Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Antibiotics, Other
Class Summary
The use of antibiotics is somewhat controversial; however, in patients with a known urinary tract obstruction, antibiotics should be administered before the procedure (preferably 1 h before puncture) and should be continued for at least 24 hours after the procedure. Antibiotics should be chosen on based on urine culture results, if available. If culture results are not available, use of a broad-spectrum antibiotic is recommended.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Patients at low-risk of infection are given a single intravenous dose of 1 g of ceftriaxone 30 minutes to 1 hour prior to intervention.
Cefazolin
Cefazolin is a first-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Patients at low-risk of infection are given a single intravenous dose of 1 g of cefazolin 30 minutes to 1 hour prior to intervention.
Cefuroxime (Ceftin, Zinacef)
Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity of first-generation cephalosporins; it adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Patients at low-risk of infection are given a single intravenous dose of 1.5 g of cefazolin 30 minutes to 1 hour prior to intervention.
Analgesics, Opioid
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that are beneficial for patients who experience pain.
Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)
Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation of the drug in fat and delays the weaning process. Consider continuous infusion because of the medication's short half-life.
The parenteral form is the drug of choice for conscious-sedation analgesia. Fentanyl citrate is ideal for analgesic action of short duration during anesthesia and the immediate postoperative period. It is an excellent choice for pain management and sedation with short duration (30-60 min) and is easy to titrate. The drug's effects are easily and quickly reversed by naloxone. A dosage of 50-100 mcg/dose may be administered 30-60 minutes prior to the procedure.
Anxiolytics, Benzodiazepines
Class Summary
By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and the action of other inhibitory transmitters.
Midazolam
Midazolam is a shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Midazolam is also useful for its amnestic effects.
Local Anesthetics, Amides
Class Summary
Local anesthetics are used for local pain relief.
Lidocaine (Xylocaine with Epinephrine)
Lidocaine 1-2% with or without epinephrine (1:100,000 or 1:200,000 concentration) is used. Lidocaine is an amide local anesthetic used in 1-2% concentration. The 1% preparation contains 10 mg of lidocaine for each 1 mL of solution; the 2% preparation contains 20 mg of lidocaine for each 1 mL of solution. Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.
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Percutaneous nephrostomy. Shown are two types of nephrostomy tubes: the Malecot (top) tube, and the pigtail catheter (bottom).
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Percutaneous nephrostomy. The needle is positioned in the mid-pole posterior calyx, filled with air. A filter in the inferior vena cava.
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A 0.018-inch guidewire has been advanced through the needle into the ureter.
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An 8F locking pigtail catheter has been placed in the renal pelvis.
