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 mid- ureter, 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 high- volume 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

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