Case Report: Point-of-care ultrasound-guided rescue of massive haemothorax after percutaneous nephrolithotomy

1 Introduction

Percutaneous nephrolithotomy (PCNL) is the first-line therapeutic strategy for renal stones larger than 2 cm and has superiority to open surgical techniques for renal stone treatment (1). Despite being minimally invasive operation, the complications of PCNL are as high as 83%, but many of them are minor (2). The serious complications of PCNL are present with rates between 1.1% and 7.0%, including bleeding, renal pelvis injury, abdomen viscera injury, pneumonia/atelectasis, escape of stone fragments, which require early diagnosis and timely treatment (3).

Haemothorax is a rare but well-documented complication following PCNL (4). It almost invariably occurs at or immediately following the surgical procedure as a consequence of pleural injury (5). Massive haemothorax with occult presentation poses a diagnostic challenge, as initial perinephric drainage may not reveal bleeding. Therefore, PCNL-induced hemothorax is a critical perioperative complication that anesthesiologists must promptly recognize and manage.

Point-of-care ultrasound (POCUS) has emerged as a valuable tool in the perioperative period, facilitating real-time assessment and management of complications (6). It is particularly effective in diagnosing pleural effusion, pneumothorax, and other critical conditions, thereby guiding immediate interventions (7). Here, we present a case of successfully managed massive hemothorax following PCNL, resulting from renal artery injury combined with pleural injury. This case highlights the crucial role of POCUS in managing rare complications following PCNL, such as hemothorax.

2 Case presentation

2.1 Patient information

A 64-year-old man with an American Society of Anesthesiologists (ASA) physical status of II, a body mass index (BMI) of 24.5 kg/m², and a functional capacity >4 metabolic equivalents (METs) was scheduled for PCNL for a left renal stone. His medical history was notable for acute coronary vascular disease two years prior, for which he had undergone percutaneous coronary intervention (PCI). He reported a history of bleeding gums and had discontinued aspirin 20 days before surgery. Preoperative coagulation studies—including prothrombin time, activated partial thromboplastin time, and platelet count—were within normal limits. Other preoperative laboratory tests, electrocardiogram, and chest radiography were unremarkable, with a hemoglobin level of 15.6 g/dL. Computed tomography revealed multiple stones in the left renal pelvis with associated hydronephrosis.

2.2 Anesthesia and surgical procedure

Upon entering the operating room, the patient's blood pressure was 138/75 mmHg, heart rate was 85 bpm, and SpO₂ was 98%. General anesthesia was induced with etomidate, fentanyl and cisatracurium. After endotracheal intubation, anesthesia maintenance was with propofol and remifentanil, with the bispectral Index kept between 40 and 60.

In the prone position, the left renal middle calyces were punctured under the guidance of ultrasound via the 11th left intercostal space. A standard PCNL started after confirming access to the renal collecting system. Approximately 2 h into the surgery, airway pressure increased to 28 cm H₂O. After administering additional muscle relaxants and suctioning, the airway pressure was maintained at 25 cm H₂O, with clear breath sounds in both lungs. Given that the elevated airway pressure was likely due to the prone position, no further intervention was deemed necessary. However, a progressive decrease in blood pressure was noted, with hemoglobin levels dropping to 14.0 g/dL. Blood pressure was maintained at around 100/60 mmHg through intermittent administration of ephedrine and fluid resuscitation. The total duration of the operation was 3.5 h. Blood loss through the working channel was less than 50 mL, urine output was 750 mL, and intraoperative fluid replacement included 1,000 mL of colloids and 1,100 mL of crystalloids.

Upon transferring the patient to a transport stretcher, his blood pressure acutely dropped to 60/40 mmHg, with a HR of 115 bpm. We continued fluid resuscitation and initiated dopamine at 5 µg/kg/min. Subsequently, the patient's blood pressure was sustained at 80–90/50–60 mmHg. Arterial blood gas analysis revealed a hemoglobin level of 8.2 g/dL and a hematocrit of 0.28.

2.3 Postoperative course

2.1.1 Postoperative period in the post-anesthesia care unit (PACU)

The patient was then transferred to the post-anesthesia care unit (PACU), and extubated upon regaining consciousness. Oxygen was administered at 2 L/min through a nasal catheter. About 10 min after extubation, the patient's oxygen saturation could not be maintained and dropped to about 80%, while blood pressure gradually dropped to 60/40 mmHg. The patient was then pumped with dopamine (10 μg/kg/min) and epinephrine (0.5 μg/kg/min), which helped maintain blood pressure at 90/60 mmHg with a HR of 130 bpm. Blood gas analysis revealed a hemoglobin level of 6.0 g/dL, PaO₂ of 61.8 mmHg, and PaCO₂ of 40 mmHg, suggesting ongoing active bleeding. Notably, no significant amount of bloody fluid was observed in the perinephric drain (nephrostomy tube) that had been placed for retroperitoneal drainage.

2.1.2 Transfer to anesthesia intensive care unit (AICU) and POCUS diagnosis

Therefore, the patient was urgently transferred to the Anesthesia Intensive Care Unit (AICU) for further diagnosis and treatment. An extended focused assessment with sonography in trauma examination (eFAST) was performed using POCUS. Immediate ultrasound scan showed massive pleural effusion in the left chest (Figure 1), while the abdominal, pericardial, and suprapubic scans were normal. Supplementary Video S1 shows the ultrasound images of the massive pleural effusion in the left chest, clearly demonstrating the accumulation of fluid and further confirming the diagnosis. Supplementary Video S2 illustrates the pericardial ultrasound examination, showing normal findings and thus ruling out the possibility of myocardial infarction.

2.1.3 Thoracentesis and chest tube placement

Following POCUS diagnosis, thoracentesis was performed, and a chest tube was inserted. A total of 500 mL of sanguineous drainage was obtained from the left chest. Considering that the drainage rate was too fast, chest tube was temporarily clamped. At this time, the patient was receiving oxygen at 2 L/min via a face mask, with pulse oximetry saturation maintained at approximately 90%. Blood pressure was stabilized at 100/60 mmHg following blood transfusion (4 units of red blood cells and 200 mL of plasma).

2.1.4 Renal artery embolization and follow-up

Subsequently, the patient underwent digital subtraction angiography, which revealed hemorrhage from the superior branch of the left renal artery. Renal artery embolization was performed, with satisfactory hemostasis achieved and no further active bleeding observed in the superior branch of the left renal artery (Figure 2). The patient was then returned to the ward. The chest tube was intermittently clamped, and a total of 2,500 mL of sanguineous drainage was collected from the left chest over the following 2 days. The drainage tube was removed on postoperative day 5, and the patient's hemoglobin level was 8.2 g/dL. The patient was discharged on postoperative day 7. The patient was followed for 3 months post-discharge. He remained asymptomatic, with hemoglobin normalized to 13.8 g/dL and no evidence of recurrent pleural effusion on follow-up chest imaging.

3 Discussion

Hemothorax, pneumothorax and hydrothorax are uncommon complications following PCNL, with an overall incidence of less than 2% (8). The supracostal (superior to the 12th rib) approach is associated with a higher incidence of thoracic events (4). Pulmonary complications have been reported with incidences of 10% and 25% when the surgery access is obtained superior to the 12th and 11th rib, respectively (9). Stone site and burden or calyceal anatomy may necessitate the need for upper pole renal access via a supracostal approach. The indications for the upper pole approach include staghorn calculi, multiple calculi in the superior and inferior calyceal groups, renal pelvis, large upper ureteral calculi and calculi in specific anatomy. However, the supracostal approach for PCNL increases the risk of hydropneumothorax due to pleural damage. In addition, the access tract is lost during the operation due to rough operation or deep breathing of the patient, and repeated puncture also increases the probability of pleural damage.

In this case, the left renal artery was injured during the operation, resulting in hemorrhage of the superior branch of the left renal artery, and the pleura was injured due to the supracostal puncture. The blood in the perinephric, retroperitoneal space is drawn into the pleural cavity due to lower pressure in the pleural cavity compared to the working access, thereby ultrasound scan showed a large amount of pleural effusion. The patient's blood pressure decreased progressively at 2 h after the operation started, and the elevated airway pressure implied hemorrhage and chest complication. If the operation is performed under epidural anesthesia, the awake patient may complain of pain, dyspnea, and lower pulse oxygen saturation may occur. However, the symptoms of patients with general anesthesia are relatively insidious, and the patient's condition does not get worse due to correlational treatment, thus these cause led to a delayed diagnosis and treatment.

PCNL is a safe procedure with a low incidence of severe complications. Most complications are mild without surgery intervention. Uncontrollable hemorrhage with hemoglobin drop (>4 g/dL) and/or poor hemodynamics is an indication for emergent intervention (10). Therefore, we should check blood gas analysis during the operation, especially when the hemodynamics is unstable. The surgery access should be performed under ultrasound guidance to avoid pleural damage.

Pulmonary complications are most often identified in the operating room at the time of extubation or in the immediate postoperative period. After extubation in PACU, this patient suffered from hypotension and dyspnea, and we immediately performed POCUS. The ultrasound scan showed massive pleural effusion on the left chest, and excluded acute myocardial infarction and heart failure. Subsequently pleural cavity drainage revealed massive hemorrhage in the left thoracic cavity, but the cause and position of bleeding could not be identified. The final diagnosis and treatment were performed with digital subtraction angiograph, hemorrhage of the left renal artery was successfully stopped via artery embolization. The early diagnosis of POCUS prevented this patient from further damage.

Differential diagnoses considered in this patient included acute myocardial infarction, pulmonary embolism, heart failure, and tension pneumothorax. Acute myocardial infarction was ruled out by the absence of echocardiographic wall motion abnormalities and normal serial troponin levels. Pulmonary embolism was considered less likely given the absence of right heart strain on POCUS and the rapid response to pleural drainage. Heart failure was excluded by the absence of pulmonary edema on lung ultrasound and normal cardiac function. Tension pneumothorax was ruled out by the presence of lung sliding and the absence of a pleural point on POCUS.

POCUS is a critical skill for all anesthesiologists and critical care physicians to help diagnose relevant complications related to routine practice and guide perioperative management (6, 11). POCUS includes airway ultrasound, lung ultrasound, gastric ultrasound, the focused assessment with sonography for trauma (FAST) examination and focused cardiac ultrasound (6). The FAST exam is a well-validated POCUS examination with broad applications in the fields of regional anesthesiology and chronic pain medicine (12). It is undisputed that ultrasound is one of the most sensitive, effective and reliable tools to assess any trauma victim, attributing to the eFAST and FAST scan used in trauma series (13). While FAST exam scans four areas, perihepatic space (called the Morison's pouch), perisplenic space, pericardium and the pelvis, the eFAST exam scans additional sonography of both lungs. The eFAST exam is quick and easy to perform, its specificity is as same as chest x-rays and more sensitive than the latter in diagnosis of pneumothorax after trauma (14).

POCUS allows for rapid bedside assessment of pleural effusion, avoiding delays associated with traditional imaging modalities like chest x-rays. Early diagnosis and intervention, as facilitated by POCUS, can significantly improve patient outcomes and reduce the risk of further complications. Massive haemothorax during PCNL is rare. In our case, since the pleura was injured due to supracostal puncture, combining with the left renal artery injury during the operation, massive haemothorax occurred. The eFAST exam quickly identified pleural effusion compared to chest x-ray, contributed to avoiding the worsen situation. Therefore, POCUS in the perioperative period is essential. Anesthesiology residents can achieve competence in rescue echocardiography and lung ultrasound by participating in a structured, longitudinal POCUS (Point-of-Care Ultrasound) curriculum (15). What makes this case particularly instructive is the diagnostic challenge posed by the absence of significant output from the perinephric drain, which could have delayed recognition of thoracic bleeding. POCUS enabled prompt diagnosis despite this confounder, highlighting its value when clinical signs and drain output are discordant.

4 Conclusion

This case demonstrates that POCUS is highly effective in detecting occult massive haemothorax after PCNL, particularly when perinephric drain output does not correlate with hemodynamic deterioration. The eFAST examination enabled rapid bedside diagnosis and facilitated timely thoracentesis and chest tube placement. Surgeons and anesthesiologists should acquire and master POCUS skills to enhance perioperative patient safety.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fanes.2026.1780418/full#supplementary-material

Supplementary material Supplementary material at the source

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Footnotes

Edited by: Marvin Chang, Massachusetts General Hospital and Harvard Medical School, United States

Reviewed by: Habib Md Reazaul Karim, All India Institute of Medical Sciences, India

Chinnakhet Ketsuwan, Mahidol University, Thailand