From the Research
Management of a left hemothorax following left percutaneous nephrolithotomy (PCNL) should prioritize prompt intervention with thoracostomy tube placement and administration of tranexamic acid to reduce bleeding and transfusion requirements, as supported by the most recent and highest quality study 1. The initial management of a left hemothorax post-PCNL involves assessing the severity of the condition and the patient's symptoms.
- For small hemothoraces with minimal symptoms, observation with serial chest imaging may be sufficient.
- For moderate to large collections or symptomatic patients, a chest tube (typically 28-32 French) should be inserted in the 4th-5th intercostal space at the mid-axillary line.
- The tube should be connected to underwater seal drainage with suction at -20 cm H2O. Supportive care includes:
- Oxygen supplementation
- Pain control with analgesics such as acetaminophen or opioids if needed
- Hemodynamic monitoring The use of tranexamic acid has been shown to reduce bleeding and transfusion requirements in patients undergoing PCNL, with a systematic review and meta-analysis demonstrating a decreased transfusion rate and blood loss in patients receiving tranexamic acid compared to those receiving a placebo 1.
- Complete blood count should be followed to assess for ongoing bleeding, and blood transfusion may be necessary if hemoglobin drops significantly (typically below 7-8 g/dL) or if the patient is hemodynamically unstable.
- Antibiotics are generally not required unless there is evidence of infection. The chest tube can be removed when drainage is minimal (less than 100-150 mL/day), the lung is fully expanded on imaging, and there is no air leak.
- Persistent or massive hemothorax may require surgical intervention via video-assisted thoracoscopic surgery (VATS) or thoracotomy. This complication occurs due to pleural injury during the PCNL procedure, typically from a supracostal approach that traverses the pleural space or diaphragm. The administration of tranexamic acid has been shown to be safe and effective in reducing blood loss and transfusion requirements in patients undergoing PCNL, and its use should be considered in the management of left hemothorax post-PCNL 2.