Simultaneous bilateral hemorrhagic pleural effusion and hemorrhagic ascites during percutaneous nephrolithotomy: a...

Percutaneous nephrolithotomy (PCNL) may cause severe thoracic and abdominal complications. Because their onset can be insidious and their intraoperative manifestations atypical, recognition may be delayed. We report a case of sudden bilateral hemorrhagic pleural effusion with hemorrhagic ascites during PCNL and discuss strategies for intraoperative identification and management.

A 63-year-old woman underwent PCNL for multiple right renal calculi. During the procedure, renal pelvic bleeding occurred, followed by a sudden increase in airway pressure to 40 cmH2O, a decrease in oxygen saturation to 92-95%, and a fall in blood pressure to 78/59 mmHg. Bedside ultrasound revealed substantial bilateral pleural effusion and moderate intraperitoneal fluid accumulation. Emergency bilateral chest tube drainage and abdominal paracentesis were performed, evacuating a large volume of pale red blood-tinged fluid. After volume expansion, blood transfusion, and vasopressor support, the patient's vital signs stabilized. She was discharged after 10 days of recovery, and the 3-month follow-up showed no significant abnormalities.

During PCNL, sudden hypoxemia and elevated airway pressure should prompt immediate assessment for severe pleural or peritoneal effusion. In this case, the findings may have resulted from pressure-related communication between the abdominal and thoracic cavities, with fluid translocation through small diaphragmatic defects into both pleural spaces. Bedside ultrasound can serve as a first-line screening tool during PCNL. Continuous ultrasound monitoring, including wearable devices, may offer advantages in prone-position surgery, particularly when ongoing surveillance for pulmonary complications is required.