521 Check list for arranging renal biopsies

  • Renal biopsy procedure

    We currently have no regular allocated theatre spot for biopsies at RCH although Renal and Radiology are working on a solution for 2014.

    The process for renal biopsies:

    1. Call or e-mail (preferred) Chris Vanderstock from waitlist on x54559 to obtain a few potential work-in list or labs ‘n’ lines times for the coming weeks. (If urgent biopsy, call Anaes in charge x52000 to assess the Emergency list, keeping in mind after hours is problematic for us and radiology). Fax (9345 4045) or drop green bookings form to him- write on form proceduralist’s contact details ~20 mins prior and that ultrasound should be notified of approximate time on the day on x56780.
    2. Confirm that ultrasound are able to provide a sonographer/machine for these times x56780 (if urgent, they can get a radiology fellow to come). Fill out green radiology request and fax (9345 6694) or drop to USS.
    3. Call family to confirm date and fasting times; ensure no vigorous activities planned in the weeks after biopsy.
      1.    FBE, coags, UECr, and urine performed within one week and faxed to x55611 if performed outside RCH
      2.    Ask family to bring in a urine specimen on the day.
      3.    No family history bleeding disorders and not on aspirin/anticoagulants?
      4.    Renal ultrasound shows two normal sized kidneys?
      5.    Confirm family have a follow up appointment booked for 1-2 weeks post-biopsy?
    4. Fellow to complete pathology request slip after discussion with treating consultant with regards to number of cores necessary and needs for immunological stains, EM or other special studies.
    5. On the day:
      1.  Obtain consent from family if not already done
      2.  Confirm blood tests results safe and perform urine dipstick to exclude active urine infection.
      3.  Notify Anatomical Pathology in the morning on x55748. If urgent results required (rejection; RPGN) discuss frozen section with Pathologist as an extra core will be required.
      4.  If bloods required intra-op ensure correct tubes put in front of file along with request slip for Anaesthetics to collect.
      5.  Collect biopsy gun + spare, provide pathology request slip and a copy of equipment list below for theatre staff. Biopsy guns are kept in the cupboard behind the Renal fellow’s desk.

    Equipment list for theatre staff

    -Marker pen

    -2 blueys
    -sponge forceps, gauze, iodine for skin prep (chlorhex removes blue marker pen!)
    -four sterile drapes and four towel clips
    -sterile probe cover and two rubber bands
    -sterile gel
    -drawing up needle, 22G needle and 22G spinal needle if native biopsy
    -10mL syringe
    -10mL 0.5% bupivicaine without adrenaline
    -size 7 scalpel
    - packet gauze
    -small tegaderm
    -2 sterile specimen pots
    -5mL N/saline

    • Theatre nursing staff to please phone ultrasonographer on x56780 to notify them 20 minutes ahead of schedule so they can bring portable ultrasound machine to theatre.
    • Theatre nursing staff to please phone Anatomical Pathology on x55748 when skin prepped so they can come to theatre to collect specimen – they will stand outside the theatre for someone to take the specimen to them to confirm >10 glomeruli seen.

    Post procedure

    Fill out operation note and post op orders on theatre software: à patient à documentation à edit à type op note. This will print to recovery.

    Example operation note:

    GA. Time out.

    Chlorhex/alcohol/iodine prep with sterile drapes, gown, glove and mask.

    USS localisation of lower pole of the left kidney/midpole of the transplant kidney.

    0.5% plain marcain infiltrated to capsule under ultrasound guidance – volume:

    One pass through lower pole of left kidney under real time ultrasound guidance.

    Visualised through cortex on USS.

    No post biopsy haematoma.

    Tegaderm island dressing.

    Usual post-op orders (copy and paste into the theatre system and amend as necessary):

    Ideally lie supine or on side for 3 hours if child not distressed.  If child upset, agitated, allow them to find a position

    of greatest comfort such that they remain still.

    May eat and drink once awake. Encourage oral fluids early.

    For first 3 hours, use bed pan in bed, thereafter can mobilise gently to toilet if pain permits but must collect all urine

    for inspection for visible haematuria.


    (heart rate, blood pressure, respiratory rate, capillary refill, pain score, review biopsy site for bleeding):

    • 15 minutely for first hour
    • 30 minutely for next 2 hours
    • hourly for next 3 hours then routine

    Notify if

    • HR greater than … or less than …,
    •          SPB greater than … or less than …,
    •          RR greater than … or less than…,
    •          Sats <92% in air
    •          Any increasing pain at biopsy site or bleeding from site
    •          Any macroscopic haematuria.

    Collect a sample of every micturition in a specimen container and label with the time, regardless of the presence of visible haematuria.  Keep near patient bedside for medical review just in case.  Dipsticking is not necessary.

    •         Notify any macroscopic haematuria. If clots in urine, IV fluid must be commenced or increased if not already running.

    Discharge criteria

    •          patient is not required to remain in hospital for urgent treatment
    •          patient has passed urine at least twice
    •          there is visible blood in urine
    •          pain is well controlled with paracetamol
    •          patient is mobilising comfortably
    •          parents have been provided with discharge summary
    •          there is a follow up appointment booked to discuss results
    •          no nursing or parental concerns requiring medical consultation

    Advise no vigorous activity for 4 weeks; tegaderm dressing to remain on for 7 days.

    Registrar to complete renal biopsy discharge pro-forma on Clara prior to patient departure in order to provide post-procedure instructions for the family.