csw nephrolithiasis pathway - seattlechildrens.org · this pathway was developed through local...

Diagnosis Confirmed: Proceed to

Urine analysis results on Confirmed

Phase

PHASE I (SUSPECTED)

Inclusion Criteria· 1 year or older

· Symptomatic/chief complaint of UTI

flank pain, nausea or vomiting AND

· High suspicion of nephrolithiasis

Exclusion Criteria· Less than 1 year

· Low suspicion of nephrolithiasis

· Concern for septic shock

(use septic shock pathway)

Nephrolithiasis v2.0

Explanation of Evidence RatingsSummary of Version Changes

Last Updated: January 2018

Next Expected Review: September 2020© 2018 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

For questions concerning this pathway,

contact: [email protected]

Approval & Citation

Initial Management

Pain Medications

· Ketorolac

· Morphine

Anti-emetics

· Ondansetron

Urinalysis

· Reflex culture

!

Consider

other diagnosis:

Appendicitis

Ovarian/Testicular torsion

Small bowel obstruction

UPJ obstruction

UTI

UA Concern for Infection:

Consider UTI Pathway· Nitrites OR

· Leukocytes esterase OR

· Microscopy shows bacteria OR

· ≥ 10 WBC/HPF

Imaging

· Abdominal ultrasound or renal bladder ultrasound

· CT (not required)

· If ultrasound not diagnostic/clinical suspicion high

discuss with urology prior to CT scan

IV Fluids: 20mL/kg, NS, 1L maximum

NPO

Presenting Symptoms· Pain (47-80%)

· Gross Hematuria (32-55%)

· Nausea/vomiting

Clinical Predictors for Nephrolithiasis· Personal history of nephrolithiasis

· > 5 RBC per HPF on microscopic urinalysis

· History of nausea/vomiting

· Flank pain on physical exam

Phase

Change

Ultrasound Indeterminate

Contact Urology to

determine appropriateness

of low-dose CT scan

Positive

Negative

Consider other diagnosis

Off

Pathway

Abdominal ultrasound or renal bladder ultrasound

[email protected]

septic shock pathway

http://www.seattlechildrens.org/terms-of-use#medical

http://www.seattlechildrens.org/pdf/UTI-pathway.pdf

mailto: [email protected]

http://www.seattlechildrens.org/pdf/septic-shock-pathway.pdf

PHASE II (CONFIRMED)



flank pain, nausea or vomiting and

· High suspicion of Nephrolithiasis


· Low suspicion of Nephrolithiasis


· (use septic shock pathway)


Approval & Citation

Admission Criteria· Not tolerating PO

· Pain not controlled

· Need for IV antibiotics

· Per Urology Recommendation

· Fever ≥ 101.5 F

Reassessment· Pain Management (oxycodone, ibuprofen and

acetaminophen)

· Tamsulosin (only over 2 years of age) if ureteral calculus

· Maintenance IV Fluids

· Trial PO (Clear liquids)

Urology consultation to determine need for admission and plan of care (if not already consulted)

Indications for consult: suspected infection; inability to tolerate PO; poor pain control; return to the ED

Suspected Infection· Urology consultation

· Antibiotics

· Labs: CBC with diff; BUN; creatinine; lytes; blood culture if

concern for obstructed stone & sepsis (Use septic shock

pathway)

Discharge Criteria· Pain well managed

· Tolerating PO

Initial Management

(If not already received)

Pain Medications

· Ketorolac

· Morphine

Anti-emetics

· Ondansetron

Urinalysis

· Reflex Culture

· Renal bladder ultrasound

· CT (not required)

· If ultrasound not diagnostic/

clinical suspicion high discuss

with urology prior to CT scan

IV Fluids: 20mL/kg, NS, 1L

maximum

NPO

UA Concern for Infection:· Nitrites OR

· Leukocytes esterase OR

· Microscopy shows bacteria OR

· ≥ 10 WBC/HPF

UA negative for infection UA positive for infection

Review Urinalysis Results

Phase

Change

Explanation of Evidence RatingsSummary of Version Changes

Discharge

Instructions· Antiemetics, antibiotics & pain

medications if needed

· Return to clinic – 4-6 weeks

for stone in kidney (PCP

referral required); 2 weeks for

stone in ureter. Ureteral stone

f/u can be scheduled by ED in

dedicated Urology clinic slots

· Tamsulosin if indicated

Renal bladder ultrasound

!

Pain Management (oxycodone, ibuprofen and




contact: [email protected] [email protected]





PHASE III (INPATIENT)


IV Fluids

· Administer IV Fluids per pathway

Pain Management

· Ketorolac

· Narcotics

Tamsulosin (only over 2 years of

age) if ureteral calculus

Anti-emetics

· Ondansetron

IV Antibiotics (if infection)

Labs

· CBC with diff

· Blood culture

· Lytes

Nursing

· Pain assessment

Diet

· NPO if surgical patient

Vital signs

· Strict I/O

Admission· IV Fluids per Maintenance IV Fluids Pathway

· Ketorolac; acetaminophen; oxycodone/morphine; ondansetron

· If surgery, IV cefazolin for peri-operative prophylaxis

· If infection then ampicillin + gentamicin OR cefazolin



flank pain, nausea or vomiting and

· Confirmed diagnosis by a providing

MD by ultrasound or CT scan



· (use septic shock pathway)

Discharge Criteria· Pain well managed

· Tolerating PO

Discharge Instructions· follow up appointment in

urology clinic (PCP referral if

needed)

· Antiemetics, antibiotics & pain

medications if needed

· Return to clinic – 4 to 6 weeks

for stone in kidney; 2 weeks for

stone in ureter

· Tamsulosin if indicated

Ongoing Management

Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation




contact: [email protected] [email protected]





Suspected Nephrolithiasis

• This phase is for patients without an imaging-confirmed diagnosis of

nephrolithiasis

• Clinical suspicion for nephrolithiasis should be high (see table below)

CLINICAL PREDICTORS FOR NEPHROLITHIASIS Odds Ratio

Personal history of nephrolithiasis OR 6.55

> 5 RBC per HPF on microscopic urinalysis OR 3.10

History of nausea/vomiting OR 2.39

Flank pain on physical exam OR 2.23

Persaud, Andre C., et al. "Pediatric urolithiasis: clinical predictors in the emergency

department." Pediatrics 124.3 (2009): 888-894.

Phase I (Suspected)

Imaging in Suspected Nephrolithiasis

Renal/Bladder Ultrasound is the recommend 1st line imaging study for children

with suspected nephrolithiasis (AUA1, ESPU2)

Urology on-call should be contacted to help guide ordering of CT in the following

situations:

•Negative ultrasound and very high suspicion of nephrolithiasis

•Hydronephrosis

•Twinkle artifact

•Ureteral dilation

1) Fulgham, Pat Fox, et al. "Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA

technology assessment." The Journal of urology 189.4 (2013): 1203-1213.

2) Riedmiller, H., P. Androulakakis, D. Beurton, R. Kocvara, and U. Köhl. "Guidelines on paediatric urology." European Association of

Urology (2005).

Phase I (Suspected) Phase II (Confirmed)

Phase I (Suspected) Phase II (Confirmed) Phase III (Inpatient)

Phase II (Confirmed)

Suspected Infection

• Fevers or urinalysis suspicious for infection (+ nitrates, bacteria or > 10

WBC/HPF) should prompt urological consultation and antibiotics

• Note: a completely obstructing ureteral calculus with a proximal infected

urinary system may present with a normal urinalysis; if clinical signs of

infection (i.e. high fever) and obstructing ureteral calculus is seen, these

patients should be treated as a suspected infection even in the absence of

abnormalities on the urinalysis

Phase III (Inpatient)

Pre- Operative Antibiotics

• Cefazolin or ampicillin + gentamicin are considered equal alternative 1st-line

pre-operative options according to AUA guidelines1

• Ampicillin + gentamicin should be considered when there is a history of

enterococcal or multi-drug resistant colonization/infection, or if there is a

high suspicion of current bacterial colonization

• Culture-directed peri-operative antibiotics should be utilized if a current

urine culture is available for review

Phase II (Confirmed) Phase III (Inpatient)

Follow Up

• Patients should receive education materials prior to discharge

• Patients with ureteral calculi:

• warrant shorter-interval follow-up, by 2 weeks, as they may be surgical

candidates if the calculus does not pass. Follow up for ureteral stones

only, can be scheduled by the ED in dedicated Urology follow up clinic

slots.

• Will need to strain their urine and watch for a passed calculus

Nephrolithiasis Citation & Approval

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Approved by the CSW Nephrolithiasis Team for the September 29, 2015 go live.

CSW Nephrolithiasis Team:

Urology, Owner Jonathon Ellison, MD

Urology, Owner Paul Merguerian, MD, MS, FAAP

Urology, Stakeholder Thomas Lendvay, MD

Emergency Department, MD Russ Migita, MD

Emergency Department, CNS Sara Fenstermacher, RN

Clinical Pharmacy Eric Harvey, PharmD, MBA

Pharmacy Informatics Rebecca Ford, PharmD

Surgical Unit, CNS Kristine Lorenzo, RN

Urology Clinic Nurse Andrea Bakke, RN

Clinical Effectiveness Team:

Consultant Sara Vora, MD

Project Manager Jennifer Magin, MBA

CE Analyst Holly Clifton, MPH

CIS Informatician Mike Leu, MD, MS, MHS

Carlos Villavicencio, MD, MMI

CIS Analyst Heather Marshall

Librarian Sue Groshong, MLIS

Program Coordinator Asa Herrman

Executive Approval:

Sr. VP, Chief Medical Officer Mark Del Beccaro, MD

Sr. VP, Chief Nursing Officer Susan Heath, RN, MN, NEA-BC

Surgeon-in-Chief Bob Sawin, MD

Retrieval Website: http://www.seattlechildrens.org/pdf/nephrolithiasis-pathway.pdff

Please cite as:

Seattle Children’s Hospital, Ellison, J., Merguerian, P., Fenstermacher, S., Magin, J., Migita, R.,

Vora, S., 2015 September. Nephrolithiasis Pathway. Available from: http://www.seattlechildrens.org/

pdf/nephrolithiasis-pathway.pdf

http://www.seattlechildrens.org/pdf/nephrolithiasis-pathway.pdf

Evidence Ratings

To Bibliography

This pathway was developed through local consensus based on published evidence and expert

opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include

representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical

Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed

as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the

following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):

Quality ratings are downgraded if studies:

· Have serious limitations

· Have inconsistent results

· If evidence does not directly address clinical questions

· If estimates are imprecise OR

· If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that:

· The effect size is large

· If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR

· If a dose-response gradient is evident

Guideline – Recommendation is from a published guideline that used methodology deemed

acceptable by the team.

Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE

criteria (for example, case-control studies).

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Summary of Version Changes

· Version 1.0 (9/29/2015): Go live

· Version 2.0 (1/19/2018): Updated discharge instructions to reflect new availability of dedicated

appointments in Urology clinic for ureteral stones patients

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Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information

that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the

authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the

preparation or publication of this work warrants that the information contained herein is in every

respect accurate or complete, and they are not responsible for any errors or omissions or for the

results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to

consult with their health care provider before making any health care decision.

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Bibliography

Identification

Screening

Eligibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Studies were identified by searching electronic databases using search strategies developed and executed by a medical

librarian, Susan Groshong. An initial search was performed in March, 2015. The following databases were searched –

on the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere: Embase, Clinical Evidence,

National Guideline Clearinghouse, TRIP and Cincinnati Children’s Evidence-Based Recommendations. Retrieval was

limited to humans, English language and 2005 to current. In Medline and Embase, appropriate Medical Subject

Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was

adapted for other databases using text words. Concepts searched were nephrolithiasis, urolithiasis, ureterolithiasis,

urinary calculi and renal colic. Additional articles were identified by team members and added to the results.

Two additional searches were conducted in June, 2015. The first of these used the same databases as above, for the

concept antiemetic therapy. Retrieval was limited to ages 0 – 18, English language and 2005 to date. The following

databases were used for the last search – on the Ovid platform: Medline and Cochrane Central Register of Controlled

Trials; plus Embase. Concepts searched were nephrolithiasis, and related concepts as above, and antibiotic therapy.

Search results were limited to humans, English language, and 2000 to date. Retrieval for all searches was further

limited to certain evidence categories, such as relevant publication types, Clinical Queries, index terms for study types

and other similar limits.

To Bibliography, Pg 2

469 records identified

through database searching

6 additional records identified

through other sources

475 records after duplicates removed

475 records screened 382 records excluded

62 full-text articles excluded,

57 did not answer clinical question

5 outdated relative to other included study93 records assessed for eligibility

31 studies included in pathway

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Bibliography

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csw nephrolithiasis pathway - seattlechildrens.org · this pathway was developed through local...

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