Biliary drainage Flashcards
types of biliary drainage?
Endoscopic (ERCP)
or
Percutaneous (PTC)
- percutaneous transhepatic cholangiography
what to remember on admission for biliary drainage?
- Full clerking
- Antiplatelets / anticoagulation?
- Vitamin K
- Blood tests
- IVT
- NBM
- DHx - VTE, reg meds, +/- Abx
if patient is on antiplatelets/anticoagulation on admission?
- Inform SpR/SCF on admission if patient is taking these medications
- Antiplatelets (e.g. Clopidogrel) should be suspended for 5 days pre-procedure. D/w Spr/SCF when to suspend.
- Warfarin/NOAC’s should be suspended. D/w SpR/SCF the need for tinzaparin (will need to be withheld day prior to procedure).
what Vit K dose to give a jaundiced patient before PTC/ERCP?
10mg IV Vit K (this is to make their clotting/INR less deranged and therefore decrease bleeding risk)
what blood tests to do before a PTC/ERCP?
- FBC – If platelets <100,000 inform SpR/SCF
- LFT’s
- U&E’s
- Clotting – if PT prolonged inform SpR/SCF
- Group & Save
what IVT to give before PTC/ERCP?
- Make an assessment of the patients hydration – obstructive jaundice is a major risk factor for AKI
- Encourage oral fluid intake (2-3L/day)
- In those patients unable to maintain euvolaemia prescribe IVT (especially in those with a Bilirubin > 150µmol/L)
- Consider suspending nephrotoxic medications (e.g. ACE inhibitors, NSAID’s, diuretics). D/w Spr/SCF
do ERCP/PTC need NBM?
- ERCP will be required to be NBM from midnight the day prior to their procedure.
- PTC do not require NBM (unless under GA)
DHx/prescribing when clerking pre-ERCP or PTC?
- VTE (assess, tinz, TEDs, d/w reg if bleedy)
- Reg meds!!!
- if on nephrotoxics/anticoags, Rx, then immediately suspend!!
- +/- Abx
Abx for PTC or ERCP?
- YES for PTC (cholangitis complication)
- Not normally for ERCP (if yes the endoscopist gives them)
- check if C diff/Hx of
- IV Abx w/n 30 mins of procedure
- oral Abx w/n 2 hrs of procedure
Abx regimes pre-procedure?
- gent 1.5mg/kg IV (unless eGFR<20)
- if gent CI, cefuroxime 750mg IV
- if eGFR<20ml/min AND previous C diff then Tazocin 4.5g IV
- If gent CI and true penicillin allergy then ciprofloxacin 750mg PO or 200mg IV
For patients who have had a liver transplant or are neutropenic:
- Tazocin 4.5g IV
- If penicillin allergy then Ciprofloxacin 200mg IV & IV Teicoplanin; if neutropenic also add metronidazole 500mg IV
IV Teicoplanin dosing: (Weight/kg) - <50? - 50-80? - >80?
- 600 mg
- 800 mg
- 1000 mg
Post-procedure checklist? (4)
1 • OpNote - follow instructions
2 • PTC drain - bile sample for culture, ensure drain flush Rx 10mls saline QDS
3 • 1hrly obs for first 6hrs, then as per NEWS
4 • high NEWS? assess
what to include in a high NEWS assessment post-procedure? (4)
1 • ABCDE, resus (O2, IVT, etc)
2 • Bloods (FBC, U&E, LFTs, amylase, CRP, cultures, ABG)
3 • Uncap drain (if capped)
4 • Inform SpR/SCF
three categories of PTC procedures?
- No external drain. PTC performed, stent(s) placed, with PTC track gel-foamed.
- External biliary drains enter percutaneously and sit in the intra-hepatic biliary tree above the stricture. These should never be capped off.
- Internal/External biliary drains enter percutaneously, cross the stricture and enter the duodenum. With these drains bile can drain both into the external bag and into the duodenum. It is therefore possible to cap them off.
drain Mx post PTC?
- check if external only or internal/external drain
- drain flush with 10ml 0.9% saline QDS to prevent blockage
- fluid balance maintenance
