Abstract
A 29-year-old patient with normal preanesthetic evaluation was planned for percutaneous nephrolithotomy (PCNL) for right nephrolithiasis with right pyelolithiasis. Surgery was performed under general anesthesia with endotracheal intubation with muscle relaxation. At the conclusion of surgery, when the patient was turned over to supine position, tense abdomen was noted. Immediately extended focused assessment with sonography in trauma (eFAST) was done in which both right and left quadrants of abdomen including pericardial and suprapubic region, right and left thoracic, and both lung basis were examined. Fluid collection was seen in Morison’s pouch which was drained by the urologist under real-time ultrasonography guidance by anesthesiologist. Distension of abdomen subsequently subsided and patient had normal vitals. Trachea was extubated and patient shifted to post-operative ward. eFAST and FAST scans are routine procedures in the rapid assessment of trauma victims in emergency settings. The fluid extravasation during a routine PCNL procedure may lead to abdominal compartment syndrome. This case demonstrated that use of eFAST rapidly detected abdominal collection and ruled out life-threatening conditions such as hemothorax and pneumothorax and prevented abdominal compartment syndrome. Our case is only an example that potentially lethal conditions like these may be encountered in the perioperative setting and the knowledge of eFAST scan may be of great help.
Highlights
Complications such as abdominal compartment syndrome are rare but potentially life-threatening conditions [1] that occur during percutaneous nephrolithotomy (PCNL) and require urgent diagnosis and treatment to prevent morbidity and mortality
We report a case where the use of extended focused assessment with sonography in trauma (eFAST) helped diagnose and promptly treat one such serious complication of PCNL within the operation theater
While classically in focused assessment with sonography in trauma (FAST) scan included four areas for fluid collection, namely perihepatic space, perisplenic space, pericardium and the pelvis, the eFAST allowed the examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. eFAST is quick and easy to perform, it is as specific as chest X-rays but more sensitive than the latter in terms of detection of occult pneumothoraces after trauma [2]
Summary
Complications such as abdominal compartment syndrome are rare but potentially life-threatening conditions [1] that occur during percutaneous nephrolithotomy (PCNL) and require urgent diagnosis and treatment to prevent morbidity and mortality. The large numbers of stones and their fragments required further surgical time and the initial decrease of tidal volume to 6 ml/kg was done to decrease the intrathoracic pressure. EFAST was done in which the left and right thoracic views were done to exclude hemothorax and pneumothorax Both right and left quadrants of the abdomen were scanned along with the pericardial and suprapubic scan. After the return of adequate muscle strength, spontaneous breathing, and normalization of intrathoracic pressure, trachea was extubated and patient was shifted to post-operative ward. In the post-operative ward, patient was managed conservatively with analgesics, antibiotics, fluids, and diuretics. A repeat ultrasonogram done by radiologist 2 days later showed fluid collection in Morrison’s pouch, left upper abdomen, and bilateral iliac fossa but the collection was smaller in volume. Patient’s condition had normalized in the follow-up visit a week later
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