WSHT Renal Pathway

Initial assessment including (but not exclusively):

• History (including detailed pain history) • Examination • Any signs or symptoms of urosepsis (SIRS criteria to be documented) • Dipstick to be documented - including b-HCG in women under 55 • Bloods, including FBC, U+E, Calcium, Uric Acid and CRP

If Renal Colic suspected clinically, the following should be considered immediately:

• Analgesia o 100mg PR to all patients without contraindications o Paracetamol 1g (PO, or IV if vomiting) o Opiate analgesia (e.g 5-10mg PO/IM/SC/IV) to be considered only if NSAIDs and Paracetamol not effective. Antiemetics should be given in conjunction.

• Imaging o Non Contrast CT-KUB is the gold standard for suspected Renal Colic o Urolithiasis is a recurrent disease afflicting young adults (who are susceptible to radiation) and appreciation of previous radiation doses should be made to recurrent stone formers o Prompt CT enhances safety (ensuring the right diagnosis), and enables most patients to be discharged home – improving both patient experience and bed pressures. o During the day (8am – 8pm) – CT KUB can be requested directly from the Emergency Medicine Physician to aid prompt diagnosis and appropriate management o At night (8pm – 8am) – unwell patients (see section below) can have a CT approved through the out-of-hours radiology service to aid prompt diagnosis and management. If a patient doesn’t meet the criteria below, and other diagnoses can be excluded on clinical presentation, then the following procedure is possible: § Patient to be managed in Accident and Emergency overnight (possibly A+E Ward or CDU), ensuring good analgesia § Submit a CT KUB form to A+E X-ray (annotating it at the top right-hand corner for Fast-track slot the next morning) § Either the “Early CT Radiographer” or ISW to arrange for the scan to be done the following morning

Patients requiring special consideration include:

• Any sign or symptom of sepsis with proven ureteric stone o Urgent discussion with the Registrar or Consultant is mandated, and the patient is likely to require fluid resuscitation, intravenous broad spectrum antibiotics, and immediate decompression of the obstructed kidney (nephrostomy or stent) with consideration of a higher level of care (HDU/ITU)

• Single kidney, bilateral ureteric stones, or deranged renal function o Urgent assessment of renal function, and patient is likely to require prompt decompression (nephrostomy or stent). Keep NBM until discussion with Urology Registrar o Patient will be admitted if acute kidney injury (AKIN stage 1, or RIFLE category “Risk”)

• Following ESWL o Steinstrasse – multiple ureteric fragments may block the after successful fragmentation in the upper urinary tract. Stones are likely to be radio-opaque so KUB X-ray could be used to diagnose rather than repeat CT o Peri-nephric haematoma – rare (less than 1/500) but potentially serious and symptoms and signs of shock following ESWL (with or without haematuria) should alert the treating team to the possibility

• Pregnant patients o stones in pregnancy are challenges to diagnose and manage, and early discussion with the Urology and Obstetric teams is recommended in all patients with severe in pregnancy

Most renal colic patients can be managed as an outpatient. The following are indications for admission and involvement of the Surgical SHO: • Pain not controlled with NSAIDs, Paracetamol and other oral analgesia • Any symptoms or signs of urosepsis (e.g. WBC >16, Nitrites/Leuk on dipstick, Fever) • At risk of loss of renal function (Acute Kidney Injury, single kidney, bilateral ureteric stones) • Stones >6mm are less likely to pass spontaneously and consideration should be made for primary treatment ( or ) or disobstruction with a ureteric stent.

Note – UNTIL STONE DISEASE IS CONFIMRED ON CT, these patients should be treated as a pain of unknown origin and managed in the A+E Departments (or A+E Wards) on either site

Discharge planning

• The patient should be alerted to the fact that pain will come and go in waves but if controllable with analgesia then it is best managed at home • 400mcg Tamsulosin might be offered to all patients being discharged to facilitate Medical Expulsive Therapy although recent high level evidence questions its efficacy. Patients must be informed that this is an unlicensed use. NOT to be used in breastfeeding mothers. • Analgesia for discharge should include the following if there are no contraindications: o 100mg PR Diclofenac od (to be taken for 4d regardless of pain) o 50mg PO Diclofenac orally OD (to be taken PRN once a day) o 1g Paracetamol QDS to be taken for 4d regardless of pain

All patients should be told to re-present if: • Any sign or symptom of sepsis • Pain not controllable with analgesia provided • Stops passing

Follow up • Please ensure that Calcium and Uric Acid are tested before discharge, and if there is any derangement in eGFR then NSAIDs should be withheld and the U+E repeated before clinic • If the patient sees the stone pass, it would be useful to bring it to clinic in a sealed bag. Please suggest that patients micturate through a sieve to try and catch it. • There will be slots in the Specialist Stone Clinic at St Richards for these patients to be seen within 2-4 weeks. To book them on SemaHelix please discharge as follows: o A+E Attend > Situation list > Discharge > Urology Stone Clinic o Please inform the patients that they should receive an appointment in 2-4wks. • For Worthing patients, please also discharge them as above but also send a copy of the A+E notes to the Urology Secretaries to ensure that the patients get booked to the correct clinic.