經皮腎臟腎石截除術與腎臟切除術後之罕見併發症——輸尿管雙J導管之誤置與被誤切後移行至肺動脈

Renal Vascular Injury during Percutaneous Nephrolithotomy and Migration of a Double-J Catheter Fragment into Pulmonary Artery in the Following Nephrectomy —A Case Report

經皮腎臟腎石截除術（PCNL）已廣泛被使用於腎結石摘除，然而其於術中或術後可能造成致命之併發症，麻醉人員不可不慎。我們在此報告一位60歲男性病人，因復發性左側腎結石而接受經皮腎臟腎石截除術。手術順利完成；泌尿科醫師於手術結束前在內視鏡操作下放置一條輸尿管雙J導管，其本應置於輪尿管，卻被錯置於腎盂與下腔靜脈間。術後病人出現腰部極度疼痛，碓給予止痛劑仍無效；而後出現噪動不安、呼吸窘迫與低血壓，於是病人被重新插管並轉送醫學中心加護病房。病人於加護病房出現心室快跳（ventricular tachycardia）與休克，在高度懷疑是腎臟大量出血下，病人接受緊急剖腹探查與腎臟切除術。不幸地、泌尿科醫師於腎臟摘除後，卻找不到已被剪斷導管之另一端（長22公分），此時監視器突然出現血壓快速下降與無脈搏電流活動（PEA），但約2分鐘後即恢復正常。於詳細腹部探查與活動式腹部X光檢查後，並無所穫，只好結束手術並回ICU觀察；之後於常規胸部X光無意間發現此被剪斷導管之影像，其經CT掃瞄證實位於右心房與左肺動脈。病人即刻被送至心導管室，心臟內科醫師以經皮穿刺血管內異物取出術，經股靜脈順利地將此異物取出。

A 60-year-old male underwent percutaneous nephrolithotomy (PCNL) for left renal stone at a community hospital. The surgery was, in general, unremarkable and a double-J ureteral catheter was placed before completion of surgery. Dyspnea, irritability, hypotension and flank pain developed in the recovery room. In addition, pleural effusion and elevation of the left hemidiaphragm were revealed on chest roentgenogram, and mild hypoxemia and respiratory acidosis were also detected by gas analysis. He was transferred to our hospital for further management. After arrival at our hospital, we decided to reintub ate the patient and transfer him to the intensive care unit (ICU). There, the vital signs deteriorated, so an emergent laparotomy was performed and left nephrectomy was done because of severe and unmanageable renal hemorrhage. A catheter fragment was found to be missing after left kidney was dissected. During the search for the missing fragment, pulseless electrical activity (PEA) happened. The patient recovered shortly after the use of vasopressors. Postoperatively, a chest X-ray (CXR) taken to search for the missing section of the cather revealed that there was a catheter-like foreign body in the heart, which was also demonstrated by computed tomography (CT) scan. The catheter fragment was quickly removed soon via percutaneous angiography. The patient was discharged 2 weeks later. We present this case with two iatrogenic complications, each in two consecutive renal procedures, to emphasize the importance of vigilance in anesthesia.