When is a patient with a renal hematoma ready for discharge?

Discharge Criteria for Patients with Renal Hematoma

A patient with renal hematoma is ready for discharge when they are hemodynamically stable with no signs of ongoing bleeding, have normal or stable renal function, and show clinical improvement with resolving or stable hematoma on follow-up imaging. 1

Hemodynamic Stability Assessment

Hemodynamic stability is the primary criterion for safe discharge:

• Patient must demonstrate sustained hemodynamic stability without requiring fluid resuscitation or blood transfusions
• Vital signs should be within normal limits for at least 24-48 hours
• No evidence of ongoing bleeding (stable hemoglobin/hematocrit values)
• No signs of shock or hemodynamic compromise

Clinical Parameters to Monitor Before Discharge

Renal Function

• Stable or improving renal function parameters
• Creatinine levels returning to baseline or stable
• Adequate urine output

Pain Management

• Pain adequately controlled with oral medications
• Decreasing analgesic requirements

Imaging Findings

• Follow-up CT imaging showing stable or resolving hematoma in patients with:
  • Deep lacerations (AAST Grade IV-V injuries)
  • Clinical signs of complications (fever, worsening flank pain, ongoing blood loss, abdominal distention) 1
• No evidence of expanding hematoma or active extravasation
• Resolution of any urinary extravasation if previously present

Special Considerations

Urinary Extravasation

• Isolated urinary extravasation is not an absolute contraindication to discharge if the patient is otherwise stable 1
• Non-resolving urinomas may require ureteric stenting or percutaneous drainage before discharge 1

Anticoagulation Management

• If the patient was on anticoagulation therapy, ensure appropriate plan for resumption
• Consider delaying resumption until follow-up imaging confirms hematoma stability or resolution 2

Post-Angioembolization Patients

• Patients who underwent angioembolization should demonstrate:
  • No post-procedural complications
  • Stable vital signs
  • No evidence of recurrent bleeding
  • Pain adequately controlled with oral medications 1

Discharge Planning Requirements

1. Clear follow-up plan with urology
2. Scheduled follow-up imaging as indicated (typically 2-4 weeks post-discharge for high-grade injuries)
3. Patient education regarding:
   • Warning signs requiring immediate medical attention (increased pain, fever, hematuria, dizziness)
   • Activity restrictions (typically 4-6 weeks of limited physical activity)
   • Medication management

Common Pitfalls to Avoid

1. Premature Discharge: Discharging patients before ensuring hemodynamic stability for at least 24-48 hours
2. Inadequate Follow-up: Failing to arrange appropriate follow-up imaging for high-grade injuries
3. Overlooking Delayed Complications: Some complications may present days after initial injury (e.g., delayed bleeding, infection of hematoma) 3
4. Inadequate Patient Education: Patients must understand warning signs requiring immediate return to hospital

Discharge Algorithm

1. Confirm hemodynamic stability:

   • Stable vital signs for 24-48 hours
   • No active bleeding (stable hematocrit)
   • No transfusion requirements

2. Verify clinical improvement:

   • Decreasing pain requirements
   • Afebrile status
   • Normal or improving renal function
   • Tolerating oral intake

3. Review imaging:

   • For high-grade injuries (AAST IV-V): Follow-up CT showing stable or improving hematoma
   • For low-grade injuries (AAST I-III): Follow-up imaging may not be necessary if clinically improving 1

4. Establish follow-up plan:

   • Urology appointment within 1-2 weeks
   • Follow-up imaging as indicated by injury grade
   • Clear instructions for medication management

5. Provide discharge instructions:

   • Activity restrictions
   • Warning signs requiring immediate medical attention
   • Medication regimen

By following this structured approach, clinicians can ensure safe discharge while minimizing the risk of complications and readmission for patients with renal hematoma.