Air embolism complicating percutaneous ultrasonic lithotripsy

Area of Science:

• Urology
• Medical Device Safety
• Pathology

Background:

• Percutaneous ultrasonic lithotripsy is a common procedure for kidney stone removal.
• Venous air embolism is a known but rare complication of certain medical procedures.

Observation:

• Sudden death occurred during percutaneous ultrasonic lithotripsy.
• Autopsy revealed evidence of air embolism.

Findings:

• The air embolism resulted from a suction pump connected in reverse.
• The reversed pump forced air into the urinary tract instead of aspirating fluid.
• This specific cause of air embolism during this procedure is previously unreported.

Implications:

• Highlights the critical importance of correct medical device setup.
• Suggests a need for enhanced safety protocols in lithotripsy procedures.
• Underscores the potential for rare but fatal complications with standard equipment.