Assessment, History and Physical. Renal Ultrasound

Transcription

1 UROLITHIASIS ALGORITHM Assessment, Histry and Physical Orders Labs- UA, cnsider RFP, CBC, Urine Culture, and UPT Pain meds (see therapeutics chart) IV fluids Imaging Renal Ultrasund Inclusin Criteria: Patients with suspected Urlithiasis Symptms may include but are nt limited t: Abd pain (sharp, intermittent, ften unilateral and/r fcused in the flank) Hx f nephrlithiasis Nausea r Vmiting Hematuria Dysuria Radiatin t pelvic regin! Nte: These symptms may verlap with Nt ther cnditins. Carefully cnsider recmmended differential diagnsis t increase urine utput t facilitate passage f stne Stne Visible US psitive fr secndary signs nly and N Stne Visible Or US negative/incnclusive and High Clinical Suspicin Negative, Incnclusive, r Lw Clinical Suspicin Lw dse CT withut cntrast Pain cntrl, hydratin, cnsider Tamsulsin Yes Psitive fr Urlithiasis? N Further evaluatin f presenting symptms Cnsider alternative diagnsis Yes Eligible fr Discharge? N Discharge with Outpatient Urlgy Fllw-up Urlgy Cnsult Admit Fr: Inability t tlerate PO Pain requiring IV analgesia Risk factrs (Slitary kidney, renal transplant, bilateral renal bstructin, renal insufficiency, cncmitant UTI) Page 1 f 8

2 TABLE OF CONTENTS Algrithm Target Ppulatin Backgrund Definitins Initial Evaluatin Clinical Management-N/A Labratry Studies Imaging Therapeutics Admissin Discharge Criteria Parent Caregiver Educatin- N/A References Clinical Imprvement Team TARGET POPULATION Inclusin Criteria Patients with suspected Urlithiasis Symptms may include but are nt limited t: Abdminal pain (sharp, intermittent, ften unilateral and/r fcused in the flank) Histry f nephrlithiasis Nausea r Vmiting Hematuria Dysuria Radiatin t pelvic regin Nte: These symptms may verlap with ther cnditins. Carefully cnsider differential diagnsis. BACKGROUND DEFINITIONS Urlithiasis may present with abdminal pain that is sharp, intermittent, ften unilateral, and/r fcused in the flank. A patient with suspected urlithiasis may r may nt present with the fllwing: Histry f urlithiasis Radiatin t the pelvic regin Hematuria Dysuria Nausea r vmiting Page 2 f 8

3 INITIAL EVALUATION Triage Assessment Review triage infrmatin, vital signs Assess hydratin status, need fr pain cntrl, need fr IV placement Cmplete Histry & Physical Fr a cmplete histry assess the fllwing: Abdminal, flank, scrtal, penile, r vaginal pain Hematuria Dysuria Urine utput Nausea r vmiting Fever Knwn urinary tract infectin Clic in infants T btain pertinent past histry, assess the fllwing Nephrlithiasis Urlgical surgeries Metablic disrders, including hypercalciuria r hypcitraturia Determine if family histry f nephrlithiasis Physical examinatin Abdminal exam CVA tenderness GU exam High Risk Family histry f stne disease r kidney failure Knwn histry f: bne disease, inflammatry bwel disease, cystic fibrsis, gut, deafness, failure t thrive, seizure disrder, immbility, cerebral palsy, spina bifida, nephrectmy, single kidney, nephrcalcinsis Urlgy abnrmality: Ureterpelvic junctin bstructin, psterir urethral valves, duplex system, bladder extrphy Medicatin expsure: Fursemide, calcitril, tpiramate, crticsterids, antiretrvirals, supplement/vitamin use, ketgenic diet, acetazlamide Page 3 f 8

4 LABORATORY STUDIES IMAGING Labratry Studies Obtain urinalysis Send RFP if: Cncern fr electrlyte abnrmality Renal insufficiency Send CBC & urine culture if: Cncern fr urinary tract infectin Send hcg if (female) patient t underg CT scan Imaging Renal Ultrasund Psitive fr stne: fllw Clinical Management Guideline Negative fr stne with secndary findings (hydrnephrsis r hydrureter): Lw dse CT withut cntrast Negative fr stne withut secndary findings High clinical suspicin: Lw dse CT withut cntrast Lw clinical suspicin: Cnsider alternative diagnsis THERAPEUTICS Analgesia (using Visual Analg Pain Scale 1-10) Oral fr Pain Scres 1-4 Ibuprfen every 6 hurs as needed- refer t CHCO standard dsing *Preferred (max dse: 600mg) Acetaminphen every 4 hurs as needed- refer t CHCO standard dsing (max dse: 650mg) Oral fr Pain Scres 5-7 r nt relieved by ther PO medicatins Oxycdne mg/kg every 4 hurs as needed (max dse: 10mg) IV fr Pain Scres 5-7 r nt tlerating PO Ketrlac 0.5mg/kg every 6 hurs as needed (max dse: 30mg, max duratin: 48hrs) Cnsider alternative pain management in patients with renal insufficiency Ensure patient is adequately hydrated at time f administratin IV fr Pain Scres 8-10 r nt relieved by ketrlac Mrphine mg/kg every 2 hurs as needed (max dse: 4mg) Intranasal fr Pain Scres 8-10 with n IV access Fentanyl 1-2mcg/kg x1 dse (max dse: 100mcg) Medical Expulsive Therapy Tamsulsin (Brand: Flmax) MOA: alpha1a-receptr antagnism, smth muscle relaxatin and dilatin f distal ureter In the Emergency Department, patient can be given first dse if frmulary and given in the right timing (befre bed), but can als just be sent hme with prescriptin Page 4 f 8

5 Dsing: Greater than (>) 4 years f age: 0.4mg PO nightly at bedtime Less than r equal t ( ) 4 years f age: 0.2mg PO nightly at bedtime (caregiver t mix capsule cntents with 4mL water and administer 2mL fr 0.2mg dse and discard remainder f slutin) Administratin: Give at night befre bed ptimally. Available as a 0.4mg capsule that may be swallwed whle r pened and administered in applesauce r mixed with water/juice IV Fluids Fr clinical dehydratin, nging lsses Nrmal Saline blus (10-20mL/kg) Nt recmmended t increase urine utput in an effrt t facilitate passage f calculus ADMISSION DISCHARGE CRITERIA Admissin criteria Unable t tlerate ral intake Pain requiring IV analgesia Urinary tract infectin Presence f risk factrs: Slitary kidney Renal transplant Bilateral renal bstructin Renal insufficiency Otherwise, may cnsider discharge if: Adequate pain cntrl Able t maintain hydratin rally Discharge with Outpatient Fllw-up Prvide urine strainer t patient, with instructins Prvide prescriptin fr tamsulsin age greater than (>) 4 years: 0.4mg PO nightly at bedtime age less than r equal t (<) 4 years: 0.2mg PO nightly at bedtime Review imprtance f hydratin Prvide prescriptin(s) fr pain cntrl, as needed Recmmend fllw-up in 2 weeks in the Urlgy Clinic Family may call the fllwing business day fr an appintment Page 5 f 8

6 REFERENCES 1. Tasian GE, et al. Tamsulsin and spntaneus passage f ureteral stnes in children: A multi-institutinal chrt study. J Url 2014; 192(2): Mkhless I, et al. Tamsulsin fr the management f distal ureteral stnes in children: a prspective randmized study. J Pediatr Url 2012; 8(5): Persaud, A.C., et al., Pediatric urlithiasis: clinical predictrs in the emergency department. Pediatrics, (3): p Page 6 f 8

7 CLINICAL IMPROVEMENT TEAM MEMBERS Jeffrey B Campbell, MD Urlgy Brian Caldwell MD Urlgy Jhn Strain, MD Radilgy Sarah Mellin, MD Emergency Medicine Michelle Zapapas, PharmD Kaylee Wickstrm, PI Specialist APPROVED BY Pharmacy & Therapeutics Cmmittee Nvember 3, 2016 Clinical Care Guideline and Measures Review Cmmittee Nvember 29, 2016 MANUAL/DEPARTMENT Clinical Care Guidelines/Quality ORIGINATION DATE Nvember 29, 2016 LAST DATE OF REVIEW OR REVISION Nvember 29, 2016 APPROVED BY Lalit Bajaj, MD, MPH Medical Directr, Clinical Effectiveness REVIEW REVISION SCHEDULE Scheduled fr full review n Nvember 29, Clinical pathways are intended fr infrmatinal purpses nly. They are current at the date f publicatin and are reviewed n a regular basis t align with the best available evidence. Sme infrmatin and links may nt be available t external viewers. External viewers are encuraged t cnsult ther available surces if needed t cnfirm and supplement the cntent presented in the clinical pathways. Clinical pathways are nt intended t take the place f a physician s r ther health care prvider s advice, and is nt intended t diagnse, treat, cure r prevent any disease r ther medical cnditin. The infrmatin shuld nt be used in place f a visit, call, cnsultatin r advice f a physician r ther health care prvider. Furthermre, the infrmatin is prvided fr use slely at yur wn risk. CHCO accepts n liability fr the cntent, r fr the cnsequences f any actins taken n the basis f the infrmatin prvided. The infrmatin prvided t yu and the actins taken theref are prvided n an as is basis withut any warranty f any kind, express r implied, frm CHCO. CHCO declares n affiliatin, spnsrship, nr any partnerships with any listed rganizatin, r its respective directrs, fficers, emplyees, agents, cntractrs, affiliates, and representatives. Page 7 f 8

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