Continuous quality improvement of clinical practice guideline for management of patients undergoing percutaneous nephrolithotomy under general anesthesia in srinagarind hospital
nephrolithotomy (PCNL) is a minimal invasive surgery
for treatment of renal calculi. It may cause pleural
cavity injury, i.e., pneumothorax, hydrothorax, or
hemothorax (P/H/H), which mostly occurs in
supracostal access of trocar puncture. The previous
practice guideline requires that, for safety,
endotracheal tube must be retained at the end of
surgery in all patients undergoing PCNL with
supracostal access leading to patient discomfort and
agitation. They were extubated after pleural cavity
injury was assessed using portable CXR at PACU. To
reduce patient discomfort, we improved the guideline
using PaO2/FiO2 (P/F) ratio ≤ 300 mmHg as criteria to
retain endotracheal tube in these patients. The
objective of this study was to evaluate the efficacy of
the new guideline.
Methods: This was a prospective, descriptive study.
We included all adults undergoing elective PCNL at
Srinagarind hospital, Khon Kaen university between
July 2017 and November 2018. We identified the
incidence of endotracheal tube retaining and pleural
cavity injury. Results: Forty-seven patients were included. There
were 20 cases (42.6%) with supracostal access. Among
supracostal patients, there were 9 cases (45%) with
P/F ratio ≤ 300 mmHg who required endotracheal
tube retaining with 2 cases (4.3%) complicated with
hydrothorax and 3 cases (6.4%) with sepsis.
Conclusions: The improved guideline using P/F ratio
≤ 300 mmHg as criteria to retain endotracheal tube
in patients undergoing PCNL with supracostal access
can reduce incidence of endotracheal tube retaining
from 100% to 45% without complications. The
incidences of pleural cavity injury and sepsis were
4.3% and 6.4%.
Keywords
Percutaneous nephrolithotomy PCNL PaO2 FiO2 ratio Endrotrachial tube Agitate