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Vascular and Interventional Radiology |
1 From the Departments of Radiology (M.J.H., B.D.C., W.E.S.) and Pediatric Surgery, Division of Urology (V.R.J., S.A.K.), Columbus Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. Received December 13, 1999; revision requested January 24, 2000; revision received February 23; accepted March 2. Address correspondence to M.J.H. (e-mail: mhogan@chi.osu.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Percutaneous nephrostomy was performed in 102 kidneys in 87 patients at 93 separate encounters. Patients were excluded from outpatient treatment if they presented with signs of infection, were hospitalized for other reasons, were undergoing additional endourologic stone procedures, had solitary kidneys or poor renal function, had social problems precluding outpatient care, or had a procedural complication. Follow-up was performed by means of direct communication and/or chart review.
RESULTS: Successful outpatient percutaneous nephrostomy was performed in 39 (42%) of the 93 encounters. Reasons for exclusion included infection (n = 23), concomitant problems requiring hospitalization (n = 11), stone therapy (n = 7), solitary kidney with renal failure (n = 3), and social reasons (n = 10). No procedure-related complication occurred. No patient required readmission within 3 weeks for a tube- or procedure-related problem.
CONCLUSION: Outpatient percutaneous nephrostomy can be safely performed in a selected group of patients.
Index terms: Interventional procedures, in infants and children, 81.1267 • Kidney, abnormalities, 81.14, 81.81, 81.84 • Kidney, interventional procedures, 81.1267
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Our interest in discharging patients after percutaneous nephrostomy was initiated by requests from parents who wanted to take their children home after these procedures. We had not performed outpatient percutaneous nephrostomy before. At the request of these patients’ parents and with the knowledge of these prior study findings, we began a study to determine if children and adolescents could be safely treated on an outpatient basis. To our knowledge, no article describing the safety and feasibility of performing these procedures on an outpatient basis in children has been published.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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All patients were sedated. Pentobarbital sodium (Nembutal; Abbott, Abbott Park, Ill; 2–3 mg per kilogram of body weight per dose up to 7 mg/kg; maximum, 200 mg) or midazolam hydrochloride (Versed; Roche, Nutley, NJ; 0.05 mg/kg per dose up to 0.10 mg/kg; maximum, 5.00 mg) and fentanyl citrate (1 µg/kg per dose up to 3 µg/kg) were intravenously administered, or chloral hydrate (50–100 mg/kg; maximum, 2,000 mg) was orally administered. All patients underwent continuous pulse oximetry and cardiac monitoring with blood pressures obtained every 2 minutes. A pediatric radiology technologist and a pediatric radiology nurse were present to assist in all cases.
A single dose of antibiotics was administered before the procedure in all but two encounters. These antibiotics were ampicillin (25 mg/kg; maximum, 1 g) or cefazolin (100 mg/kg; maximum, 1 g) with gentamicin (2.5 mg/kg) administered intravenously or sulfamethoxazole and trimethoprim (2.5 mg/kg; maximum, 100.0 mg), cephalexin (25 mg/kg; maximum, 1 g), or amoxicillin (25 mg/kg; maximum, 500 mg) administered orally. At the beginning of the study, the type and route of prophylactic antibiotic coverage were chosen by each interventional radiologist (M.J.H., B.D.C., W.E.S.). This procedure later became standardized, and since March 1997, all patients received one dose of ampicillin (25 mg/kg, intravenous infusion) and gentamicin (2.5 mg/kg, intravenous infusion) immediately prior to the procedure.
All procedures were performed with both fluoroscopic and ultrasonographic (US) guidance. US guidance was performed with 3–8-MHz probes and an HDI 3000 or 5000 machine (ATL, Bothell, Wash). The procedures were performed by using an LCA interventional table (GE Medical Systems, Milwaukee, Wis). The technique of percutaneous nephrostomy in children has been previously described (1–8).
Sizes of nephrostomy tubes were 5-F nonlocking and 6-, 8-, or 10-F locking (Cook, Bloomington, Ind; Navarre, Plymouth, Minn; Boston Scientific/Medi-Tech, Watertown, Mass). Catheter size was determined on the basis of patient size and character of the urine, with larger tubes used when sediment or pyuria was present.
After completion of the procedure, indwelling tubes were left to drain by means of gravity either into a bag or between a set of double diapers. Tubes were secured with an ostomy wafer, 2-0 silk suture, and a sterile occlusive dressing. The patients were observed during recovery either in the radiology department or on the inpatient floor to which they had been previously admitted. When the patients were awake to their preprocedural level, they were given clear fluids. They were discharged when they could tolerate the fluids for 30 minutes. The results of the procedure were discussed with the parents. They were educated about the care of the tube—how to measure the tube output, keep the dressing and tube clean, and empty the drainage bag. They were also educated about what problems may occur, including signs of infection, hemorrhage, or mechanical tube problems.
Follow-up of the results and complications was performed by directly communicating with the patients during appointments with the urologists and interventional radiologists. In addition, charts were reviewed at the conclusion of the study. Follow-up was from 4 months to 4 years after the procedure. Institutional review board approval and informed consent were obtained.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In the 39 outpatient encounters, there were no procedure-related complications and only two late complications, both of which occurred at least 1 month after the procedure. A urinary tract infection occurred in a 4-year-old patient, necessitating hospitalization and intravenous administration of antibiotics. This infection occurred 2 months after percutaneous balloon dilation of a distal ureteral stricture, antegrade ureteral stent placement, and placement of a nephrostomy tube. In a 2-month-old patient with bilateral ureteropelvic junction obstruction, one pair of nephrostomy tubes was accidentally dislodged 5 weeks after placement. Five-French nonlocking catheters were used to connect the second pair of tubes in this patient. The first pair was dislodged, although the patient was admitted because of concerns about adequate home care after the procedure was performed.
In patients who were admitted after the procedures were performed, accidental dislodgment occurred in one patient (again admitted because of concerns about parental home care), and one patient developed a new infection 10 days after tube placement.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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There are added risks in outpatient procedures in children and adolescents compared with adults. Sedation is almost always needed, and in children and adolescents undergoing radiologic procedures, deep sedation is often required (11–13). Due to the deeper level of sedation, recovery times may be longer. We do not specify a definite time for recovery, but we do require that all patients be alert with their preprocedural neurologic status and be able to tolerate ingestion of fluids.
Younger children with limited verbal ability cannot describe pain or discomfort well. Parents are usually best at detecting clues to their children’s problems. We educate parents on what to watch for (signs of dehydration, sepsis, and hemorrhage) and provide 24-hour access to an interventional radiologist and urologist. Younger children are not able to care for the tube, and therefore the parent must assume this responsibility. Tube damage or dislodgment is a concern with active children. One set of tubes (bilateral nephrostomy tubes) was dislodged in our outpatient group.
The risk of procedure-related sepsis is a major concern (9). The incidence of sepsis is reported to be 0%–5% (4,5,8), although one study had a higher incidence of 21% (9). In that same study (9), the incidence of sepsis decreased to 9% when antibiotics were administered. In the study by Gray et al (10), antibiotics were not routinely administered, but there was no substantial increase of sepsis. We excluded 23 patient encounters (25%) from outpatient management due to signs and symptoms of infection. No patient without prior signs or symptoms of infection developed a procedure-related infection or sepsis.
Spies et al (14) have developed a guideline for the use of antibiotics in interventional procedures. Because of the concern of undiagnosed infection, the request of the referring urologists, and the previously mentioned findings (9), all but two patients received antibiotics prior to the procedure. We currently treat all patients as having a potential asymptomatic infection and administer one dose of ampicillin (25 mg/kg) and gentamicin (2.5 mg/kg) immediately prior to the procedure.
The presence of stones has been identified as a substantial risk factor in the development of sepsis, especially in patients with no signs of infection (9). In our population, only one (8%) of 13 patients with stones was treated on an outpatient basis because of the concomitant presence of sepsis or because of the need for further genitourinary intervention, such as lithotripsy (extracorporeal or transendoscopic) or nephrolithotomy and stone extraction. Seven patients with stones obstructing the urinary tract and no signs of infection prior to the procedure had procedure-related sepsis.
Patients of all ages were successfully treated on an outpatient basis. However, early in our experience, five patients younger than 2 years were admitted due to concerns about home care or about access to appropriate medical care close to home. Some of these patients may have been treated on an outpatient basis later in the study as our experience increased. Overall, the ages in the inpatient and outpatient groups were similar (Table 3).
In conclusion, outpatient percutaneous nephrostomy can be performed safely in a selected group of children and adolescents. Antegrade pyelography and the Whitaker test are already established as outpatient procedures. Candidates for outpatient percutaneous nephrostomy should not have signs of active infection, should have responsible parents who can be educated about care of the tubes, should have access to appropriate medical care near their home, should have no coexistent medical illnesses requiring hospitalization, and should have adequate renal function prior to the procedure. Parents often prefer to take care of their children at home, and on the basis of these results, we believe we can encourage them to do so.
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FOOTNOTES |
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REFERENCES |
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This article has been cited by other articles:
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  U. Patel and M. Z. Abubacker Ureteral Stent Placement without Postprocedural Nephrostomy Tube: Experience in 41 Patients Radiology, February 1, 2004; 230(2): 435 - 442. [Abstract] [Full Text] [PDF]
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 D J Roebuck Paediatric interventional radiology Imaging, December 1, 2001; 13(4): 302 - 320. [Abstract] [Full Text] [PDF]
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