What is the recommended protocol for flushing a nephrostomy tube?

Nephrostomy Tube Flushing Protocol

Primary Flushing Recommendation

Nephrostomy tubes should be routinely flushed with normal saline solution when not in use, with proper flushing technique being more critical than the addition of heparin. 1

Standard Flushing Protocol

Solution Selection

• Normal saline is the recommended irrigation fluid for nephrostomy tubes to prevent hemolysis, hyponatremia, and electrolyte abnormalities that can occur with other solutions 2
• Heparinized solutions may be used as a lock (after proper saline flushing) only when specifically recommended by the manufacturer or when tubes remain closed for more than 8 hours 1
• The concentration of heparin is less important than ensuring adequate saline flushing before any heparinization 1

Flushing Technique

• Use gentle pressure when flushing to avoid tube damage or overdistention of the collecting system, which can increase the risk of sepsis or retroperitoneal contamination 3
• Flush with 40-60 mL of warm water or normal saline as the initial approach 4
• The syringe must aspirate and flush with ease; resistance may indicate tube obstruction or malposition 1
• Monitor for signs of complications during flushing, including pain, swelling, or inability to flush 1

Frequency of Flushing

• Tubes should be flushed regularly when not in continuous use to maintain patency 1
• For tubes accessed infrequently, more regular flushing intervals are necessary to prevent occlusion 1
• Continuous irrigation during procedures should use normal saline exclusively 2, 5

Special Considerations for Infected Systems

Antibiotic Irrigation

• For fungal urinary tract infections with nephrostomy tubes in place, irrigation with amphotericin B deoxycholate (25-50 mg in 200-500 mL sterile water) is recommended as part of treatment for fungal balls or pyelonephritis 1
• This antifungal irrigation should be performed in conjunction with systemic antifungal therapy 1
• Consider removal or replacement of the nephrostomy tube if feasible when treating fungal infections 1

Infection Prevention

• Avoid overdistention of the collecting system during flushing, as this increases sepsis risk 3
• If purulent urine is encountered, establish drainage immediately and administer broad-spectrum antibiotics 2

Troubleshooting Occluded Tubes

Initial Management

• Attempt flushing with 40-60 mL of warm water using gentle pressure as the first-line approach, which clears approximately one-third of obstructions 4
• Position the patient upright during flushing attempts to minimize aspiration risk 4

Advanced Techniques

• If warm water fails, an alkaline solution of pancreatic enzymes demonstrates a 96% success rate in clearing formula-related clogs and can clear an additional 50% of occluded tubes 4
• Mechanical devices (Fogarty balloon catheter, biopsy brush, commercial decloggers) should be reserved for cases where enzymatic treatment fails 4
• Tube replacement should only be considered after all other methods have failed 4

Critical Safety Points

• Never use excessive force when flushing, as this can cause tube damage, collecting system injury, or dislodgement 4, 3
• Confirm intracollecting system location before aggressive flushing attempts 3
• Use only self-retaining drainage catheters to minimize inadvertent dislodgement 3
• If excessive bleeding occurs during or after flushing, tract tamponade with a balloon catheter or appropriate-sized nephrostomy tube can usually control hemorrhage 3