|Year : 2020 | Volume
| Issue : 1 | Page : 60-62
Intraoperative water intoxication and hypothermia in a patient undergoing hysteroscopic submucosal fibroid resection
Nagalakshmi Palanisamy, Mamie Zachariah, Nikitha Mani
Department of Anaesthesiology, Pondicherry Institute of Medical Science, Puducherry, India
|Date of Submission||23-Sep-2019|
|Date of Decision||26-Dec-2019|
|Date of Acceptance||17-Jan-2020|
|Date of Web Publication||20-Jul-2020|
Department of Anaesthesiology, Pondicherry Institute of Medical Science, Puducherry
Source of Support: None, Conflict of Interest: None
Hysteroscopy is a useful diagnostic tool as well as a treatment option in many of the gynecological procedures. Although hysteroscopic procedures are generally safe in expert hands, the clinicians can face complications during and after the procedure. One of the intraoperative complications is water intoxication during the procedure. The pathophysiology and treatment of this complication are similar to the TURP syndrome. Hypothermia due to the absorption of cold irrigation fluid is another complication we must be aware of. Vigilant monitoring and choice of regional anesthesia can help early detection and prevention of these complications.
Keywords: Hypothermia, operative hysteroscopy, water intoxication
|How to cite this article:|
Palanisamy N, Zachariah M, Mani N. Intraoperative water intoxication and hypothermia in a patient undergoing hysteroscopic submucosal fibroid resection. J Curr Res Sci Med 2020;6:60-2
|How to cite this URL:|
Palanisamy N, Zachariah M, Mani N. Intraoperative water intoxication and hypothermia in a patient undergoing hysteroscopic submucosal fibroid resection. J Curr Res Sci Med [serial online] 2020 [cited 2020 Sep 24];6:60-2. Available from: http://www.jcrsmed.org/text.asp?2020/6/1/60/290249
| Introduction|| |
Hysteroscopic surgeries have evolved in the era of minimally invasive surgeries. The main indications are polypectomy, resection of uterine septum, endometrial ablation, intrauterine adhesiolysis, and as a diagnostic tool in infertility and abnormal uterine bleeding. Although these procedures are safe in expert hands, complications can occur. The complications may be procedure related (bowel or bladder injury, hemorrhage, and uterine perforation), related to irrigation fluid (anaphylaxis, fluid overload, pulmonary edema, hyponatremia, hypervolemia, and gas embolism), or postoperative (sepsis). We report a case of intraoperative water intoxication and hypothermia in a patient who underwent hysteroscopic submucosal fibroid resection.
| Case Report|| |
A 41-year-old female with secondary infertility was posted for hysteroscopy and laparoscopy for submucosal polyp resection. She was 150 cm tall with a body mass index of 36 kg/m2. She was hypothyroid, on T. Eltroxin 125 μg OD. Her preoperative laboratory investigations revealed hemoglobin 12 gm%, sodium 139 mmol/L, and potassium 4.1 mmol/L. Her renal parameters and thyroid status were within normal limits. General anesthesia was planned as she had to undergo hysterolaparoscopy. A baseline heart rate (HR) of 78 bpm and blood pressure of 108/68 mmHg were noted. General anesthesia was instituted, and the patient was positioned in lithotomy. Since the patient was a known hypothyroid, warmed fluids were used and the patient was warmed with forced air warmer. The fibroid polyp was resected using the cutting loop electrodes with 1.5% glycine as irrigation at a pressure of around 100 mm Hg. The procedure was uneventful for 120 min with minimal blood loss. By then, 6 L of glycine had been used for irrigation. After 2 h, the patient developed abdominal distension and facial puffiness. The airway pressures increased from 20 cmH2O to 35 cmH2O. HR increased by 15 bpm and mean arterial pressure 20% above baseline. Intravascular absorption of glycine was suspected and the procedure was discontinued even though only 80% of the polyp was resected. The patient was repositioned to supine and injection furosemide20 mg was given. The airway pressures came down after furosemide and ventilation with Positive End Expiratory Pressure (PEEP). After 20 min, the hemodynamic parameters also reverted back to preoperative values. The patient started breathing spontaneously and responded to oral commands after reversal of muscle relaxant. She was extubated after thorough oral suctioning. Fifteen minutes postextubation, the patient became drowsy and started to desaturate with oxygen mask. The patient was reintubated immediately with injection propofol and succinylcholine and ventilated with 100% oxygen. Saturation improved and ABG done at this point revealed sodium 125 mmol/L, potassium 3.2 mmol/L, and fall in hematocrit from 35.8% to 28.8%. Furosemide 20 mg IV was repeated. Nasopharyngeal temperature was 33°C. Active rewarming was done with forced air warmer and blankets. The patient was ventilated with air/oxygen 50:50 with PEEP 5 cmH2O to achieve an EtCO2 of 30–35. The patient was ventilated till the temperature reached 36°C and was extubated. The patient was shifted to the intensive care unit for observation.
| Discussion|| |
Glycine 1.5% is used as irrigation fluid during operative hysteroscopy, as it is nonconductive and nonhemolytic with a refractive index close to water. The osmolality of glycine is 200 mosm/L. Glycine is nonelectrolytic, and when metabolized, it can lead to free water accumulation in intravascular space resulting in dilutional hyponatremia.
The frequency of dilutional hyponatremia in hysteroscopy surgeries ranges between 0.24% and 10%. These complications are similar to transurethral resection of prostate syndrome. In TURP syndrome, it is due to the absorption of irrigation fluid through the prostatic plexus of veins. However, in hysteroscopic surgeries, fluid absorption takes place mainly through the blood vessels opened up in the operative field. Some fluid may enter the abdomen through the fallopian tubes. Fluid absorption is mainly dependent on irrigation pressures. The uterine cavity is a thick walled, low compliant cavity that requires irrigation pressures up to 100–110 mmHg to visualize tubal orifices. This is usually achieved by gravity or pressurizing the infusion bag. Fluid absorption is also dependent on the phase of the menstrual cycle. It is lesser when resection takes place in avascular mid-proliferative phase of the endometrium. Keeping these in mind, it is advisable to limit the duration of procedure and the pressures to 60–70 mmHg.
The volume of fluid absorbed is the difference between the fluid infused, and that passes out into the drapes and swabs. Volumetric and gravimetric methods used to measure fluid deficit are inaccurate. A noninvasive method to analyze the fluid absorption is using ethanol. The irrigation fluid is tagged to 1%–2% ethanol. A single breath analyzer measuring ethanol concentration in breath would reflect the ethanol concentration in blood. Nomograms have been developed to correlate blood ethanol concentration with the amount of fluid absorbed.
The clinical features of fluid overload depend on the development of hyponatremia. Early recognition is possible if the patient is conscious. Fluid overload presents as headache, dizziness, chest pain, and seizures in conscious patients. Hypertension, hypothermia, dilated pupils, and reduced oxygen saturation are common signs in all patients. Bradycardia, pulmonary edema, cerebral edema, and cardiopulmonary collapse may follow if unattended. Regional anesthesia would have helped us to identify the symptoms earlier, but our patient was given GA as she was planned for hysterolaparoscopy.
Signs and symptoms of hyponatremia are related to the rate of sodium drop. Clinical signs manifest when the Na+ drops by 15–20 mmol/L. Electrocardiographic changes are characterized by a wide QRS complex, ST elevation followed by ventricular tachycardia or fibrillation. Plasma sodium concentration and osmolality should be monitored closely. Sodium concentrations <120 meq/L is considered to be potentially fatal and should be treated with 3% hypertonic saline over 4–5 h. The rate of sodium correction should be <1 mmol/h to prevent osmotic myelinolysis. Fluid overload may be treated with frusemide and if severe, should be treated with positive pressure ventilation and PEEP. Hypothermia should be treated with forced air warmers and warm fluids. Our patient's temperature dropped to 33°C causing under ventilation leading to delayed recovery.
The prevention of fluid overload is of prime importance. Early assessment of fluid overload can be done by parotid area sign (increase in the philtrum mastoid prominence distance). Regional anesthesia may be advantageous as clinical signs can be identified earlier. If general anesthesia is administered, it is advisable to measure serum sodium at regular intervals to avoid complications.
| Conclusion|| |
Vigilant monitoring of infused fluid, serum sodium concentration, and maintenance of body temperature would help to prevent fluid overload and hyponatremia in hysteroscopy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sethi N, Chaturvedi R, Kumar K. Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue. Indian J Anaesth 2012;56:179-82.
] [Full text]
Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: Predicting patients at risk. Obstet Gynecol 2000;96:517-20.
Magos AL, Baumann R, Turnbull AC. Safety of transcervical endometrial resection. Lancet 1990;335:44.
Paschopoulos M, Polyzos NP, Lavasidis LG, Vrekoussis T, Dalkalitsis N, Paraskevaidis E. Safety issues of hysteroscopic surgery. Ann N
Y Acad Sci 2006;1092:229-34.
Umranikar S, Clark TJ, Saridogan E, Miligkos D, Arambage K, Torbe E, et al
. BSGE/ESGE guideline on management of fluid distension media in operative hysteroscopy. Gynecol Surg 2016;13:289-303.
Istre O, Skajaa K, Schjoensby AP, Forman A. Changes in serum electrolytes after transcervical resection of endometrium and submucous fibroids with use of glycine 1.5% for uterine irrigation. Obstet Gynecol 1992;80:218-22.
Shah VR, Parikh GP, Gupta S. Monitoring of irrigant fluid absorption during endoscopic resection's using 1% ethanol as a marker. Indian J Anaesth 2003;47:201.
Kaijser J, Roelofs HJ, Breimer LT, Kooi SG. Excessive fluid overload with severe hyponatremia, cardiac failure, and cerebral edema complicating hysteroscopic myomectomy. J Pelvic Med Surg 2007;13:367-73.
Chauhan R, Ganesan V, Luthra A. Operative hysteroscopy intravascular absorption syndrome: The gynecological transurethral resection syndrome. J Obstet Anaesth Crit Care 2018;8:112-4. [Full text]
Sinha M, Hegde A, Sinha R, Goel S. Parotid area sign: A clinical test for the diagnosis of fluid overload in hysteroscopic surgery. J Minim Invasive Gynecol 2007;14:161-8.