Loop-o-gram / Pouch-o-gram PRINT
I. Equipment (May vary between sites)
a. Cystografin (300cc’s) (double check order to verify limit)
b. Sterile catheter tray (if needed)
c. Foley catheter w/ 30cc balloon (assortment of sizes 12,14,16,20,22)
d. 10 cc saline syringe for inflating balloon
e. Cystogram tubing
f. IV pole
g. Hemostats
h. Sterile pack of 4×4’s (have extra available)
i. Betadine
II. Personnel
a. Radiologist/RA
i. Responsible for administering contrast and taking spot images
b. Hospital Technologist
i. Prints order for radiologist/RA approval
ii. Documents patient history, allergies, and pregnancy status prior to exam
iii. Assists the radiologist/RA during procedure
iv. Provides patient with aftercare instructions and communicates with floor nurse
III. Procedure
a. Scout KUB
b. Remove top of stoma bag
c. Wipe away stoma residue with sterile 4×4’s covered in betadine
d. Place catheter into stoma gently and drain residual urine/residue (do not disturb ureteral stents)
e. Connect blue Christmas tree attachment to catheter and attach IV tubing
f. Instill contrast via gravity drip
g. Capture AP, Lateral and Oblique images of ileal conduit and ureters
h. Keep a fresh blue towel/4×4’s on the ostomy to collect contrast that flows back out of the ostomy or ureteral stents
i. Post drain KUB
j. Replace stoma cover
IV. Special Considerations
a. Follow contrast allergy protocol
b. RA’s may be asked to inject contrast for CT loopograms