RAD 214: Urinary & Venipuncture

functional

• IVU

• VCUG

Nonfunctional

• retrograde cystography

• retrograde urethrography

IVU patient prep

• light evening meal

• laxative

• NPO 8 hours

• enema the morning of the exam

IVU Room prep

• contrast media drawn up

• IV supplies

• emesis basin

• emergency cart

• access to oxygen and suction

IVU: 1 minute projection

nephrogram or nephrotomogram

IVU: 5 min & 10-15 mins

KUB

IVU: 20 min projection

obliques

IVU: post void projection

done erect or prone

nephrogram

• standard x ray of kidneys

• center midway between xiphoid and crest

• 1 minute after injection

nephrotomogram

• tomogram of the kidneys

• CR:

  • midway between xiphoid and crest

• uses tomogram cut measurement to determine how far apart images are taken

• 1 minute after injection

• blurs region around kidneys

tomogram kidney cut size

initial fulcrum found by measuring abdomen at lower ribs and divide by 3

after how many minutes are your kidneys blushing?

1 minute

when do you start obliques?

• when the ureters are full

• 10-15 mins

KUB (IVU)

• patient supine

• CR to iliac crest & MSP

• entire urinary system, symphysis pubis

• expose on expiration

Kidney Projection

• 10×12

• patient supine

• CR

  • between xiphoid and iliac crest & MSP

• 1 min after contrast injection

• nephrons fill with contrast in the renal parenchyma before contrast moves into collecting system

IVOblique

• AP/ PA

• oblique patient 30°

• CR to

  • iliac crest & spine

• 10 minute mark

• 14×17

• expiration

IVU Oblique evaluation

• side up kidney = area of interest

  • parallel to IR

• side down ureter = area of interest

  • free from superimposition

RPO (IVU)

• right kidney

• left ureter

LPO(IVU)

• right kidney

• left ureter

ureteral compression

• enhances filling of pelvicalcyceal system & proximal ureters

• allows renal collecting system to hold contrast logner

what if ureteral compression cannot be used?

use trendelenburg instead

Retrograde Cystography

• nonfunctional

• retrograde filling of the bladder by gravity only

• contrast media delivered through catheter

• 150-500 ml

• done under fluoro

• AP/ posterior obliques

AP Axial Bladder

• patient supine

• CR

  • angled 10-15° caudal

    • 2” superior to symphysis pubis & MSP

• 10×12 crosswise

• bladder not superimposed by pubic bones

Oblique Bladder

• 45-60° patient oblique (LPO/RPO)

• contrast filled bladder

• LPO/RPO

  • not superimposed by lower limbs

60° oblique bladder

better visualizes posterolateral aspect of bladder and UVJ

kidney blushing

nephrons fill with contrast in the renal parenchyma before contrast moves into collecting system

venipuncture needle size

18-22 gauge needle

upright post void

• patient erect or prone

• CR to

  • upright: 1” below iliac crest & MSP

  • prone: iliac cest & MSP

bevel insertion degree

always insert bevel up at 20-45° angle

kidneys are surrounded by

adipose tissue allowing them to be seen on x ray

kidney movement

up and down with breathing or position change

kidney functions

• production and elimination of urine

• removes nitrogenous waste

• regulate water levels in the body

• regulate acid/base balance & electrolyte levels of the blood

A

minor calyx

B

renal papilla

C

renal medulla

D

fibrous capsule

E

cortex

F

renal pelvis

G

major calyx

H

ureter

A

minor calyx

B

major calyx

C

renal pelvis

D

ureteropelvic junction

E

proximal ureter

function of ureters

transport urine between the kidneys and bladder

where do the ureters begin?

• anterior to its respective kidney

• follows natural curve of vertebral column

urine is forced down the ureters by

peristalsis and gravity

urine enters the bladder

posterolateral at the ureterovesical junction (UVJ)

proximal point of constriction

• uteropelvic junction (UPJ)

• renal pelvis funnels into smaller ureter

middle point of constriction

• pelvic brim

• iliac blood vessels cross over the ureters

distal point of constriction

• ureterovesical junction (UVJ)

• where the ureter joins the bladder

common site for calculus to become lodged

ureterovesical junction (UVJ)

urinary bladder function

reservoir for urine

urinary bladder capacity

350-500 ml

urinary bladder shape

empty = flattened

full = oval

rugae

numerous folds of the inner mucosa

trigone

smooth, triangular portion of the inner mucosa

bladder calculi

• calcifications within the bladder or signs of obstruction of urinary system

cystitis

inflammation of urinary bladder

Polycytic renal disease

cysts scattered throughout one kidney or both

Hydronephrosis

• distention of the renal pelvis & calyces of the kidneys

• result from obstruction of ureters & renal pelvis

Pyelonephritis

inflammation of kidney & renal pelvis

Renal Obstruction

caused by debris, calculus, thrombus or trauma

renal calculi

• calcifications that occur in luminal aspect of the urinary tract

• can lead to

  • renal obstruction

  • hydronephrosis

• patients with acid urine & high calcium levels = renal stones more often

Venipuncture Veins

• median cubital

• cephalic

• basilic

venipuncture

puncture of a vein for withdrawal of blood or injection of a solution such as contrast media for urographic proceudres

Kidneys sit how many degrees to MCP

30°

IVU oblique which kidney is shown ?

kidney closest to IR

IVU oblique which ureter is shown?

ureter furthest (upside) from IR

IVU

• functional

• visualize the collecting portion of the urinary system

• assess the functional ability of the kidneys

• evaluate the urinary system for pathology or anatomic anomalies

IVU Contraindications

• iodine allergy

• anuria

• multiple myeloma

• diabetes

• renal disease

• CHF

• pheochromocytoma

• sickle cell anemia

• patient on metformin

• renal failure

Retrograde Urography

• nonfunctional

• retrograde filling of the urinary system

• done in OR

• patient sedated

• modified lithotomy position

Voiding Cystourethrography (VCUG)

• functional

• study of the urethra

• done under fluoro

• retrograde filling of bladder by gravity only

• followed by removal or catheter and imaging while patient is voiding

venipuncture tourniquet placement

3-4 inches above injection site

BUN normal ranges

8-25 mg/100 mL

Cr normal ranges

0.6-1.5 mg/dL

extravasation

• leakage of iodinated contrast media outside of the vessel and into the surrounding tissues

• AKA: infiltration

Phlebitis

• inflammation of a vein

• pain, redness, swelling

mild (non allergic) systemic reaction

• does not require drug intervention or medical assistance

• side effects

  • metallic taste

  • warmed, flushed feelings

  • anxious

  • lightheadedness

moderate systemic reaction

• anaphylaxis / true allergy

• requires medical assistance

• moderate to severe hives

• laryngeal swelling

• bronchospasm

• angioedema

• hypotension

• tachycardia

severe systemic reaction

• life threatening requires immediate medical attention

• hypotension

• bradycardia

• cardiac arrhythmias

• convulsions

• cardiac arrest

• respiratory arrest

• no pulse

premedication

A combination of diphenhydramine and solumedrol over a 12 hour period

urinary system basic anatomy

• kidney (2)

• ureter (2)

• urethra (1)

• bladder (1)

kidneys sit how many degrees to MSP and why?

20° due to the psoas muscle

what vertebral level do the kidneys sit at

T12-L3

congenital anomalies

• duplicate ureter and renal pelvis

• ectopic kidney

• horseshoe kidney

• malrotation

duplicate ureter and renal pelvis

• double collecting system & double ureter

• sometimes just double ureter

ectopic kidney

normal kidney that didnt ascend to abdomen stays in pelvis

horseshoe kidney

• connected at upper or lower pole

• most common in lower pole 95°

malrotation

renal pelvis not medial but anterior and posterior

the kidneys and ureters are located in the ____ space

retroperitoneal

what structure creates a 20° angle between the upper and lower pole of the kidney

psoas muscle

ionic contrast

• hypaque, conray, renografin

• Osmolality: High

• Chance of Reaction: High

• increases osmolality of the blood

nonionic

• omnipaque, isovue, optiray, amipaque

• Osmolality: Low

• Chance of reaction: Low

• more water soluble

• fewer patient reactions

ureteral compression contraindications

• Possible ureteral stones 

• Abdominal mass 

• AAA

• Recent abdominal surgery 

• Severe pain 

  • Acute trauma 

ureteral compression alternative

trendelenburg position

retroperitoneal

• kidneys

• proximal ureters

infraperitoneal

• distal ureters

• urinary bladder

• urethra

which kidney sits more superior?

left kidney