With the ever-growing complexity and extensiveness in surgical procedures, it is not uncommon to encounter unique perioperative complications. Ours is an exemplary case describing the chances of occurrence of grave consequences in a seemingly simple and minimally invasive procedure. No matter how trivial the problem is, how ordinary the operative procedure is, every case is a challenge to anesthesiologist. Knowing how to operate and interpret results of ultrasound which have become a commonplace in operation theaters and ICU these days helps save lives.
It is undisputed that ultrasound is one of the most sensitive, effective and reliable tools to assess any trauma victim; all thanks to the eFAST and FAST scan in trauma series [1]. While classically in FAST scan included four areas for fluid collection, namely perihepatic space (called the Morison’s pouch), perisplenic space, pericardium and the pelvis, the eFAST allowed the examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. eFAST is not only quick and easy to perform, it is as specific as chest X-rays but more sensitive than the latter in terms of detection of occult pneumothoraces after trauma [2]. To perform the eFAST, the patient is placed in supine position and with the use of a convex transducer 3.5–5.0 MHz several regions are scanned. The subxiphoid transverse view assesses for pericardial effusion and injuries to left lobe of liver; the longitudinal view of the right upper quadrant assesses for right liver injury, right kidney injury, and Morison’s pouch; the longitudinal view of left upper quadrant is assessed to see for splenic injuries and left kidney injury; the transverse and longitudinal views of the suprapubic region are used to assess bladder and pouch of Douglas; finally, the right and left thoracic views, and both lung basis are obtained to assess for pneumothorax and hemothorax. Although the various organ and cavity scans may seem overwhelming when it comes to the necessity of a quick diagnosis of life-threatening complications, if the technique can be protocolized as to how and which to be scanned, the times can be reduced greatly. In addition, with the frequent involvement in trainings and reinforcement program, any physician can keep up the skill and perform such scan relatively quickly. The time we spent in eFAST scan was around 2 min.
However, in the developing countries, the perioperative use of ultrasound has, until now, been limited to USG-guided regional anesthesia [3] and vascular access [4]. There are reports of its use in other perioperative settings [5]. But the relatively easy access to USG these days, its non-invasiveness, and the availability of personnel such as anesthesiologists who are equipped with knowledge and expertise required to operate and interpret such equipment extend the utilities of such machines. No wonder, it becomes imperative for any anesthesiologist involved in the perioperative care to be acquainted with the ultrasonographic examination as it aids us in rapid assessment of various intraabdominal and intrathoracic pathologies. Although the diagnosis by clinical assessment cannot be superseded by any forms of diagnostic tests, it, however, can be complemented by the use of aids such as ultrasound and, therefore, must be used more frequently.
Extravasation of irrigation fluid during PCNL is not an uncommon finding. Some case reports of massive extravasation of irrigation fluid leading to abdominal compartment syndrome have also been reported [6, 7]. The gradually increasing airway pressures might have suggested pneumothorax or abdominal compartment syndrome. However, it is often difficult to distinguish between various causes of increased intrathoracic pressure such as displacement, blockage of tube due to secretions, and bronchospasm; especially when the patient is in prone position. Proper anesthetic technique, intensive monitoring for airway pressures and immediate diagnosis of fluid extravasation help prevent such unfortunate incidents of abdominal compartment syndrome. The use of ultrasound is helpful in preventing and detecting most of these complications. In our case, the most obvious sign of abdominal distension to detect extravasation was not helpful as the patient was in prone position which made the evaluation difficult initially.
The easy accessibility to the ultrasound and our prompt intervention helped prevent a condition from worsening further as we could drain the abdominal fluid relatively easily under the USG guidance. The ominous signs of pneumothorax and hemothorax were also ruled out expeditiously with the aid of ultrasound. If this was not the case, then we would have had to transfer the patient to radiology suite which would have consumed our valuable time and thus leading to formidable consequences. Certainly, the use of ultrasound in the perioperative settings cannot be understated (Additional files 1, 2).
