimizing outcomes related to morbidity, mortality, and quality of life.