Percutaneous Nephrolithotomy / Nephrolithotripsy / Nephrostomy

Anesthesia Implications

Position: Prone, Left Lateral, Right Lateral
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No
Lead: Yes

Prone Position (general considerations): Maintain cervical neutrality. Keep IV’s out of the antecubital space. The patients arms are typically flexed, which will kink the IV. Eye protection should be used as the prone position heightens the risk of corneal abrasion and/or traction on the globe (which can result in blindness). Check the patients eyes/ears/nose regularly throughout the case to ensure they are free of pressure. Positioning of the leads is typically high on the posterior and posterolateral back (somewhere free of pressure and out of surgical borders). Keep your connections and tubing where you’ll have fast access.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.

This surgery is to remove kidney stones that are 25 mm or smaller. Initially, there is a stab wound made to introduce the tube. Thereafter, the tube is guided by fluoroscopy.

Paraplegics and quadriplegics run the risk of autonomic hyperreflexia. Watch for flushing, headache, nasal stuffiness.