What is the best course of action for a patient with a completely displaced right nephrostomy (nephrostomy tube) tube and decreased urine drainage, who has a history of paraplegia and a chronic pressure ulcer?

Management of Completely Displaced Nephrostomy Tube

The patient requires urgent inpatient admission with immediate percutaneous nephrostomy (PCN) replacement by interventional radiology, IV hydration, empiric antibiotics, and multidisciplinary coordination with urology and wound care. 1

Immediate Management Priorities

Nephrostomy Tube Replacement

• Percutaneous nephrostomy replacement is the definitive intervention for complete tube displacement with confirmed absence of catheter in the renal pelvis. 1
• Complete displacement creates risk of urinary obstruction, which can lead to renal injury, urinoma formation, and infection—all requiring urgent restoration of drainage 1
• PCN placement has technical success rates exceeding 90% and is the standard approach for re-establishing urinary diversion when retrograde access is not feasible 1

Infection Prevention and Treatment

• Empiric broad-spectrum antibiotics should be initiated immediately given the risk of obstructive pyelonephritis and sepsis from displaced nephrostomy tubes. 1, 2
• The ACR guidelines emphasize that urinary tract decompression can be lifesaving in patients with pyonephrosis, and preprocedural antibiotics are recommended when infection is suspected 1
• Third-generation cephalosporins (such as ceftazidime) demonstrate superior clinical and microbiological cure rates compared to fluoroquinolones in infected obstructed systems 1
• Postprocedural bacteremia and sepsis are common when infected urinary tracts are drained, making antibiotic coverage essential 1

Supportive Care

• IV hydration maintains renal perfusion and facilitates urine production once drainage is re-established 1
• Pain management addresses flank discomfort from obstruction and the procedure itself 2

Critical Risk Factors in This Patient

Paraplegia Considerations

• Patients with paraplegia have impaired sensation and may not manifest typical pain responses to complications 2
• Close monitoring for signs of infection (fever, leukocytosis, hemodynamic instability) is essential as clinical presentation may be atypical 1, 2

Chronic Pressure Ulcer

• The presence of chronic wounds increases infection risk, particularly with instrumentation of the urinary tract 3
• Coordination with wound care is crucial to minimize cross-contamination and optimize overall healing 3
• Patients with chronic wounds and indwelling devices require heightened vigilance for polymicrobial infections 2

Timing and Setting

Inpatient Admission Rationale

• Complete nephrostomy displacement with confirmed absence of drainage requires inpatient management with close monitoring for obstructive complications and sepsis. 1
• The ACR guidelines specify that PCN placement urgency depends on clinical symptoms of sepsis, but complete tube displacement with obstruction risk warrants urgent intervention 1
• Failed instrumentation with delay to definitive renal drainage is a common factor associated with sepsis development 3

Procedural Timing

• Nephrostomy replacement should occur within hours of admission, not days, to prevent progression to pyonephrosis or septic shock 1, 3
• Delays of 1-8 days in establishing drainage are associated with increased sepsis rates and worse outcomes 3

Multidisciplinary Coordination

Urology Consultation

• Urology should evaluate for underlying causes of tube displacement and assess long-term urinary diversion needs 1, 2
• Consideration of alternative drainage methods (such as ureteral stenting if anatomically feasible) may be discussed, though PCN is typically preferred for re-establishing access 1

Wound Care Consultation

• Coordinate pressure ulcer management to prevent infection spread and optimize healing environment 3
• Address positioning strategies that minimize pressure on both the nephrostomy site and existing ulcer 2

Post-Replacement Monitoring

Tube Function Assessment

• Confirm adequate urine output through the new nephrostomy tube (typically >30 mL/hour initially) 2
• Monitor for signs of tube malfunction: decreased output, flank pain, fever, or leaking around the site 2

Infection Surveillance

• Serial monitoring of vital signs, white blood cell count, and inflammatory markers 1, 3
• Urine culture results should guide antibiotic de-escalation or modification 1
• Fever, persistent leukocytosis, or hemodynamic instability after tube placement may indicate inadequate drainage or sepsis requiring immediate re-evaluation 1, 3

Complications to Monitor

• Sepsis is the most serious complication of nephrostomy procedures and may contribute to mortality, particularly after failed or delayed drainage. 3
• Major hemorrhage occurs in <4% of cases but requires monitoring for hematuria, hemodynamic changes, or flank hematoma 3
• Tube dislodgement can recur, particularly in patients with limited mobility; secure fixation and caregiver education are essential 2

Common Pitfalls to Avoid

• Never delay nephrostomy replacement in complete displacement—sepsis risk increases exponentially with time to drainage. 1, 3
• Do not treat asymptomatic bacteriuria in well-appearing patients with functioning tubes, but maintain high suspicion for infection in symptomatic patients 2
• Avoid omitting preprocedural antibiotics in patients with suspected infection or high-risk features (chronic wounds, immunocompromise) 3
• Do not discharge patients with newly replaced nephrostomy tubes until adequate drainage is confirmed and infection risk is mitigated 1, 3

Patient and Caregiver Education

• Emphasize signs of tube malfunction requiring immediate attention: decreased output, fever, severe pain, or tube displacement 2
• Provide clear instructions on tube care, site hygiene, and securing the catheter to prevent recurrent displacement 2
• Counsel on the importance of scheduled tube exchanges (typically every 8-12 weeks) to prevent encrustation and obstruction 4