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Bersabal, Shazna Myles B.

28, 2011

BSN-3B

April

PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE


Percutaneous Transhepatic Biliary Drainage (PTBD) is a specialized procedure done to relieve blockages in the bile ducts without having to perform surgery. During a PTBD procedure, a catheter (thin tube) is placed within the bile ducts to relieve pressure caused by narrowing or blockage, such as gallstones, strictures, or tumors. Often, PTC is done with PTBD. Percutaneous transhepatic cholangiography, or PTC, is a way of examining the bile duct system in the liver. This procedure is done under local anesthesia by a radiologist. During the exam, a thin needle is inserted through the skin (percutaneous) and through the liver (transhepatic) into a bile duct. Then dye is injected, and the bile duct system is outlined on x-rays (cholangiography). Why is PTC/PTBD done? Bile is a body fluid that helps your body digest fats. It is produced by the liver and collected in tiny bile ducts that empty into increasingly larger ducts. Finally, a main bile duct carries bile to the small intestine. Bile also is stored in the gallbladder. When one or more bile ducts narrows or has a blockage, bile may back up and cause problems such as jaundice, a yellowing of the skin. Or, a leak in a bile duct may allow bile to flow into the abdominal cavity. PTC allows your doctor to see on the x-rays if the ducts are partially or completely blocked. If necessary, a thin, flexible tube (catheter) may be inserted to allow the bile to drain into a collection bag outside the body, or into the small intestine. This procedure is called biliary drainage. The drawing below shows the liver with the bile duct (biliary) tree, and the PTC needle inserted into a bile duct. A thin needle through your skin, between the ribs, through the liver, into a bile duct. As the needle is withdrawn, a small amount of dye will be injected and x-rays will be taken. If the PTC results show a problem, such as a blockage in the bile duct, the doctor may replace the thin needle with a small drainage tube (catheter) that will be threaded into the small intestine (see illustration). A small pouch may be attached to the end of the catheter outside your body to collect bile. PTC usually takes about one hour to perform. If a drainage tube needs to be inserted, the procedure may take longer, depending on how easily the tube can be threaded through the bile duct.

What is a pigtail catheter? A pigtail catheter is a medical device designed to be inserted into the body for the purpose of drainage or introducing fluids like soluble dyes for medical imaging studies. Pigtail catheters are produced by numerous medical supply companies and are available in a range of lengths and sizes to meet different needs. It is a catheter with a tightly curled end and multiple side holes to reduce the impact of the injectant on the vessel wall or to

remain in a chamber or space for drainage. They can be ordered through supplier catalogs by medical practitioners for use in clinical and hospital settings. Like other catheters, the pigtail catheter is a long, flexible tube that can be guided into the body. The design of this particular style of catheter includes small holes that allow for drainage and a coiled end. The coiled end acts to hold the pigtail catheter in place and it can also be used to slow the flow of fluids injected through the catheter so that they do not burst out in a jet and cause injuries or obscure a medical imaging study. One reason to use a pigtail catheter is to drain body fluid. The catheter is equipped to handle clear fluids that are not heavily coagulated, like urine, bile, and pancreatic fluid. Medical practitioners can use a pigtail catheter to provide drainage if a patient has a blockage that makes it impossible to clear the fluid independently. The catheter ensures that fluid does not build up and cause pain and pressure. It can be attached to a bag to collect the fluid. Collecting the fluid improves sanitation, allows practitioners to measure output, and provides a supply of fluid for sampling, if necessary. Another use for the pigtail catheter is in medical imaging studies that use tracer dyes. The catheter can be threaded into place and then used to introduce the dye to the area of interest. The design allows dye to diffuse evenly across the area so that it will be visible on the imaging study without clouding or obscuring the image. Once the dye is dispersed, the catheter can be removed and the body can eliminate the dye on its own over the course of several days.

Nursing Interventions Pre-operative Phase NPO post midnight. Answer questions about procedure to alleviate anxiety. In some hospitals, a radiologist will visit and describe the PTC procedure. He or she also may discuss biliary drainage. Acquire signed consent form that gives permission to have the procedures. Ask if patient is allergic to any medications, especially antibiotics or iodine. Health teachings on DBE, diversional activities, guided imagery, and other pain management techniques Health teachings on no straining and splinted coughing Be sure to tell your doctor and nurse if you have these allergies or if you have had any reactions to antibiotics or x-ray dye. Help in changing into OR gown. Administer Pre-Op Meds Assist in transfer on a stretcher to the lab where PTC is done. Intraoperative Phase Attach chest leads for cardiac monitor Attach blood pressure cuff Operative Site: Right Upper Quadrant

Site will be cleaned with skin prep, and the area will be draped with sterile cloths. Local anesthetic is then administered

Post-Operative Phase Vital signs are monitored and kept stable The bile in the collection pouch also will be checked for color, amount, and presence of blood Doses of antibiotic medication through IV to prevent infection. Going home with a catheter in place Teach you how to care for the catheter at home Teach how to change the bandage around the catheter Teach how to do daily irrigations through the tube (flushing the catheter with water) Teach what to do about showering or bathing. Bandage Changes The physician will tell how often the bandage around the catheter needs to be changed. Change it any time it becomes soiled or wet. To change the bandage, first gather all the materials one will need and place them near. Then wash hands thoroughly with warm water and soap. To change the bandage, do the following steps: 1. Remove the old bandage. 2. Soak a cotton swab in hydrogen peroxide and clean the area carefully. Or one may be told to use warm water and soap. Be careful not to put any pressure on the catheter and not to pull on it at any time. 3. Inspect the skin around the catheter for redness, tenderness, or drainage. Also check to see that the catheter has not changed position. Refer any unusualities. 4. Slit a 4-inch by 4-inch gauze square from one side to the middle of the gauze and place it around the catheter on top of the disc. Slit a second 4-inchsquare gauze pad in the same way and place it around the catheter on top of the first bandage. Make sure the slits are on opposite edges when the pads are on top of each other. Do not place a gauze bandage under the disc; this could cause the catheter to pull out. 5. Cover the bandage completely with strips of tape. Irrigations The doctor may want the catheter to be capped. A cap, rather than a collection bag, on the outside end of the catheter will allow bile to flow directly into the small intestine. If the catheter is to be capped, you may need to flush (irrigate) the catheter periodically to keep it from becoming clogged. Give teachings on how to irrigate your catheter if it is capped. If fluid will not go into the catheter when it is to be irrigated, refer immediately. Showering One may shower with the catheter in place, but cover the gauze bandage. To cover the bandage, place a piece of plastic wrap over the bandage and tape all the edges of the plastic wrap to prevent water from seeping in. If the bandage becomes wet or damp, follow the steps listed previously to change the bandage.

Source: Center for Patient and Community Education in association with the staff and physicians at California Pacific Medical Center. Last updated: 9/07. 2002 2007 California Pacific Medical Center, www.cpmc.com