Percutaneous Nephrostomy Treatment

Introduction 

The kidney is an essential organ in the human body involved in the critical physiological processes of the body such as osmoregulation, pH regulation, and excretion of waste as well as productions of hormones. Human beings are served by a pair of kidney, however, in the extreme cases arising from the health issue problems; a single kidney can still perform its functions diligently. Like any other body organ, kidneys can fail; the failures may be temporary or permanent depending on the swiftness and quality of medication. There exist a plethora of kidney diseases; such coming out naturally while others caused the general human behavior and practices. Various treatment procedures have been developed to improve the quality of medical services, such approach, the recently developed Percutaneous Nephrostomy. This treatment procedure works especially for the patients with a blockage in the urinary system or infection in the kidney, it works best through the insertion of a tube, catheter, through the skin into the kidney with aim of decompressing the kidney. To understand the working of the treatment procedure, building knowledge on the anatomy of the kidney and its physiological process is quite essential. 

Goal 1: Anatomy of the Kidney 

The kidney is located between the transverse processes of the twelfth thoracic vertebrae and the third lumbar (t12-l3) with the left kidney superior raised than the right. The renal system consists of kidney, ureter, urinary bladder and the urethra among other essential components discussed below 

The kidney is a bean-shaped organ highly vascularized located on both sides of the spine approximately 150 grams for an adult male and slightly lighter for the females. The renal artery is the main blood inlet into the kidney and usually, the blood coming into kidney is intoxicated with wastes. The kidney is surrounded by the outer membrane called the renal capsule; the membrane is made of tough fibers and collagen that help to protect kidney and its content from external damage. The renal artery enters the kidney through the hilum, inside the kidney it divides into two main branches which subdivide into tiny arteries for which the blood to flow to the nephrons. Working contrary to the functions of the renal artery is the renal vein, “it removes the filtered blood from the kidneys to the inferior vena cava” (Schnilder, 2017). The renal veins are smaller than the arteries usually carries already purified blood in which all the wastes have been filtered in the kidney. Inside the kidneys is basin-like structures called renal pelvis, they are located toward the narrow of the ureter and their functions include acting as a reservoir for urines from the kidney. 

The calyx is basically an extension of the renal artery; a typical kidney consists of 6-10calyces that form the beginning of urine collection. Another critical and conspicuous component of the renal cortex, which is “the outer region of the kidney; extensions of the cortical tissue, contains about one million blood filtering nephrons” (Schmilder 2017). It is in the cortex that the renal corpuscles and the renal tubules are located. The cortex is also well vascularized as there are blood vessels running through it, similarly, there is the presence of cortical collecting ducts. The inner part of the kidney is referred to as the medullary pyramids and is formed by the collecting ducts; a kidney has between 8-12 renal pyramids. 

An essential component of the kidney is the kidney nephrons, all the activities and functions of the kidneys are discharged in the nephrons. A properly functioning kidney has about a million nephrons. The nephrons are located at the tail end of the multi-divided thin blood vessels; each nephron consists of a long tubule called the loop of Henle extending downwards about 30-55mm. At one end of the tubule is the cuplike structure called the Bowman’s capsule consisting of microscopic blood vessel called the glomerulus. The high pressure exerted in the glomerulus comes from the blood supply from the capillaries making the ultrafiltration process to take place effectively. During the ultrafiltration process, there is the removal of water, ions: sodium, chloride, calcium, potassium, magnesium, phosphate, bicarbonate amino acids, and glucose and other substances such as creatinine and urea. The blood enters the glomerulus through the afferent arteriole and leaves through the efferent arteriole. 

The filtrates of the glomerulus process enter the distal convoluted tubules where re-absorption of the essential components is done. The loop of Henle found in the renal medulla is the filtrate is concentrated through absorption of the water molecule. The collecting tubule is the final stage where a last bit of filtration takes place before entering the ureter. 

The ureter acts as a collecting duct for the filtrates coming from the collecting tubule and urine from renal pelvis and takes it to the bladder for urination. The ureter exist in pairs of muscular ducts with narrow lumina channels the urine to the bladder. 

Function of Kidney 

A properly functioning kidney of a mammalian has its activities well cut out to include the homeostasis and the extensive role in maintaining the blood pressure. The duties of the kidney are also extended to encompass critical role in the maintain balance in electrolytes, acid-base, and fluid in the blood. Removal of waste products such as the nitrogenous waste, excess salt and water also falls under the purview of the bean-shaped kidney. 

Maintaining the body entails balancing the intake of substances with the removal. Substances such as water and the electrolyte counts in the blood, water, Ph and temperature are essential in the body, however, if their levels are not checked; the person may likely to suffer the conditions resulting from excess accumulation or deficiency of the substances. It is in striking the balance between the deficiency and the excess that the kidney comes into importance. Elsa Bello-Reuss and Luis Reuss (1983) asserts that “the kidneys have a central role in the homeostasis of water and electrolytes, i.e., in the maintenance of volume and ionic composition of body fluids.” This role is enabled by the changes happening within the kidney that respond to the needs of the body. Regulating the water balance in the body takes the renal excretion of water and electrolytes. The kidney nephrons play a significant role in the homeostasis, “the large changes in urine volume and composition which occur in response to alterations in the diet” (Bello-Reuss & Reuss, 1983). The homeostatic functions of the kidney include the control of the balance of water, sodium, chloride, potassium, calcium, magnesium, hydrogen ions, and phosphate. Depending on the person, their health and location, the process of water re-absorption vary, usually; the variation is caused by the variation in the length of the distal tubules and the loop of Henle. 

Another essential function performed by the kidney is the renal excretory purposes. The excretory process involves the removal or elimination of waste products that otherwise would tremendously impact to the body, some of the waste products removed through the kidney includes the acid catabolism), creatinine (end product of creatine metabolism), metabolites of hormones, and foreign chemicals and their derivative. In performing this function, the nephrons are extensively engaged; the arrangement is intimately related to the functional properties of the organ. Bello-Reuss and Reuss (1983) note that the “first capillary segment (glomerulus) has a high a luminal hydrostatic pressure, as compared to other capillary systems because it is interposed between two arterioles, ., resistive vessels. Therefore, filtration is favored at this level.” The processes of ultrafiltration and re-absorption are the significant determinants of the excretion process for which the kidney does at its best. 

Another critical function of the kidney is the blood pressure regulation. Normally, the kidney operates under certain levels of blood pressure in order to perform its functions such as ultrafiltration and re-absorption. Changes in the blood pressure can generally have a great impact on the normal operations in the body, to ensure balance, the kidney “a blood vessel-constricting protein (angiotensin) that also signals the body to retain sodium and water” (Schmidler, 2017). The blood pressure can be regulated through the hormones produced by the Kidney, for instance, the renin. 

The anatomy of the kidney and the functions it performs are crucial in understanding the treatment process and the need for urgency is needed while selecting the treatment process. Therefore, in the use of various intervention procedures, it is good to have the general knowledge of the essential functions of kidney and the best radiological surgery such as Percutaneous Nephrostomy should be considered. 

Goal 2: Indications needed to perform Percutaneous Nephrostomy 

Percutaneous Nephrostomy is radiological and surgery process performed help the patient recover from their kidney problem. It is the passage of a catheter through the skin into the kidney to administer treatment, the process requires specialized skills from a trained person, it is very complicated and cannot be performed every given need or problems with the kidney. Carrying out a Percutaneous Nephrostomy is normally triggered by certain health conditions of the patients; however, certain indications are needed before the treatment is administered. Generally, there are four broad indications that necessitate the Percutaneous Nephrostomy treatment; these are (1) relief of urinary obstruction, (2) diagnostic testing, (3) access for therapeutic interventions, and (4) urinary diversion. 

Relief of urinary obstruction 

The relief urinary obstruction is among the common indicators of Percutaneous Nephrostomy. Urinary obstruction is the health condition caused by a blockage in the urinary tract that inhibits the flow of urine through its normal path. It may occur in the parts of the urinary systems such as the kidneys, ureter, bladder, and urethra. The blockage is normally caused by the arrangement of factors such as polyps in the ureter, the blood clot in the ureter and tumors in or near the ureter among other factors. The effect of this is increased pressure in the urinary systems and lowers the flow of the urine. The occurrence of the obstruction may be sudden or systematically develop over given period of time. The urinary obstruction may affect both kidneys and just one at one at a given time, moreover, the blockage on the urine system may be full to the extent no urine is through at all just a partial blockage in which the flow of urine is much slower than the normal process. There are several classifications of the urinary obstruction; Dagli (2011) notes that “the three most common causes of renal obstruction in adults are urinary stones, malignancy, and iatrogenic benign stricture.” These types of obstructions may vary in terms of the symptoms they exhibit and the demography of the people they attack. 

The causes of the urinary blockage vary mostly according to the victim, for children it may be a birth defect while the young adult may experience it as result of stone in the kidney or ureter. The relief urinary obstruction has its own unique symptoms; however, the typical symptom is a flank pain. The growth of obstructions may be very fast, moderate or slow, nonetheless, the faster the rate of development, the intensity is the pressure mounted on the renal capsule and the greater is the pain caused to the patients. An abrasive process irritating the sensitive urothelium, such as a “stone will also produce a flank pain. However, a slowly developing partial obstruction, such as due to malignancy, may be painless and only incidentally discovered on imaging” (Dagli 2011). Generally, any kind of obstruction causes a lot of pressure on the kidney as the urine is removed. Being a waste product, the urine consists of poisonous elements which if left in the urinary for long, may gradually affect the operations of the kidney. 

Diagnostic Testing 

Under diagnostic testing, the aim is to differentiate between the unobstructed from obstructed dilated upper urinary tract. “Contrast is infused at a steady rate through the nephrostomy while the pressure gradient between the renal pelvis and the bladder is measured” (Dagli 2011). From the test, a gradient is established and a comparison against a set benchmark is made. Usually, a gradient greater than 22 mm H 2 O or less than 15 mm H 2 O suggests obstructed or unobstructed systems, respectively. There exist a wide spectrum of diagnostic methods that can be used an indicator for Percutaneous Nephrostomy, the may include the latest and the preferred less-invasive diagnostic methods such as diuretic renography and the Whitaker test. 

Urinary Diversion 

Urinary diversion is the systematic rerouting of the urine flow from the body as a result of blockage faced in a section of the urinary tract. There are two main types of urinary diversion, the non-continent and the continent urinary diversion, the former involves linking the ureter to a piece of intestine that is brought out of the belly where the urine drains outside the body through an ostomy bag. For the continent urinary diversion, there are two main approaches that the surgeon may consider, “those that have a stoma brought out of the belly and those in which a neobladder is made, with a surgical stoma, you will need to insert a tube into the stoma to drain the urine 4 or 5 times a day” (urologyhealth.org). The two types of continent urinary diversions are admired because of the patient do not have to use ostomy bags at all. 

Generally, urinary diversions do arise as a result of medical conditions and diseases, the ureteral leak, fistula and hemorrhagic cystitis are some of the common health problems may easily lead the patient to the problem (Dagli 2011). For urinary diversion, however, patients still have health problems making it very difficult for them to operate normally, this makes the approach just a temporary one and an indication that Percutaneous Nephrostomy treatment is needed. The urinary diversion caused Hemorrhagic cystitis, the symptoms may be exhibited long after the condition has begun, and it is characterized by persistent hematuria most commonly occurs in the oncology population secondary to bladder epithelial and vascular damage. “Nerve damage severe enough to require permanent urinary diversion generally occurs from multiple sclerosis, among other diseases; spinal cord injuries; and damage caused by pelvic trauma or radiation injury” (niddk.nih.gov). In addition, there are cases of permanent urinary diversion arising from cases of advanced bladder cancer; the bladder is usually damaged to the extent that leakage is experienced, the symptoms of this condition include birth defects or chronic or long-lasting inflammation. 

Access to Therapeutic Interventions 

Therapeutic interventions are deliberate efforts by individuals or a group to improve the health of the patient is in dire need of medication or treatment but refuses or is unable to get access. Through such as actions, the patient’s conditions can be assessed and the consideration for Percutaneous Nephrostomy treatment be made. Dagli (2011) notes that PCN access may be “necessary for the management of renal stones, percutaneous therapy of upper tract urothelial cancer, and the extraction of fragmented ureteral stents that cannot be removed through a retrograde approach,” this enables the realization of the condition in the patient. Through therapeutic intervention, the common indications for Percutaneous Nephrostomy such as stones may be discovered. There are several diseases and disorders who therapeutic interventions may give an indication for the need of the PN treatment. The treatment of renal and lumbar ureteral calculi may lead to the formation of obstructions in the urinary tract 

RENAL TRANSPLANTS 

Renal transplant is a delicate medical process that in not done in the right approach usually leads to the leakage or urinary obstruction. Whereas the chances of complications arising from renal transplants are few and in most cases less than 10 percent, the symptoms arising from the problem indicates the need for PN treatment. Like any other process, the renal transplant complications usually affects the distal ureteral. Dagli (2011) remarks that “the distal transplant ureter receives blood only from an arterial branch descending from the renal hilum,this makes it prone to ischemia secondary to surgical manipulation.” The real transplant obstruction may also be necessitated by the kinking, compression by an external mass or fluid collection, calculi, and postsurgical fibrosis or adhesions. The renal transplant obstruction or leakage depicts certain symptoms, these may include extreme pain and swelling as well as a “leakage of fluid from the surgical incision, rising creatinine, or an ultrasound showing a perinephric anechoic collection in association with hydronephrosis” (Dagli 2011). The leakages may arise from different structures within the urinary system. 

Summary and Reflection 

Indicators are good measures through which a consideration for medication and treatment is made. For Percutaneous Nephrostomy, there are several indicators that all borders to the health condition of the patients usually arise because of the health problems or diseases on the part of organs in the urinary system. Some of these indicators may be medication processes or simply problems in the system. The common indications for PN treatment include relief of urinary obstruction expressed in the form of Urosepsis or suspected infection, acute renal failure and intractable pain. Others include urinary diversion, access for the endourologic procedure and diagnostic testing as well as a renal transplant. 

The indicators of PN treatment suggest that any form of blockage in the urinary system may be catastrophic in the long to the patient and quick actions should be taken in order to prevent the kidney from failing. Furthermore, health treatments should be done delicately and extreme care should be exercised in order to present the aftermath that may result to leakage in the urinary system or other essential parts of the body that may have a direct implication on the normal operation of the kidney. 

Goal 3: Contraindications for Percutaneous Nephrostomy 

The treatment through the Percutaneous Nephrostomy at times can be withheld, this because of either the dissatisfaction of the patient with the process or the side effects of the medical processes. Generally, there no absolute contraindications for Percutaneous Nephrostomy, but the common contraindications are the bleeding diathesis (most commonly, uncontrollable coagulopathy), uncooperative patient and severe hyperkalemia. 

Bleeding diathesis 

Bleeding diathesis is a relative contraindication in which the patient is characterized by abnormal bleeding, however, the condition can only be corrected through various medication processes. Usually, the bleeding diathesis occurs to the uremic patients and is primarily seen due to abnormalities in primary homeostasis, particularly platelet function disorder and impairment of the platelet-wall interaction that occurs as a result of PN treatment. The treatment causes abnormal bleeding from the vital organs of the body such as the kidney, the vulnerability of the patient is further increased by the strategies and the procedures used in the PN treatment. The treatment includes various such as percutaneous nephrolithotomy (PCNL) which is a standard procedure performed in patients with kidney stones, “although prone to bleeding more than most of the widely performed surgical procedures, there are not much data regarding PCNL in patients with bleeding disorders or coagulation defects” (Zumrutbas et al 2016). The bleeding diathesis is quite a rare occurrence; it is normally common among people with the special conditions of common coagulation defects, including hemophilias. 

The coagulation disorder another name for the bleeding diathesis can be detected through a number of means, if a patient has a hemorrhage before then they are more likely to experience bleeding diathesis during or after the PN treatment. Similar it can be realized through other means such as a high amount of hemorrhage after minor or major surgical procedures such as circumcision, tonsillectomy, labor and delivery, menses, dental procedures, menses and injections, and trauma, in daily life, excessive bruising or excessive bleeding. Such observations made from experiences from daily life may influence the decision on the practicality of the PN treatment to a given patient. 

While PN treatment for patients with symptoms of bleeding diathesis may be withheld or completely terminated because of the safety, there is various mechanisms through which the tests can be administered to ascertain the risk and evaluate the condition of the patient. First, the bleeding time is the screening test for the coagulation which helps in determining any disorders of platelet-vessel wall interactions. Similarly, platelet counts also play a vital role as a screening test for the coagulation. Other critical methods used are the PT (prothrombin time) and the PTT (partial thromboplastin time), whereas the former “measures the integrity of the extrinsic and common pathways of coagulation” (Zumrutbas et al 2016), the latter differs slightly in that it measures the integrity of the intrinsic and common pathways. The accuracy of the PT and PTT is quite astonishing, it levels to less than 30 percent of normal and only detects more severe factors of deficiencies. 

This condition makes it very difficult to employ the use of PN treatment because the implication might be disastrous; however, the less invasive aspects of the PN treatment such as RIRS should be considered purposely to decrease the risk of bleeding before the treatment is commenced. 

Uncooperative patient 

The PN treatment process is usually a delicate process that requires the full cooperation of the patient for it to be successful. One of the contraindications of the treatment is the existence of uncooperative patients. Being the treatment requires a continuous monitoring of the patients and administration of various medications, the actions of the patients may greatly define the possibility of the continuity of treatment of termination. The treatment process generally varies according to the nature and condition of the patients, there are those admitted at the treatment facilities and the outpatients, both kind of patients, however, have some obligations that they should achieve and terms they should adhere to failure to which the treatment might be discontinued. 

The uncooperativeness of the patients is usually experienced more during the medication period. The treatment of most patients’ tend to stagnate or be withheld at this stage because of the patients poor cooperation with the medical procedures and demands, as it is required that patients should receive broad-spectrum parenteral antibiotics, many would avoid taking such medications according to the requirement. 

Another factors influence the unresponsiveness of the patients towards the general treatment process, first, for women, the biological orientation of the body during the pregnancy and post pregnancy period greatly impact the applicability of the PN treatment process, “during pregnancy, nephrostomy is limited to only selected individuals, such as those with symptomatic renal obstruction and an inability to access the kidney from the bladder” (urologyhealth.org). The effects of the process thus result in the withdrawal or postponement of the treatment. Patients may generally fail to cooperate with the process because of the side effects of the drugs and the medical procedures, “drug contraindications include corresponding drug allergies and urinary tract infection in an elective setting, hepatic failure, and renal failure” ((urologyhealth.org). The patients’ uncooperative approach to the process could also be informed by the factors such as old age, the high cost of treatment and the tedious processes involved as well as the development of other diseases and health disorders rising because of the treatment. 

Severe hyperkalemia 

Severe hyperkalemia is the conditions arising as result of extremely high levels of potassium in the blood, at its severe level; it can easily lead to cardiac arrest and even death. Potassium is an essential element in the functioning of the kidney as it plays an active role in the control of the smooth muscles in the critical organs of the body. Similarly, the potassium essential is an element in maintaining the blood’s electrolytic levels. The control of the potassium levels is the reserve of the kidney, any interference in the normal operations of the kidney either through a medical process or disorder directly impacts to the levels of potassium in the body for which either reduction or increase have effects to the body. Patients with hyperkalamia are at greater risk if exposed to PN treatment, Dagli (2011) notes that patients with “life-threatening electrolyte or metabolic disorder such as hyperkalemia with significant electrocardiogram changes (particularly if K >7) or severe metabolic acidosis should undergo emergent dialysis.” This would be safer and reliable as it alleviates the life threats than drainage. 

This disorder normally occurs as result of various problems such as obstructive diseases of the urinary tract, transplant rejection, acute and chronic renal failure and medications that can increase blood potassium levels such as PN. In addition, the disorder can be compounded by kidney dysfunction. The presence of this disorder can be observed through various symptoms that are also supposed to be used as an indicator for withholding the PN treatment. When the patient shows the signs of nausea, fatigue or muscle weakness during treatment, swift precautionary measures should be taken. Other patients may slow heartbeat and weak pulse as well as tingling sensations but in the severe cases, heart stoppage may be examined. 

Summary and Reflection 

The PN treatment is never is a fixed process that cannot be altered; it takes into the cognizant the fact that humans may have conditions that may be compounded by the process arising due to the treatment process. It is, therefore, gives special consideration to the patients with extreme cases of bleeding diathesis and severe hyperkalemia for the tow disorders are greatly affected by the PN treatment. Similarly, the treatment process may be withheld permanently halted as result of the behavior and conduct of the patient. The actions may be deliberate and health-related while other may be fueled by the social, economic and cultural beliefs of the patients. The side effects of the treatment and the medical process to a great extent influence the contraindication of the PN treatment. For the severe hyperkalemia, the treatment must consider the potassium balance in the body of the patient and ascertain the whether the treatment may not result in the side effects. 

Administering the PN treatment, the medics should analyze the historical treatment records of the patients to avoid cases where the process may result in to a more health disorders. The general health conditions of the patients must to be assessed for the determination of their fitness for treatment in order to avoid cases of allergy, pregnancy issues and ill health. For the patients, perseverance in the course of medication would be beneficial I n the long run; proper mechanisms for continuity of treatment should be considered through proper means of funding, community support and personal commitment to the full medications process. 

Goal 4: Percutaneous Nephrostomy Procedure and Intended Outcome 

Administering Percutaneous Nephrostomy treatment calls for a holistic understanding of the condition of the patients based on the indications and the contraindication reports. The treatment begins by assessing the risk factors and review of all cross-sectional imaging for a better understanding of the anatomic structure of the patient. 

Pre-procedural evaluation 

The treatment process is triggered by evaluation of the safety measures and the preparation of the stage and the patient for the treatment process. First, the assessment of the anesthesia marks the beginning of the process. “Assessment of airway and anesthesia risk is of particular importance prior to Nephrostomy placement” (Dagli 2011), this is because the patient will be placed in a prone position during medication which will make it difficult to monitor the airway. This assessment helps in determining the patients with higher risk of respiratory compromise in the prone position. Another pre-procedural evaluation carried out before treatment process is the assessment of the coagulation status of the patient. This is partly in abiding by the Society of Interventional Radiology guidelines for the peri-procedural management of coagulation categorizes Nephrostomy placement and partly as health precaution measure against the bleeding problems such diathesis bleeding. During this stage, there is routine “pre-procedural testing of the International normalized ratio (INR) and platelet counts in all patients and of a partial thromboplastin time (PTT) in those receiving intravenous (IV) unfractionated heparin” (Dagli 2011). The procedure may happen hours of even days before the actual treatment day to ensure that the correct coagulation status that supports PN treatment requirements are adhered to. 

The next pre-procedural step is the consideration of the antibiotics which is administered in accordance with the SIR guidelines on antibiotic prophylaxis. The antibiotic prophylaxis is most effective when “started within 1 hour prior to the procedure, with the incidence of infectious complications increasing significantly when prophylaxis is given perioperatively or greater than 2 hours prior to the procedure” (Dagli 2011). The prophylaxis antibiotics are important in reducing the risk of infectious complications such as stones, uroenteric, anastomosis, bacteriuria, and prior manipulation. For patients with great risk of infectious complications, the main purpose of administering antibiotics prior to the actual treatment is to offer real treatment rather than just risk reduction. Finally, periprocedural monitoring that takes places before and after treatment procedure which involves assessing the monitoring of vital signs is essential to detect early signs of significant bleeding or sepsis. 

Treatment procedure 

A thorough familiarity with the renal anatomy of the patient is the beginning of treatment process; this is necessary and fundamental in defining the safe route through the kidney where the catheter for PN treatment will be inserted. The process also involves understanding the position of the optimal entry plane, aligning the patient properly to the plane may be achieved through several means, however, most the time when vertical fluoroscopy is used, “the patient may be placed in an oblique position with the side of the kidney to be punctured elevated 20°–30” (Dyer 2000). The next step involves selecting the puncture site; this selection involves the consideration of the anatomical constraints. The selection of the puncture site also dependent on the nature of the problems, when the intention of the medication process calls for urinary drainage, a lower pole posterior calyx accessed through the sub-costal approach becomes the appropriate spot for inserting the catheter. Similarly, for simple and uncomplicated kidney stones, puncturing the behind the stone would be the most proper means. In other instances, the need for the puncture to be made in the posterior calyx in the upper pole, this more used when the risk for complications is greater but is usually preferred more because it provides the opportunity for visualization of a greater portion of the collecting system for removal of complex stones. Of noteworthy is that at times, multiple puncturing may be called depending on the treatment process envisaged or the nature of the disease problem being solved. 

There are various techniques for placing the catheter into the patient. The common techniques include the one-stick technique, the two-stick technique and the nondilated system. 

One-stick Technique 

The intention of the process is to make just a single and accurate needle insertion through either the posterior or lower pole calyx under the ultrasound guidance. Under this technique, the same needle access point is used for both opacification of the collecting system and the placement of the Nephrostomy tubes into the kidney. The ultrasound technique is as critical in the process as it helps proper visualization of the renal anatomy and best applies to the kidney with a well dilated system. A proper insertion through this technique requires the patient to assume position depending on the kind of kidney problems they have, Dyer (2000) remarks that “although lower pole calyces have the lowest risk of complications, interpolar calyces may provide greater mechanical advantage for future placement of a ureteral stent.” Normally, the skin entry is chosen from the region below the 12 th rib minimize the risk of trans-pleural complications. A lot of caution needs to be taken as too medial entry comes with extreme pain while lateral entry may increase the risk of colonic transgression. Therefore, to minimize injuries that may arise as a result of the process, a fluoroscopic survey is necessary. 

A well-visualized target allows for the insertion of an 18-gauge trocar needle or a 21-guage Chiba needle at slanting angel of 20-30 degrees to the sagittal plane through the skin into the calyx. The process provides an effective approach for the treatment of “stone disease, where there tends to be pericapsular fibrosis, which can deflect a smaller gauge needle and prevent accurate placement of the needle into the desired calyx” (Dagli 2010). 

Two-stick technique 

This technique utilizes the service of two needles; the first insertion only has its function limited to opacifying the collecting system only. The actions of the first needle allow the second needle to have an appropriate entry into the posterior calyx under the guidance of the fluoroscopy. The technique best applies to patients whom a single needle cannot be visualized the fluoroscopic processes. The process utilizes the 21 or 22 gauge needle in which the renal pelvis is directly targeted; the efficiency of this process is pegged on its ability to minimize the risk of injury to the adjacent organs or unnecessary bleeding. Unlike the one-stick technique, this approach has its needles inserted perpendicularly into the renal pelvis. 

Nondilated Systems 

The nondilated systems adopt the use of poor visualization, under this technique, “the collecting system is only opacified for a limited time and the contrast opacifies the more dependent anterior calyces, some follow IV contrast injection with a modified two-stick method” (Dagli, 2011). There is made directly to the renal pelvis to enable efficient opacification of the collecting system, in this technique, the carbon dioxide is an essential element. The outcome of the process, however, may involve the emergence of small or large urinary leakages arising out of the process. This could happen if the PN treatment was done to correct the urinary blockage. 

Another technique that can be applied in the PN treatment process is the Large-Bore Track Creation. Under this technique, a larger diameter tract is bored into renal pelvis; it is best suited for the percutaneous stone therapy, nephroscopy, or antegrade ureteroscopy. Like the two-stick technique, the puncture is directly into the renal pelvis with the lower side of the calyx being the preferred entry point for the needle. “An angiographic catheter is used to direct the working wire into the ureter and ultimately into the bladder to produce the most stable position for the wire” (Dyer et al 2000). This treatment requires the removal of the tube is not more than 7 days, however; the outcome of the process may include bleeding or other complications. 

Summary and Reflection 

The treatment of the kidney related problems through the PN techniques can take different approaches ranging from the single stick technique; double stick technique and nondilated system as well as the large bore track creation. All these techniques aim at inserting the catheter into the renal pelvis with the least pain to the patient, highest accuracy and minimize the risk of complications that might arise after the process. The wide range of the techniques available for the PN treatment matches the diverse health problems that relate to the kidney also meets the different nature and conditions of the patients. 

Assessment of the conditions of the patients prior to the onset of medication allows for the risks that may arise due to the treatment process to be reduced significantly. Administering anesthesia and antibiotics are pre-procedural techniques that should be carried before any process to thoroughly prepare the patient for the medical process. Mechanisms to address post-treatment challenges should also be emphasized and implemented under the monitoring and evaluation to assess the complication that may arise. 

Goal 5: Investigating complications arising from the intervention 

It is a norm that complications may arise after a treatment process regardless of the medication process. Though it is usually not the intention of the medics, they are unavoidable, however; great the care one may take. The Percutaneous Nephrostomy treatment is considered among the death for addressing the kidney obstruction problems because of the precautionary measures that it employees, however, considering the conditions of the patients or other factors beyond control, the aftermath of the process sometimes may be very unfortunate, complications may occur. 

Bleeding 

The PN treatment usually depends on inserting the needle through the skin into the renal pelvis in order to pave way for the insertion of the catheter for medication processes. Whereas treatment envisages slight bleeding, at times, the process may lead to excessive bleeding leading to hemorrhage. The bleeding might be experienced immediately after the process, or several days after the treatment. Some bleeding cases might control if detected at the earliest time, however others may be quite severe leading to the death of the patient. Dyer (2000) notes that in most instances, “Significant bleeding noted at the time of nephrostomy can be controlled by tamponade of the track with a nephrostomy catheter for a small-bore track or with a balloon dilation catheter for large tracks.” For cases that are identified late, the bleeding may lead to other secondary diseases may arise. Significant blood loss thus puts the patient at a risk of a renal arteriovenous fistula, pseudoaneurysm, or vessel laceration. This complication may arise as result of the improper insertion of the catheter, the patient’s disturbance or errors by the medics during the treatment process or at the removal of the tubes after medication. 

There are other patterns of bleeding that are common after the PN treatment. The transient minor bleeding has an occurrence of up to 95 percent of all cases; its prevalence is due to the bleeding of the tiny vessels or venous bleeding. Severe cases of bleeding can be rectified through the transfusion as the basic technique but other interventions can also be applied effectively to control bleeding problems that may include but not limited to hematuria or retroperitoneal bleeding. There are instances of continuous bleeding even after remedial processes have been carried out; this could be majorly as a result of the arterial injury. The workup and treatment of suspected arterial injury consist of a renal angiogram followed by sub-selective coil embolization of disrupted vascular branches (Dagli 2011). 

Injury to Adjacent organs 

PN treatment involves the insertion of the sharp objects into the body with only reliance on technological aspects for visualization. There are other treatment processes such as non-dilated systems that rely on poor visualization to insert the needles for treatment. Similarly, other technique such as two-stick that uses several insertions into the body increases the risk of injuries to other adjacent internal organs. The common organs usually affected during the treatment process involves the pleura or colon, however, these incidences are rare in cases where proper and careful attention is taken during the stage of patient anatomy and pre-procedural planning. The problem may occur as colonic perforation nonetheless it remains a rare occurrence. Three large series consisting of “over 1600 patients reported only two cases of trans-colonic nephrostomy tube placement and one pneumothorax, the overall reported incidence of colonic perforation is less than 0.2% of cases” (Dagli, 2010). The few incidences of complication are common for PN treatment processes that involve the setting of the retrorenal colon. 

The occurrence of this complication is observed more often in the on the left side in patients with little intraabdominal fat. The symptoms of this complication may vary from one patient to the other and also determined by the extent to which the colon is damaged or perforated. The signs are fever, gastrointestinal bleeding or in the worse conditions, the patient may experience the drainage of gas and feces from the PCN. The effects of this complication in the long run if not corrected, may lead the patient to develop further health problems such as ephrocolic or colocutaneous fistula and associated abscess. Treatment for this complication is possible through surgery, use of antibiotics and bowel rest for a determined period. 

The pleural complication is also common just as colon, it consists of several subsidiary health conditions that arise because of prolonged detection period they include pneumothorax, hemothorax, or nephropleural fistula. The pleural complications are normally caused by the inaccuracies in the placement of the PN needles in the intercostals region. The risk of pleural complication can be reduced by exercising post-procedural chest x-ray. 

Pain 

Pain is a usual accompaniment or almost all medication processes that involve the use of surgery or radiological processes. For PN treatment and processes, pain is common; however, it is minimized through the provision of anesthesia in the pre-procedure period to relieve the pain during the surgery process. There are cases of extreme pain during or after medication that patient many find it hard to persevere, in such instances, the painkillers should be administered. Nonetheless, if proper and accurate anesthesia is applied in the preparation stage excess pain could be greatly minimized. If the pain persists or arise beyond the expected norm, the medical analysis should be considered to assess the situation of the patient and their response process. 

Sepsis 

Sepsis is a life-threatening infection that arises as a complication after the PN treatment. Normally, the complication is caused by the chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body. Whereas the risk is assessed at 1.3 percent, the effects of the condition in its severe level can lead to the death of the patient. This complication is normally characterized by the fever, chills without hypotension and a significant reduction in the urine output. Other symptoms that may vary from one patient to the other includes abrupt change in mental status, decrease in platelet count, difficulty breathing and abnormal heart pumping function as well as abdominal pain. These symptoms, however, may be experienced according to the level of infections; those in the severe level may have their signs more pronounced. The risk of getting this complication is normally high for the patients with known pyonephrosis, this is because of their vulnerability and lack of established body mechanism. 

Because of the high mortality rate for this complication, immediate medication is mandatory, Dagli et al (2011) notes that “if purulent-appearing urine is unexpectedly discovered during PCN placement, the urine should be sent for culture and sensitivity and further manipulations minimized until several days of drainage has occurred.” Preventing this complication calls for a thorough pre-procedural check up and administration of antibiotics, the patients should also be monitored after the treatment to assess their vulnerabilities and the risks they may encounter in their healing process. For the occurrence of the complication, treatment process may consist of “supportive therapy with stabilization and maintenance of blood pressure with intravenous fluid and vasoactive substances to maintain a mean blood pressure greater than 65 mm Hg and less than 90 mm Hg” (Dyer et al 2000). The treatment may also be involved oxygenation and initiation of the vast microbial treatment approach. 

Summary and Reflection 

Treatment processes at times go sour leading to the complication during or after the treatment process. Percutaneous Nephrostomy treatment is not a perfect process and on several occasions, it has led the patient to battle other health problems. Because the PN treatment involves the administering medication to the internal organs with rupturing the skin or the body parts but only relies on the insertions, risks of danger and injuries to the internal organs located alongside the route of the needle of adjacent to the kidney. Similarly, the insertion process may trigger bleeding that may be short-term or a hemorrhage that may put the life of the patient at risk. Improper handling of the treatment apparatus can cause the patients to have infections leading to sepsis. Like any other treatment process of surgical nature, pain is usually inevitable; however, excess pain may be a complication of its nature arising from the treatment process. 

PN treatment has robust pre-procedural measures that enhanced the preparedness of the patients and reduction of the risk factors that may jeopardize the treatment process of the patient. Considering that the complications arising from PN treatment, post-procedural measures for monitoring and evaluating the conditions of the patients after treatment should to implemented to boost the patient’s recovery plan. The complications arising from PN treatment at times can be severe and threaten the life of the patient, and if not checked in time death can occur. Swift measures for medication of all possible after-treatment ailment arising should be ever ready. But above all, the medics should exercise a lot of cautions and professionalism in order to reduce the risk of patients developing complications. 

References 

Schmidler, C. (2017, November 25). Kidney Anatomy and Function. Retrieved February 16, 2018, from https://www.healthpages.org/anatomy-function/kidney/#Kidney_Anatomy 

Bello-Reuss, E., & Reuss, L. (1983). Homeostatic and Excretory Functions of the Kidney. The Kidney and Body Fluids in Health and Disease, 35-63. doi:10.1007/978-1-4613-3524-5_2 

Zumrutbas, A. E., Toktas, C., Baser, A., & Tuncay, O. L. (2016). Percutaneous Nephrolithotomy in Rare Bleeding Disorders: A Case Report and Review of the Literature. Journal of Endourology Case Reports , 2 (1), 198–203. http://doi.org/10.1089/cren.2016.0105 

Dyer, R. B., Regan, J. D., Kavanagh, P. V., Khatod, E. G., Chen, M. Y., & Zagoria, R. J. (2002). Percutaneous Nephrostomy with Extensions of the Technique: Step by Step. RadioGraphics, 22 (3), 503-525. doi:10.1148/radiographics.22.3.g02ma19503 

Dagli, M., & Ramchandani, P. (2011). Percutaneous Nephrostomy: Technical Aspects and Indications. Seminars in Interventional Radiology , 28 (4), 424–437. http://doi.org/10.1055/s-0031-1296085 

Urinary Diversion. (2013, September 01). Retrieved February 18, 2018, from https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-diversion 

Percutaneous Nephrostomy. (n.d.). Retrieved February 18, 2018, from https://www.urologyhealth.org/urologic-conditions/urinary-diversion/treatment