Nephrolithiasis v.1.

0
Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

PHASE I (Suspected)

Inclusion Criteria
1 year or older
Symptomatic/chief complaint of UTI
flank pain, nausea or vomiting and
High suspicion of Nephrolithiasis
!
Consider
other diagnosis:
Appendicitis
Ovarian/Testicular torsion
Small bowel obstruction
UPJ obstruction
UTI

UA Concern for Infection:

Consider UTI Pathway

Exclusion Criteria
Less than 1 year
Low suspicion of Nephrolithiasis
Concern for septic shock (use septic
shock pathway)

Nitrites OR
Leukocytes esterase OR
Microscopy shows bacteria OR
10 WBC/HPF

Clinical Predictors for Nephrolithiasis

Presenting Symptoms

Pain (47-80%)
Gross Hematuria (32-55%)
Nausea/vomiting

Personal history of nephrolithiasis

> 5 RBC per HPF on microscopic urinalysis
History of nausea/vomiting
Flank pain on physical exam

Initial Management
Imaging
Abdominal
Abdominalultrasound
ultrasoundor
orrenal
renalbladder
bladderultrasound
ultrasound
CT (not required)
If ultrasound not diagnostic/clinical suspicion high
discuss with urology prior to CT scan

Pain Medications
Ketorolac
Morphine
Anti-emetics
Ondansetron

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

Urinalysis
Reflex culture

NPO

Contact Urology to
determine appropriateness
of low-dose CT scan

Indeterminate

Ultrasound

Negative
Consider other diagnosis

Off
Pathway

Positive

Diagnosis Confirmed: Proceed to

Urine analysis results on Confirmed
Phase

Phase
Change

For questions concerning this pathway,

contact: Nephroithiasis@seattlechildrens.org
2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: Sept 2015

Next Expected Revision: Sept 2020

Nephrolithiasis v.1.0
Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

PHASE II (Confirmed)
Initial Management
(If not already received)

Inclusion Criteria

Renal bladder ultrasound

CT (not required)
If ultrasound not diagnostic/
clinical suspicion high discuss
with urology prior to CT scan

1 year or older
Symptomatic/chief complaint of UTI
flank pain, nausea or vomiting and
High suspicion of Nephrolithiasis

Pain Medications
Ketorolac
Morphine

Exclusion Criteria
Less than 1 year
Low suspicion of Nephrolithiasis
Concern for septic shock (use septic
shock pathway)

Anti-emetics
Ondansetron

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

maximum

Urinalysis
Reflex Culture

NPO

UA Concern for Infection:

Review Urinalysis Results

UA negative for infection

UA positive for infection

Reassessment

Nitrites OR
Leukocytes esterase OR
Microscopy shows bacteria OR
10 WBC/HPF

Suspected Infection

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
Antibiotics
Labs: CBC with diff; BUN; creatinine; lytes; blood culture if
concern for obstructed stone & sepsis (Use septic shock
pathway)

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

Discharge
Instructions
Discharge Criteria
Pain well managed
Tolerating PO

PCP referral needed for

follow up appointment in
urology clinic
Antiemetics, antibiotics &
pain medications if needed
Return to clinic 4-6 weeks
for stone in kidney; 2-4
weeks for stone in ureter
Tamsulosin if iindicated

Admission Criteria

Not tolerating PO
Pain not controlled
Need for IV antibiotics
Per Urology Recommendation
Fever 101.5 F

For questions concerning this pathway,

contact: Nephrolithiasis@seattlechildrens.org
2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Phase
Change

Last Updated: Sept 2015

Next Expected Revision: Sept 2020

Nephrolithiasis v.1.0
Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

PHASE III (INPATIENT)

Inclusion Criteria
1 year or older
Symptomatic/chief complaint of UTI
flank pain, nausea or vomiting and
Confirmed diagnosis by a providing
MD by ultrasound or CT scan

Exclusion Criteria
Less than 1 year
Concern for septic shock (use septic
shock pathway)

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

Ongoing Management
IV Fluids

Administer IV Fluids per pathway

Pain Management

Ketorolac

Narcotics
Tamsulosin (only over 2 years of
age) if ureteral calculus
Anti-emetics

Ondansetron

Labs

CBC with diff

Blood culture

Lytes
Nursing

Pain assessment
Diet

NPO if surgical patient

Vital signs

Strict I/O

IV Antibiotics (if infection)

Discharge Instructions

Discharge Criteria
Pain well managed
Tolerating PO

PCP referral needed for follow

up appointment in urology clinic
Antiemetics, antibiotics & pain
medications if needed
Return to clinic 4 to 6 weeks
for stone in kidney; 2-4 weeks
for stone in ureter
Tamsulosin if indicated

For questions concerning this pathway,

contact: Nephrolithiasis@seattlechildrens.org
2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: Sept 2015

Next Expected Revision: Sept 2020

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. Khl. "Guidelines on paediatric urology." European Association of
Urology (2005).

Phase I (Suspected)

Phase II (Confirmed)

Phase I (Suspected)

Phase II (Confirmed)

Phase III (Inpatient)

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 II (Confirmed)

Pre- Operative Antibiotics

Cefazolin or ampicillin + gentamicin are considered equal alternative 1 st-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 III (Inpatient)

Phase II (Confirmed)

Phase III (Inpatient)

Nephrolithiasis Citation & Approval

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

CSW Nephrolithiasis Team:

Urology, Owner
Urology, Owner
Urology, Stakeholder
Emergency Department, MD
Emergency Department, CNS
Clinical Pharmacy
Pharmacy Informatics
Surgical Unit, CNS
Urology Clinic Nurse

Jonathon Ellison, MD
Paul Merguerian, MD, MS, FAAP
Thomas Lendvay, MD
Russ Migita, MD
Sara Fenstermacher, RN
Eric Harvey, PharmD, MBA
Rebecca Ford, PharmD
Kristine Lorenzo, RN
Andrea Bakke, RN

Clinical Effectiveness Team:

Consultant
Project Manager
CE Analyst
CIS Informatician
CIS Analyst
Librarian
Program Coordinator

Sara Vora, MD
Jennifer Magin, MBA
Holly Clifton, MPH
Mike Leu, MD, MS, MHS
Carlos Villavicencio, MD, MMI
Heather Marshall
Sue Groshong, MLIS
Asa Herrman

Executive Approval:
Sr. VP, Chief Medical Officer
Sr. VP, Chief Nursing Officer
Surgeon-in-Chief

Mark Del Beccaro, MD

Susan Heath, RN, MN, NEA-BC
Bob Sawin, MD

Retrieval Website: http://www.seattlechildrens.org/pdf/nephrolithiasis.pdf

Please cite as:
Seattle Childrens 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.pdf

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Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. 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).

To Bibliography

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Summary of Version Changes

Version 1.0 9/29/2015: Go live

Return to Home

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 Childrens 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
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 Childrens 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.

Identification
469 records identified
through database searching

6 additional records identified

through other sources

Screening
475 records after duplicates removed

475 records screened

382 records excluded

93 records assessed for eligibility

62 full-text articles excluded,

57 did not answer clinical question
5 outdated relative to other included study

Eligibility

Included
31 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

To Bibliography, Pg 2

Return to Home

antibiotics? Urol Ann [Antibiotic]. 2014;6(2):127-129.

Bariol SV, Moussa SA, Tolley DA. Contemporary imaging for the management of urinary stones.
Bibliography
EAU Update Ser [Nephrolithiasis]. 2005;3(1
SPEC. ISS.):3-9.
Barrett TW, DiPersio DM, Jenkins CA, et al. A randomized, placebo-controlled trial of ondansetron,
metoclopramide, and promethazine in adults. Am J Emerg Med [Nephrolithiasis].
2011;29(3):247-255. Accessed 20110218; 8/26/2015 4:57:04 PM. http://dx.doi.org/10.1016/
j.ajem.2009.09.028.
Becker G, Caring for Australians with Renal Impairment (CARI). The CARI guidelines. kidney
stones: Uric acid stones. Nephrology [Nephrolithiasis]. 2007;12(Suppl 1):S21-5.
Best J, Kitlowski AD, Ou D, Bedolla J. Diagnosis and management of urinary tract infections in the
emergency department. Emerg med pract [Nephrolithiasis]. 2014;16(7):1-23.
Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: A
randomized controlled trial comparing 3 common agents. Am J Emerg Med [Nephrolithiasis].
2006;24(2):177-182.
Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock MT. Alpha-blockers as medical expulsive
therapy for ureteral stones. Cochrane Database of Systematic Reviews [Nephrolithiasis].
2014;4.
Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: An updated
cochrane systematic review with meta-analysis and mixed treatment comparison in a
bayesian framework. BMJ Open [Antiemetic]. 2012;2(4).
Chua ME, Park JH, Castillo JC, Morales ML Jr. Terpene compound drug as medical expulsive
therapy for ureterolithiasis: A meta-analysis. Urolithiasis [Nephrolithiasis]. 2013;41(2):143151. Accessed 20130318; 3/16/2015 5:54:22 PM. http://dx.doi.org/10.1007/s00240-012-05383.
Coursey CA, Casalino DD, Remer EM, et al. ACR appropriateness criteria acute onset flank pain-suspicion of stone disease. Ultrasound Q [Nephrolithiasis]. 2012;28(3):227-233. Accessed
20120824; 3/16/2015 5:54:22 PM.
Crompton G, Cosson P. A systematic review comparing the appropriateness of the intravenous
urogram and the computed tomography urogram in terms of diagnostic accuracy and risk of
radiation dose for patients with urolithiasis. Radiography [Nephrolithiasis]. 2011;17(4):304310.
Edwards J, Meseguer F, Faura C, Moore AR, McQuay HJ, Derry S. Single dose dipyrone for acute
renal colic pain. Cochrane Database of Systematic Reviews [Nephrolithiasis]. 2013;6.
Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in
adult emergency department patients: Randomized controlled trial comparing ondansetron,
metoclopramide, and placebo. Ann Emerg Med [Nephrolithiasis]. 2014;64(5):526-532.e1.
Accessed 20141202; 8/26/2015 4:57:04 PM. http://dx.doi.org/10.1016/
j.annemergmed.2014.03.017.

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Ernst AA, Weiss SJ, Park S, Takakuwa KM, Diercks DB. Prochlorperazine versus promethazine
for uncomplicated nausea and vomiting in the emergency department: A randomized, doubleblind clinical trial. Ann Emerg Med [Nephrolithiasis]. 2000;36(2):89-94.
Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for
imaging in the management of ureteral calculous disease: AUA technology assessment. J
Urol [Nephrolithiasis]. 2013;189(4):1203-1213. Accessed 20130408; 3/16/2015 5:54:22 PM.
http://dx.doi.org/10.1016/j.juro.2012.10.031.
Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDS) versus opioids for acute
renal colic. Cochrane Database of Systematic Reviews [Nephrolithiasis]. 2009;4.
Hollingsworth JM, Rogers MA, Kaufman SR, et al. Medical therapy to facilitate urinary stone
passage: A meta-analysis. Lancet [Nephrolithiasis]. 2006;368(9542):1171-1179. Accessed
20061002; 3/16/2015 5:54:22 PM.
Krambeck AE, Lieske JC. Infection-related kidney stones. Clin Rev Bone Miner Metab
[Nephrolithiasis]. 2011;9(3-4):218-228.
Lu Z, Dong Z, Ding H, Wang H, Ma B, Wang Z. Tamsulosin for ureteral stones: A systematic
review and meta-analysis of a randomized controlled trial. Urol Int [Nephrolithiasis].
2012;89(1):107-115. Accessed 20120731; 3/16/2015 5:54:22 PM. http://dx.doi.org/10.1159/
000338909.
Mezentsev VA. Meta-analysis of the efficacy of non-steroidal anti-inflammatory drugs vs. opioids
for SWL using modern electromagnetic lithotripters. Int Braz J Urol [Nephrolithiasis].
2009;35(3):293-297. Accessed 20090622; 3/16/2015 5:54:22 PM.
National GC. Guidelines on urolithiasis. . http://www.guideline.gov/
content.aspx?id=45324&search=urolithiasis;. Updated 2013. Accessed 3/17, 2015.
National GC. Guidelines on paediatric urology. . http://www.guideline.gov/
content.aspx?id=47872&search=urolithiasis;. Updated 2013. Accessed 3/17, 2015.
Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of
urolithiasis: A meta-analysis. AJR Am J Roentgenol [Nephrolithiasis]. 2008;191(2):396-401.
Accessed 20080723; 3/16/2015 5:54:22 PM. http://dx.doi.org/10.2214/AJR.07.3414.
Parys B, McClinton S, Watson GM, et al. BAUS section of endourology guidelines for acute
management of first presentation of renal/ureteric lithiasis. Br J Med Surg Urol
[Nephrolithiasis]. 2009;2(3):134-136.
Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: A
multicentre, randomised, placebo-controlled trial. Lancet [Nephrolithiasis].
2015;386(9991):341-349. Accessed 20150803; 8/26/2015 5:00:51 PM. http://dx.doi.org/
10.1016/S0140-6736(15)60933-3.

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Bibliography
Picozzi SC, Ricci C, Gaeta M, et al. Urgent ureteroscopy as first-line treatment for ureteral
stones: A meta-analysis of 681 patients. Urol Res [Nephrolithiasis]. 2012;40(5):581-586.
Accessed 20120914; 3/16/2015 5:54:22 PM. http://dx.doi.org/10.1007/s00240-012-0469-z.
Picozzi SC, Ricci C, Gaeta M, et al. Urgent shock wave lithotripsy as first-line treatment for
ureteral stones: A meta-analysis of 570 patients. Urol Res [Nephrolithiasis]. 2012;40(6):725-731.
Accessed 20121112; 3/16/2015 5:54:22 PM. http://dx.doi.org/10.1007/s00240-012-0484-0.
Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral
calculi. Eur Urol [Nephrolithiasis]. 2007;52(6):1610-1631.
Steinberg PL, Nangia AK, Curtis K. A standardized pain management protocol improves
timeliness of analgesia among emergency department patients with renal colic. Qual Manag
Health Care [Nephrolithiasis]. 2011;20(1):30-36. Accessed 20101230; 3/16/2015 5:54:22 PM.
http://dx.doi.org/10.1097/QMH.0b013e31820429d9.
Wang H-, Velazquez N, Zapata D, et al. Effectiveness of medical expulsive therapy for pediatric
urolithiasis: Systematic review and meta-analysis. J Endourol [Nephrolithiasis]. 2014;28:A155.
Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on urologic surgery
antimicrobial prophylaxis. J Urol [Nephrolithiasis]. 2008;179(4):1379-1390. Accessed 20080317;
8/26/2015 4:57:04 PM. http://dx.doi.org/10.1016/j.juro.2008.01.068.

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Title v.1: Description

Executive Summary

Explanation of Evidence Ratings

PHASE I (E.D. or INPATIENT)

Test Your Knowledge

Summary of Version Changes

Citation Information
Inclusion Criteria
Text
Text

Admit Criteria
Text
Text

Exclusion Criteria
Text

Therapy or
Assessment
Text
Text

Verb,
Descriptive

Diagnostic Test

!
Safety Alerts
Tests Not
Recommended

Verb, Descriptive

Therapy or
Assessment
Text
Text

Header
Verb, Descriptive

Phase Change

Text
Text

Discharge
Criteria
Text
Text

Verb, Descriptive

Discharge
Instructions
Text
Text

Off
Pathway

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For questions concerning this pathway,

contact: xxxxxxxxxxxxxx@seattlechildrens.org
2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: Month Year

Next Expected Revision: Month Year