Urolithiasis affects 5–15% of the population worldwide.1 Nowadays, microinvasive treatments, including shock wave lithotripsy, percutaneous nephrolithotomy (PCNL) and laparoscopy, are the mainstay of treatment for urolithiasis, but some authors have given to open surgery for multiple or staghorn kidney stones.2 Pneumothorax is one of the complications in PCNL, laparoscopic surgery, as well as open surgery.3 Manipulation of infected urinary calculi could introduce bacteria into blood and lead to the development of septicaemia.4 Here, we share our experience of successful treatment for a patient who suffered from both pneumothorax and septicaemia at the same time a short period after the open surgery for urolithiasis.
A 27-year-old man with a history of right lumbar pain for 1 year presented to our hospital. His weight was 52 kg. He did not have a history of allergy, medication, hospitalization and concomitant disease. Radiograph of kidney–ureter–bladder (KUB) demonstrated high-density opacity at middle and lower segment of right renal calix, and deceased right renal excretion function. Retrograde pyelography of right kidney revealed multiple stones of right renal pelvis and calyx accompanied with hydrocalycosis. Baseline haematological, biochemical and coagulation profile, ECG and chest radiograph were all normal. A diagnosis was made of multiple stones of right kidney accompanied with hydrocalycosis, and the patient was scheduled for right kidney nephrolithotomy and fistulization.
General endotracheal anaesthesia was induced (9: 00 a.m.) and maintained with intermittent doses of fentanyl, midazolam, atracurium and propofol, and isoflurane in oxygen/air mixture. The initial heart rate (HR) was 75 beats min−1, blood pressure (BP) was 124/66 mmHg and pulse oximetry was 97%. HR and BP remained stable after induction of anaesthesia. Urinary bladder catheterization revealed cloudy urine. Ceftriaxone 1.0 g was given after the tracheal intubation. An incision was made at the right 12th rib, and the right pelvis was explored via a retrograde approach through the right ureter after opening the Gerota's fascial sac. The middle calices were incised, and one large staghorn stone and several stones with diameter of between 0.2 and 0.5 cm were removed. As a precaution against presence of residual stones in the calyx, a percutaneous right nephrostomy tube was inserted at the end of operation.
At the end of surgery, there was returned spontaneous respiration, and the respiratory rate was between 12 and 16 breaths min−1. The tidal volume (Vt) was between 350 and 450 ml. At this time, the HR increased again, gradually to 120 beats min−1. Ten minutes after the end of operation, the patient remained unconscious. The HR increased to 135 beats min−1, respiratory rate increased to 28 breaths min−1, Vt remained between 350 and 450 ml and the patient began to shiver. Eight minutes later, HR and respiratory rate increased to 145 beats min−1 and 36 breaths min−1, respectively, and BP increased to 145/93 mmHg and Vt increased to around 600 ml. When the patient responded by opening his eyes to verbal commands, the trachea was extubated. Five minutes after extubation, BP increased to 167/112 mmHg, and HR and respiratory rate were 165 beats min−1 and 55 breaths min−1, respectively. Measured by breath through a sealed face mask, Vt increased to 650 ml, and the patient shivered more. Artery blood gas analysis revealed metabolic acidosis and respiratory acidosis (pH 7.152, pCO2 57 mmHg, pO2 132 mmHg, base excess 9 mmol l−1, HCO3 20.0 mmol l−1, SaO2 95%). Then 5% sodium bicarbonate 125 ml was administered in an attempt to correct the acidosis of the patient. Physical examination revealed signs of right pneumothorax: reduced breath sounds and resonance on right chest wall. A diagnostic puncture at the second intercostals space of right chest wall was made, which confirmed the diagnosis of right pneumothorax. Closed drainage of right thoracic cavity was performed after administration of intravenous midazolam 3 mg and ketamine 100 mg. Breath sounds were equal on both sides after chest tube insertion. Although HR decreased to 145 beats min−1, and BP was 135/75 mmHg, respiratory rate was still high at 50 breaths min−1 and Vt was approximately 550 ml. The patient continued to shiver. Ten minutes later, the patient stopped shivering, but his HR varied from 135 to 170 beats min−1 and respiratory rate was around 50 breaths min−1, BP was 192/27 mmHg and his temperature increased to 38.5°C. Reticular pattern of erythema was observed on the chest wall and on the medial side of his arms and legs. His extremities felt cold to palpation. As there was empyema in calices, and right kidney was repeatedly explored during operation, a presumptive diagnosis of septicaemia was made and the blood sample for blood culture was drawn. An intravenous dose of succinohydrocortisone 200 mg was administered. His body was swabbed with alcohol, and cooling of the head, bilateral cervical, axillary and inguinal regions was performed with ice. Despite this treatment for approximately 15 min, his temperature increased to 39.8°C, but HR, BP and respiratory rate decreased to 130 beats min−1, 153/88 mmHg and 26 breaths min−1, respectively. Artery blood gas analysis showed no acid–base imbalance (pH 7.412, pCO2 38.2 mmHg, pO2 89 mmHg, base excess 2 mmol l−1, HCO3 24.8 mmol l−1). At this time, the patient's temperature was maintained at 39.5°C, and HR, respiratory rate and BP gradually decreased to 80 beats min−1, 125/68 mmHg and 16 breaths min−1, respectively. The patient was then transferred to surgical ICU (SICU) after he regained consciousness.
In consideration of the septicaemia, ceftriaxone 1.0 g twice daily (b.i.d.) was given to the patient. The patient was transferred to the ward the next day, his body temperature decreased to 37.4°C and the chest tube was removed after 2 days. Blood culture revealed the infection of Escherichia coli, which was sensitive to ceftraxone. The patient was discharged after 7 days.
Experience learned from this case is that we must be aware of any abnormal signs during anaesthesia and identify the cause and treat it. During kidney surgery, the pleura may be breached and pneumothorax may develop, and bacteria may be introduced into the blood stream and subsequently lead to septicaemia or sepsis. Signs of septicaemia include hyperthermia, hyperventilation, shivering, erythematous rash and tachycardia. In this case, tachycardia at the end of operation with shivering might be the early manifestation of septicaemia or sepsis, but the presence of pneumothorax masked the manifestation of sepsis. Sepsis was not recognized until the patient had a combination of hyperventilation, peripheral low perfusion and hyperthermia. Recognizing the presence of sepsis and treating it were critical to management in this patient. In order to avoid the morbidity in the future, every effort should be made to sterilize the urinary tract before the operation with the use of appropriate antibiotics.
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