Discharging a Patient

A patient must not be discharged if any of the following complications are suspected:

• Failure of pain control
• Anuria
• A risk of renal failure e.g. a solitary kidney or bilateral obstruction
• Infection: Aggressive therapy and monitoring is required for potentially septic patients who also have ureteric obstruction. The presence of pyrexia mandates urgent full blood count, blood and urine cultures, creatinine and lactate levels should also be obtained. Resuscitation using ‘surviving sepsis’ guidelines in a High Dependency Unit environment is advised. Antibiotic options include gentamicin and co-amoxiclav intravenously.
• Hydronephrosis: The presence of hydronephrosis is an indication for urgent nephrostomy and this is usually performed by a radiologist under fluoroscopic guidance.Patients with stones causing significant ureteric obstruction and pain are treated by stenting pending definitive treatment. Correct insertion is evidenced by x-ray confirmation of the proximal coil in the renal pelvis and distal coil in the bladder. In the 20% of cases where placement fails, then nephrostomy is required. Stents have the potential to cause distressing symptoms and impair quality of life and many urologists are attempting to decrease usage [6].

• Renal failure
• Ureteral stricture
• Urine extravasation
• Perinephric abscess
• Xanthogranulomatous pyelonephritis is an unusual suppurative granulomatous reaction to chronic infection, often in the presence of chronic obstruction from a calculus, stricture or tumor. Surgery is invariably required to completely eradicate the infection and the accompanying calculus and/or obstruction. Kidney-sparing surgery may be undertaken in patients with focal disease.

Discharging a patient

The patient can be discharged if they are pain free and apyrexial. There must be no complications or other factors such as those listed above. It is essential that the correct follow up procedures have been set up and that the patient is made fully aware of the correct advice.

Follow up

Sufficient analgesia must be provided so that the pain can continue to be controlled after discharge

Urology outpatient follow up is organised according to local protocols [2]. However, the following must be carried out:

• Outpatients urology clinic appointment must be set up so that the treatment is continued

• Patient should sieve their urine for stone fragments. These should be kept and taken to the urology clinic

Correct advice

Advise the patient of the following:

• If the pain returns, they are to return to the ED immediately
• To return to the ED immediately if they become unwell or experience fever
• How to use the analgesia
• Drink plenty of fluids, and try to increase urine output to two litres per day

Learning bite

Obstruction and infection in renal colic patients mandate urgent urological referral.