Transcript Case study of a patient with kidney stones

How to use Clinical Evidence to get the
most up-to-date information, quickly, to
aid your decision making
A case presentation
using the CE review on
kidney stones
A typical history of ureteric stones
Case history
• 37-year-old man
• Self-employed builder
• After a few twinges over past 2 months, presents with 2 hours of
excruciating pain in left groin
• KUB appears normal in A+E, but blood ++ on urine dip
• Referred to urology
• IVU showed two small calculi, 4 mm and 5 mm, sited in left midureter, with no signs of dilatation or hydronephrosis
Questions that might arise…
What is the best conservative management?
• Analgesia and fluids are the obvious answers, but…
– How much fluid?
– Some people use hyoscine as an adjunct to other analgesics —
is this a good idea?
– Is there anything else that could be done?
– How strong is the evidence supporting our usual practice?
Removing
symptomatic
ureteric stones
Management of
acute renal colic
alpha-blockers
categorised as
‘Likely to be
beneficial’
fluids categorised
as ‘Unknown
effectiveness’
antispasmodics
categorised as
‘Unlikely to be
beneficial’
moderate-quality evidence
for using alpha-blockers
full details about
the RCTs
(tamsulosin was
the most
commonly tested)
no good RCT
evidence to
support highvolume iv fluids
Changing management
• Consider adding an alpha-blocker (possibly tamsulosin)
to speed up stone explusion
• Avoid anti-spasmodics
• Stick with regular iv fluid replacement
Summary
• Clinical Evidence can be used to make sure your
practice is up to date
– Answers clinical questions
– Keeps you informed of new treatments
– Demonstrates when existing treatments are not supported by
good evidence
“BMJ Publishing Group Limited (“BMJ Group”) 2009. All rights reserved.”