Iatrogenic Cardiovascular Complication during Percutaneous Nephrolithotomy: A Case Report

經皮穿腎造瘻取石術中併發醫源性心血管併發症－病例報告

蘇智文(Chih-Wen Su)

《北市醫學雜誌》 14卷4期 (2017/12) Pp. 508-516

https://doi.org/10.6200/TCMJ.2017.14.4.11

摘要

Our patient, a 46-year-old woman without cardiovascular diseases, had undergone percutaneous nephrolithotomy (PCNL) at the right kidney 3 years before, and underwent PCNL for a renal staghorn stone at the right kidney before this report. During surgery, the electrocardiogram recorded transient sudden-onset ventricular tachycardia and ventricular fibrillation with transient perioperative hypotension. We administered xylocaine and epinephrine, and she recovered to sinus rhythm within 2 minutes. After surgery, she awakened uneventfully. However, massive blood loss was noted via the pigtail drain in the ward. Accidental iatrogenic double-J catheter misplacement in the inferior vena cava, right atrium, and right ventricle was detected through X-ray imaging. Emergency blood transfusion and surgical intervention were arranged. We used transesophageal echocardiography for intraoperative monitoring of her cardiac function and morphology. She was discharged without obvious complications. Here, we report a rare cardiovascular complication following PCNL. Our literature review revealed that a lawsuit concerning a patient experiencing massive hemorrhage following PCNL in a regional hospital in Taichung in 2007 was put on trial in the Taichung District Court. Although the patient was referred to a medical center for emergency treatment, irreversible hemorrhagic shock persisted, and the patient died. Additional attention should be paid to postoperative complications following PCNL.

關鍵字

percutaneous nephrolithotomy ； iatrogenic complication ； double-J catheter

並列摘要

經皮穿腎造廔取石術(PCNL)是一種常見臨床手術，自1970 年代起被普遍用來治療下端腎盞結石或鹿角狀結石。於X-ray 定位下進行手術之併發症機率相當低(10-20%)，嚴重內臟穿孔、大血管出血或氣血胸機率統計上＜1%。本病例為46 歲女性，沒有相關心血疾病史，曾於3 年前接受過一次右側PCNL 手術。本次進行右腎鹿角結石手術，手術時間約2 小時，術中心率監視器發現短暫突發性心室頻脈(ventricular tachycardia, VT) 及心室顫動(ventricular fibrillation, Vf)， 合併短暫術中低血壓， 經給予xylocain, epinephrine 治療後，在2 分鐘內恢復正常竇性心律。爾後手術過程平順，術後病患順利清醒拔管，生命徵象穩定。然而術後因傷口引流管血水過多，追蹤X 光片意外發現病患下腔靜脈有一Double-J 導管直達右心房右心室。經緊急輸血及安排手術取出誤植導管，並以術中食道超音波監視心臟收縮功能及結構正常，術後經加護病房觀察後順利康復出院，無顯著後遺症。經文獻回顧，台中地方法院曾於2007 年審理一例台中某區域醫院進行PCNL 手術後發生術後左腎大出血不止，經緊急轉診醫學中心治療後仍發生不可逆性休克而不幸死亡，故進行PCNL 手術後之併發症應小心謹慎處理。

並列關鍵字

經皮穿腎造廔取石術 ； 醫源性併發症 ； 雙J引流管