Nephrolithiasis - When Should I Admit?

I recently had a patient who came in complaining of severe flank pain radiating to his groin with nausea and vomiting… it was determined that he had nephrolithiasis (kidney stones). My attending asked me whether or not we should admit the patient… Good question, I thought. I was able to rattle off the text book treatments, but I wasn’t clear on the guidelines for admission vs. out-patient treatment. Below is an overview of treatment including some clear indications for admission.

General Treatment (for all types of stones):
a-PO analgesic or IV morphine, situation dependent
b-Parenteral NSAID (Ketorolac)
2-Hydration (vigorous)
3-Antibx, if UTI present

Additional treatment measures based on pain severity:
MILD-MOD pain = high fluid intake, oral analgesics, wait for stones to pass (Give pt a urine strainer because you want to know what “kind” of stone the patient has.)
SEVERE pain = IV fluids and pain control, KUB, IVP to find site of obstruction, consult urology (surgery) if stones do not pass in 3 days
ONGOING pain w/o relief from narcotics = Surgery

Types of Surgery (10,000 foot view):
Shock wave lithotripsy: most common, it breaks apart the larger stones so they can be passed spontaneously, typically used for stone >5mm and < 2cm
Percutaneous nephrolithotomy: used if the above fails, if stones are > 2cm, for struvite stones

Admission is indicated if:
1-Oral analgesics are insufficient to manage the pain.
2-Ureteral obstruction from a stone occurs in a solitary or transplanted kidney.
3-Ureteral obstruction from a stone occurs in the presence of a urinary tract infection (UTI), fever, sepsis, or pyonephrosis.
4-Large stones (>1cm)

*The above indications were found in a couple of sources, but more say that the ultimate decision is made on a clinical basis, not solely on guidelines.

Parting suggestion: brush up on the different kinds of kidney stones

Medscape: Nephrolithiasis and Treatment, http://emedicine.medscape.com/article/437096-treatment
Step Up to Medicine 2nd Ed. by Agabegi and Agabegi
Picture: http://knol.google.com/k/kidney-stones#

1 comment:

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