Nephrostomy tube placement complications of diabetes

It is essential to have a protocol for nurses to alert physicians for quick assessment and administration of antibiotics and fluids to septic patients. Management Despite increased understanding of the pathophysiology of sepsis, management has remained largely unchanged. There are three cornerstones to treatment: 1 Source control, 2 antibiotic usage, and 3 maintaining hemodynamic stability through fluids and arterial vasoconstrictors.

Source control is often the reason for the septic patient or the patient at high risk of becoming septic is sent to interventional radiology. Interventional radiologists are extremely adept at accessing fluid collections throughout the body. The question faced by interventional radiologists when dealing with a septic patient is whether or not to continue the procedure.

If the patient is stable, it could be argued that the procedure should be continued and the fluid collection drained. If, however, the patient has signs of hemodynamic instability, they may warrant further intensive care and stabilization before another drainage attempt. The answer to this dilemma will vary widely from patient to patient, institutional preference and among interventionalists.

This section will discuss management if the patient becomes septic despite prophylaxis or if they never received prophylaxis. If sepsis is suspected, broad-spectrum antibiotics are administered early, preferably after blood cultures have been drawn, but should not be delayed unnecessarily waiting on cultures.

If the patient has received prophylaxis, either repeating the dose or assuming the organism is resistant to the antibiotic and broadening the coverage are both prudent options. If a Gram-positive organism is suspected, give 1 g intravenous IV vancomycin.

If Gram-negative or mixed flora is suspected, then give 1 g ampicillin IV and 1. These individuals are more likely to be resistant to first- and second-generation penicillins and will need to be treated with third- or fourth-generation penicillins or a cephalosporin. Another consideration is the nephrotoxic side effect profile of gentamicin, especially when combined with poor renal perfusion in sepsis and the use of radiocontrast dye in interventional procedures. Instead, aztreonam or a fourth-generation cephalosporin can be administered.

Fluids act to restore intravascular volume, optimize cardiac output, and improve end-organ perfusion. Due to their higher cost and no mortality improvement, colloids are not the preferred resuscitation method. Achieving this requires L of crystalloid within the first hour and up to L over the first 24 h. Norepinephrine is the current agent preferred by critical care clinicians. Previously, dopamine was the preferred agent, but head-to-head trials have shown improved 28 days survival in patients that received norepinephrine and a 2 times higher occurrence of arrhythmias in patients receiving dopamine.

Many patients seen in interventional radiology are already septic or are at high risk of becoming septic making it quintessential for interventional radiologists to be adept at sepsis identification and initial stages in management. Judicious use of antibiotics and minimization of system disturbance can decrease the risk. Close clinical monitoring by clinicians and nurses will aid in detecting vital sign aberrations consistent with sepsis. All catheters become colonized if left in place long enough [ 23 ].

Other risk factors. Other risk factors for candiduria include extremes of age, female sex [ 24 ], use of immunosuppressive agents, use of iv catheters, interruption of the flow of urine, radiation therapy, and genitourinary tuberculosis [ 22 ]. Microbiology As stated above, the overwhelming majority of fungal infections of the urinary tract involve Candida species. In a large multicenter study by Kauffman et al.

The second most common pathogen found in [ Storfer et al. Risk factors for C. Virtually all epidemiologic studies, both prospective and retrospective, have concluded that, although C. Pathogenesis Ascending infection. Ascending infection is by far the most common route for infection of the urinary tract.

Catheterization can cause infection by introducing organisms during the catheterization process or by allowing migration of organisms into the bladder along the surface of the catheter from the external periurethral surfaces.

Ascending infection that originates in the bladder can also lead to infection of the upper urinary tract, especially if vesicourethral reflux or obstruction of urinary flow occurs, and it may result in acute pyelonephritis and, rarely, subsequent candidemia.

A fungus ball consisting of yeast, hyphal elements, epithelial and inflammatory cells, and, sometimes, renal medullary tissue secondary to papillary necrosis may complicate ascending or descending infections; the fungus ball tends to be found in dilated areas of the urinary tract, especially in the presence of obstruction and stasis. Hematogenous infection. Hematogenous spread is the most common route to result in renal infection i. Isolated hematogenous renal infection after transient candidemia can occur, and often when renal candidiasis is suspected, blood cultures are no longer positive.

Diagnosis The finding of Candida organisms in the urine may represent contamination, colonization of the drainage device, or infection [ 29 ]. Contamination of a urine specimen is common, especially if the specimen is a suboptimal urine collection from a catheterized patient or a woman who has heavy yeast colonization of the vulvovestibular area.

Given the capacity of yeast to grow in urine, a small amount of yeast that finds its way into the collected urine sample may multiply quickly. Therefore, high colony counts could be the result of yeast contamination or colonization. There is, as yet, no reliable method for differentiating colonization from infection.

Simply finding or culturing the organism does not imply clinical significance, regardless of the concentration of organisms in the urine. Given this phenomenon, some clinicians require confirmation of Candida presence by means of a second urine sample examination before they initiate treatment or further investigation, especially for the asymptomatic patient. Infection is caused by tissue invasion, both superficial and deep. Kozinn et al. Although pyuria usually reflects and supports the diagnosis of infection, in the presence of a urinary catheter, pyuria can be explained by mechanical injury of the bladder mucosa by the catheter and is frequently the result of coexistent bacteriuria.

Similarly, the number of yeasts in urine has little value in localizing the anatomic level of infection. Rarely, a granular cast containing Candida hyphal elements is found in urine that localizes the infection to renal parenchyma. Declining renal function suggests urinary obstruction or renal invasion [ 4 ]. For patients with sepsis who have candiduria, not only is it necessary to obtain blood cultures, but, given the frequency with which obstruction and stasis participate in the pathogenesis of candiduria, it is essential to perform radiographic visualization of the upper tract.

Any febrile patient for whom therapy for candiduria is considered necessary should be investigated to find the anatomic source of candiduria. In contrast, patients without sepsis require performance of no additional studies unless candiduria persists after the removal of catheters. Clinical Manifestations Asymptomatic candiduria. Asymptomatic candiduria most often occurs in hospitalized patients with indwelling catheters. These patients usually show none of the signs or symptoms associated with UTI.

Lower UTI cystitis. Symptomatic lower UTI is uncommon and may present with signs and symptoms of bladder irritation, including dysuria, hematuria, frequency, urgency, and suprapubic tenderness. Cystoscopy, although rarely indicated unless a fungus ball is suspected or ascending infection occurs, reveals soft, pearly white, elevated patches with friable mucosa underneath.

Hyperemia of the bladder mucosa is common [ 32 ]. Symptomatic Candida cystitis is extremely rare in catheterized patients, given the frequency with which candiduria occurs, which implies that the bladder is relatively resistant to invasion by Candida species.

Similarly, symptomatic Candida cystitis is rare in noncatheterized patients. Emphysematous cystitis is a rare complication of lower UTI, whereas prostatic abscess caused by Candida species is by no means uncommon, especially among patients with diabetes [ 33 , 34 ]. Upper UTI. Patients with infection of the upper urinary tract present with fever, leukocytosis, and costovertebral angle tenderness.

On clinical grounds, ascending pyelonephritis and urosepsis with Candida species is, therefore, indistinguishable from bacterial pyelonephritis and urosepsis. Ascending infection almost invariably occurs in the presence of urinary obstruction and stasis, especially in patients with diabetes or nephrolithiasis.

Candida pyelonephritis is often complicated by local suppurative disease, resulting in pyonephrosis as well as focal abscess formation, which can often be diagnosed by use of ultrasonography and CT. A major complication of upper urinary tract involvement is obstruction caused by fungal balls bezoars , which can also be visualized on an ultrasonograph [ 35 ].

Papillary necrosis has also been shown to occur as a complication of upper tract infection. Renal candidiasis. Patients with hematogenous seeding of the kidneys caused by candidemia may present with high fever, hemodynamic instability, and variable renal insufficiency. Blood culture results are positive for Candida species in half of these patients. Retinal or skin involvement may suggest dissemination [ 36 ], but often the only clue to systemic candidiasis in a febrile patient with high risk of systemic candidiasis is candiduria and a subtle decline in renal function.

A means for diagnosing invasive candidiasis continues to elude us. Management Asymptomatic candiduria. The most common approach to management of asymptomatic candiduria is to attempt to modify the risk factors table 1. This approach includes control of diabetes, and if possible, the removal of indwelling catheters and discontinuation of antibiotics. Table 1 Open in new tab Download slide Means of treating patients with candiduria. A prospective study by Rivett et al. Ang et al.

In a recent prospective, multicenter, placebo-controlled study, Sobel et al. In a smaller retrospective study, Storfer et al. In the study by Sobel et al. Nonetheless, the rate of eradication in patients who received fluconazole in this study was similar to rates obtained in patients who received amphotericin B or fluconazole in similar studies [ 12 , 13 , 38 ]. Candiduria should be considered a complicated UTI; hence, when treatment is indicated as described below, therapy should not be of short duration or of low dose.

Sobel et al. Although it was anticipated that patients infected with non-albicans Candida species, especially C. The failure to demonstrate a different outcome among patients who were infected with C. Fluconazole, in contrast to other azoles, achieves high concentration in the urine—usually fold higher than concentrations in the serum.

The MIC50 of C. Given the benign nature, the infrequency of secondary candidemia, and the frequency of asymptomatic candiduria, data now exist that treatment is neither indicated nor particularly effective in the long term [ 13 , 27 ]. Nevertheless, treatment of asymptomatic candiduria is suggested for patients who have undergone renal transplantation, in low-birth-weight infants, and for patients who have or have had neutropenia, and it should be considered as a prophylactic measure for patients who are about to undergo invasive urologic procedures.

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Both will require frequent replacement, usually every weeks, due to very rapid encrustation which is peculiar to pregnancy. Urinary Diversion Healing of injured urinary tract tissue, such as in the setting of urinary leak or fistula and hemorrhagic cystitis, may be accelerated if urine is preferentially rerouted away from the region of inflammation through bilateral nephrostomies.

Urinary urokinase tends to promote bleeding which can be eliminated with bilateral nephrostomies. This is limited to severe and refractory cases of hemorrhagic cystitis. Pyeloplasty or urethroplasty may relieve a stricture that developed secondary to inflammation from stones, trauma or other causes. Stent insertion may allow a fistula to heal.

Direct administration of a highly concentrated medication may help treat resistant infections e. Percutaneous renal access can also help with uretero-enteric anastomotic strictures in post-cystectomy patients as retrograde access across such strictures is very problematic. Antegrade nephrostograms can readily identify the location and nature of ureteral obstructions not easily imaged otherwise.

The Whitaker test involves percutaneous puncture of the kidney with or without insertion of a catheter to measure pressure within the system. First described in , the Whitaker test is designed to differentiate obstructed, hydronephrotic renal units from those with dilated but unobstructed ureters.

Through a percutaneous catheter, fluid is infused while the intrapelvic pressure is measured via a catheter. A gradient pressure of 22 mm of water or more indicates obstruction while 15 mm or less indicates no obstruction. Pressures between 22 and 15 mm are considered indeterminate. Contraindications PCN should be avoided or delayed in certain circumstances but there are no absolute contraindications. Transurethral access should generally be considered as the first line whenever feasible to avoid the risks inherent with new percutaneous access procedures.

Reconsider the procedure if the patient has a predicted very short-term survival. Untreated urinary tract infections are a relative contraindication. Attempting PCN on a non-dilated system may be deferred temporarily if there is a chance that the calyces may increase in size with a short delay to make the procedure easier and possibly safer.

Certain factors may need to be addressed prior to attempting the procedure, such as risk factors for hemorrhage and complications from sedation as discussed below. Patients with obstructed urinary tracts may have renal dysfunction resulting in hyperkalemia, which can destabilize cardiac myocytes and cause a life-threatening arrhythmia if not addressed urgently. In the setting of severe hyperkalemia i.

During informed consent for the procedure, make the patient aware of the likelihood of having a new foreign body that requires maintenance for weeks or months and may necessitate prolonged nursing or family medical support with limited lifestyle functionality. The unwillingness of a patient to accept this or to accept the risks of the procedure is a contraindication to the procedure.

Specific concerns must be addressed before attempting the procedure, such as the risks of hemorrhage and complications from sedation, with such risks mitigated if possible. The Society of Interventional Radiology SIR provides a list of recommendations for the cessation of antiplatelet and anticoagulant medications for interventional radiology procedures which it categorizes based on hemorrhage risks from level 1 to level 3.

These recommendations are discussed below under "Preparation. For level 3 procedures, the SIR recommends that the international normalized ratio be no greater than 1. The SIR also lists anticoagulants that should be withheld or their side effects medically corrected to reduce bleeding risks. Any dose of aspirin is recommended to be withheld for 5 days. Enoxaparin at prophylactic doses does not require delaying the procedure, but at therapeutic dosing should result in scheduling the procedure 24 hours later than the most recent dose when possible.

Determination of periprocedural anesthesia risk is site dependent. Many hospitals require physicians to assess the patient using the American Society of Anesthesiology ASA physical classification system and a Mallampati score. Perioperative Medicine.

London: Springer-Verlag; Pre-procedure antibiotics are given an hour before the procedure if there is a suspicion of an infected collecting system, which is frequently the setting in which the request for PCN is made. The main bacteria to cover empirically are gram-negative Escherichia coli, Proteus species, and Klebsiella species as well as gram-positive Enterococcus. Less common, but often resistant to early generation penicillins and cephalosporins, is Pseudomonas, a gram-negative rod with a beta-lactamase.

Usually, anaerobic coverage is not needed. The SIR [17] lists 4 first-line antibiotic options, all of which contain a cephalosporin or penicillin, but not all of which typically provide coverage for Pseudomonas. The AUA Best Practice Policy recommends a first or second generation cephalosporin, or clindamycin, or gentamycin and metronidazole. Hyperkalemia or metabolic acidosis may induce arrhythmias.

In this situation, it may be judicious to review an ECG. When punctures are poorly placed, there is a greater risk of complications. This may impede the success of future interventions. Therefore, a cautious approach should be taken without too much guarantee of where needle placement will be attempted until imaging confirms the anatomic layout and what options for a planned puncture route are available and ideal.

The median time to onset of infection was 42 days. The most common organisms encountered were Pseudomonas spp. The median length of follow up of PCN tubes after exchange was 55 days. The provision of discordant antibiotics preceding PCN exchange was significantly associated with recurrence of infection Conclusion Discordant antimicrobial therapy provided during PCN exchange, in the setting of a PCN infection is associated with a higher rate of relapse.

Therefore, to decrease the high rate for PCN reinfection, we propose that prior to PCN exchange secondary to infection, patients should be receiving concordant antimicrobial therapy. Disclosures All authors: No reported disclosures. This content is only available as a PDF.