Simultaneous bilateral hemorrhagic pleural effusion and hemorrhagic ascites during percutaneous nephrolithotomy: a case report.

Background: Percutaneous nephrolithotomy (PCNL) may cause severe thoracic and abdominal complications. Because their onset can be insidious and their intraoperative manifestations atypical, recognition may be delayed. We report a case of sudden bilateral hemorrhagic pleural effusion with hemorrhagic ascites during PCNL and discuss strategies for intraoperative identification and management. Case presentation: A 63-year-old woman underwent PCNL for multiple right renal calculi. During the procedure, renal pelvic bleeding occurred, followed by a sudden increase in airway pressure to 40 cmH2O, a decrease in oxygen saturation to 92-95%, and a fall in blood pressure to 78/59 mmHg. Bedside ultrasound revealed substantial bilateral pleural effusion and moderate intraperitoneal fluid accumulation. Emergency bilateral chest tube drainage and abdominal paracentesis were performed, evacuating a large volume of pale red blood-tinged fluid. After volume expansion, blood transfusion, and vasopressor support, the patient's vital signs stabilized. She was discharged after 10 days of recovery, and the 3-month follow-up showed no significant abnormalities. Conclusion: During PCNL, sudden hypoxemia and elevated airway pressure should prompt immediate assessment for severe pleural or peritoneal effusion. In this case, the findings may have resulted from pressure-related communication between the abdominal and thoracic cavities, with fluid translocation through small diaphragmatic defects into both pleural spaces. Bedside ultrasound can serve as a first-line screening tool during PCNL. Continuous ultrasound monitoring, including wearable devices, may offer advantages in prone-position surgery, particularly when ongoing surveillance for pulmonary complications is required.