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Vilos GA, Vilos AG, Abu-Rafea B, Ternamian A, Laberge P, Munro MG. Good practice with fluid management in operative hysteroscopy. Int J Gynaecol Obstet 2025; 168:118-125. [PMID: 39171580 DOI: 10.1002/ijgo.15860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 07/31/2024] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.
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Affiliation(s)
- George A Vilos
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Angelos G Vilos
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Basim Abu-Rafea
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Artin Ternamian
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Laberge
- Department of Obstetrics and Gynecology, Université Laval, Quebec City, Québec, Canada
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, California, Los Angeles, USA
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Chung CH, Tsai CC, Wang HF, Chen HH, Ting WH, Hsiao SM. Predictors of Infused Distending Fluid Volume in Hysteroscopic Myomectomy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1424. [PMID: 39336465 PMCID: PMC11434096 DOI: 10.3390/medicina60091424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 08/21/2024] [Accepted: 08/28/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: The use of a bipolar resectoscope has become popular due to the lower risk of hyponatremia. However, gynecologists might overlook the risk of water intoxication. Water intoxication is associated with the infusion of distending fluid. We were interested in the prediction of the infused distending fluid volume in the era of bipolar hysteroscopy. Thus, the aim of this study was to identify the predictors of the infused distending fluid volume for hysteroscopic myomectomy. Materials and Methods: All consecutive women who underwent monopolar (n = 45) or bipolar (n = 137) hysteroscopic myomectomy were reviewed. Results: Myoma diameter (cm, coefficient = 680 mL, 95% confidence interval (CI) = 334-1025 mL, p <0.001) and bipolar hysteroscopy (coefficient = 1629 mL, 95% CI = 507-2752 mL, p = 0.005) were independent predictors of infused distending fluid volume. A myoma diameter ≥4.0 cm was the optimal cutoff value to predict the presence of >5000 mL of infused distending fluid. One woman in the bipolar group developed life-threatening water intoxication. Conclusions: Myoma diameter is associated with an increase in infused distending fluid volume, especially for myomas ≥4 cm. Meticulous monitoring of the infused distension fluid volume is still crucial to avoid fluid overload during bipolar hysteroscopic myomectomy.
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Affiliation(s)
- Chia-Han Chung
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan; (C.-H.C.); (H.-F.W.); (H.-H.C.); (W.-H.T.)
| | - Chien-Chen Tsai
- Department of Anatomic Pathology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan;
| | - Hsiao-Fen Wang
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan; (C.-H.C.); (H.-F.W.); (H.-H.C.); (W.-H.T.)
| | - Hui-Hua Chen
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan; (C.-H.C.); (H.-F.W.); (H.-H.C.); (W.-H.T.)
| | - Wan-Hua Ting
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan; (C.-H.C.); (H.-F.W.); (H.-H.C.); (W.-H.T.)
- Department of Industrial Management, Asia Eastern University of Science and Technology, New Taipei 220303, Taiwan
| | - Sheng-Mou Hsiao
- Department of Obstetrics and Gynecology, Far Eastern Memorial Hospital, Banqiao District, New Taipei 220216, Taiwan; (C.-H.C.); (H.-F.W.); (H.-H.C.); (W.-H.T.)
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei 100226, Taiwan
- Graduate School of Biotechnology and Bioengineering, Yuan Ze University, Taoyuan 320315, Taiwan
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Hahn RG. Isotonic saline causes greater volume overload than electrolyte-free irrigating fluids. J Basic Clin Physiol Pharmacol 2023; 34:717-723. [PMID: 34563101 DOI: 10.1515/jbcpp-2021-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/11/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Systemic absorption of the irrigating fluid used to flush the operating site is a potentially serious complication in several types of endoscopic operations. To increase safety, many surgeons have changed from a monopolar to a bipolar resection technique because 0.9% saline can then be used instead of electrolyte-free fluid for irrigation. The present study examines whether the tendency for excessive plasma volume expansion is greater with saline than with electrolyte-free fluid. METHODS Pooled data were analyzed from four studies in which a mean of 1.25 L of either 0.9% saline or an electrolyte-free irrigating fluid containing glycine, mannitol, and sorbitol was given by intravenous infusion on 80 occasions to male volunteers and patients scheduled for transurethral prostatic surgery. The distribution of the infused fluid was analyzed with a population volume kinetic model based on frequently measured hemodilution and the urinary excretion. RESULTS Electrolyte-free fluid distributed almost twice as fast and was excreted four times faster than 0.9% saline. The distribution half-life was 6.5 and 10.6 min for the electrolyte-free fluid and saline, respectively, and the elimination half-lives (by urinary excretion) from the plasma volume were 21 and 87 min. Simulation showed that the plasma volume expansion was twice as great from 0.9% saline than from electrolyte-free fluid. CONCLUSIONS Isotonic (0.9%) saline expands the plasma volume by twice as much as occurs with electrolyte-free irrigating fluids. This difference might explain why signs of cardiovascular overload are the most commonly observed adverse effects when saline is absorbed during endoscopic surgery.
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Affiliation(s)
- Robert G Hahn
- Research Unit, Södertälje Hospital, Södertälje, Sweden
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
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Tabuchi M, Morozumi K, Maki Y, Toyoda D, Kotake Y. Hyperchloremic metabolic acidosis due to saline absorption during laser enucleation of the prostate: a case report. JA Clin Rep 2022; 8:20. [PMID: 35267114 PMCID: PMC8913822 DOI: 10.1186/s40981-022-00499-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recent technological advancements have enabled the use of electrolyte solutions such as saline or buffered electrolyte solution during transurethral resection or laser enucleation of the prostate. However, saline absorption may cause hyperchloremic metabolic acidosis. Case presentation A male in his late seventies underwent holmium laser enucleation of the prostate under a combination of subarachnoid block and general anesthesia. Intraoperatively, abdominal distension prompted the attending anesthesiologist to consider the possibility of SGA malposition, and the trachea was intubated. Oropharyngeal and neck edema was observed, and laboratory examination revealed considerable acidosis with hyperchloremia. Further evaluation confirmed the absorption of a large amount of saline into the circulation via the perforated bladder. Application of the simplified Stewart approach clearly suggested that hyperchloremia was the principal cause of metabolic acidosis. The dilution of albumin attenuated acidosis. Conclusions Absorption of normal saline during laser enucleation of prostate caused hyperchloremic metabolic acidosis and airway edema.
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Affiliation(s)
- Makiko Tabuchi
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan.
| | - Kohei Morozumi
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yuichi Maki
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Daisuke Toyoda
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro, Tokyo, 153-8515, Japan
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Meester DD, Bels DD, Honoré PM, Redant S. Hyperchloremic Metabolic Acidosis Post Hysteroscopy: a Place for Balanced Solutions? J Transl Int Med 2022; 10:79-81. [PMID: 35702181 PMCID: PMC8997802 DOI: 10.2478/jtim-2022-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Dorien De Meester
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels1020, Belgium
| | - David De Bels
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels1020, Belgium
| | - Patrick M. Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels1020, Belgium
| | - Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels1020, Belgium
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A Fluid-Management Drape for Hysteroscopy: Innovation for Improved Patient Safety and Surgical Care. Obstet Gynecol 2021; 138:905-910. [PMID: 34735388 DOI: 10.1097/aog.0000000000004604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hysteroscopy requires accurate collection of unabsorbed distension media to measure patient fluid absorption. We assessed the effectiveness and usability of a novel total capture drape compared with a standard drape during hysteroscopy. METHOD Simulation trials were followed by an early-phase study to compare fluid-capture efficiency and measures of drape usability during hysteroscopy randomizing the total capture drape compared with a standard drape. EXPERIENCE Simulation trials indicated complete collection of unabsorbed fluid with the total capture drape and progressive loss of unabsorbed fluid with the standard drape. An early-phase study with 68 women found no statistical difference between groups for the hysteroscopic fluid deficit, but saw fewer cases with lost fluid in the total capture drape compared with the standard drape. Direct observation and focus group data indicated a trend for better capture of unabsorbed fluid with the total capture drape, along with increased usability once surgeons became familiar with correct placement. CONCLUSION Simulation and early-phase study results are favorable for the total capture drape, demonstrating comparable fluid collection with the standard drape. With repeated use and in-service training, surgeons expressed greater confidence in the accuracy of the hysteroscopic fluid deficit with the total capture drape compared with the standard drape. Design modifications should improve overall usability and fluid-capture efficiency.
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Han K, Huang MQ, Deng X, Shang YC. Remaining Vigilant to Paradoxical Air Embolism in Patients Undergoing Hysteroscopic Surgery: A Case Report and Review of the Literature. J Perianesth Nurs 2021; 36:606-611. [PMID: 34740530 DOI: 10.1016/j.jopan.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 10/19/2022]
Abstract
The purpose of this case study and review was to understand the perianesthestic care of paradoxical air embolism (PAE) in patients undergoing hysteroscopic surgery. The perianesthestic management record of a patient undergoing hysteroscopic surgery was analyzed to study the characteristics of PAE, and the literature describing the perianesthestic care for PAE was reviewed. The first symptom of PAE in hysteroscopic surgery is often a decrease in end-tidal carbon dioxide (ETCO2), and the complications include embolism of the pulmonary artery, coronary artery, and cerebral artery. The best monitoring method is continuous ETCO2 monitoring, and intraoperative echocardiography is an excellent method to diagnose and guide the treatment of PAE. PAE is a rare but serious complication of hysteroscopic surgery that is associated with organ ischemia and hypoxia. Prevention and treatment of PAE requires the vigilance and cooperation of not only perianesthesia nurses and anesthesiologists but also the surgeons and operating room nurses. Early prevention, proper monitoring, and effective treatment are the keys to successful rescue for PAE.
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Affiliation(s)
- Kun Han
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Man-Qiu Huang
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xi Deng
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yu-Chao Shang
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Resectoscopic Surgery Part I: Overcoming Obstacles and Mastering the Basics. Surg Technol Int 2021. [PMID: 33942886 DOI: 10.52198/21.sti.38.gy1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The introduction of the continuous flow gynecologic resectoscope (CFGR) in 1989 revolutionized minimally invasive gynecologic surgery (MIGS) by introducing such intrauterine procedures as hysteroscopic myomectomy, polypectomy, and endometrial ablation. However, with the subsequent introduction of global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the CFGR has fallen into relative disuse-a regrettable situation since it remains ideally suited for accomplishing many procedures that are otherwise not achievable with these newer technologies. Procedures which involve greater precision and control-endomyometrial resection (EMR), hysteroscopic metroplasty, the correction of isthmoceles, the resection of intramural myomas, and the management of late-onset endometrial ablation failure-are only possible with the CFGR. In addition, the CFGR permits a variety of functions that would otherwise require several different disposable platforms. Despite the benefits of the gynecologic resectoscope, there are clear impediments to its use including a scarcity of educational resources and trained experts, medico-legal concerns, institutional obstacles to organizing an operative team, and the need to develop and maintain an adequate caseload. In Part I of this three-part series, the author will review why the CFGR remains a relevant and indispensable tool for the minimally invasive gynecologic surgeon, the composition of an operating room team, and the instrumentation and skills necessary to accomplish basic resectoscopic surgery. In Part II, we will describe how ultrasound guidance can be used to assist the execution of more challenging intermediate-level cases. Finally, in Part III, we will discuss the most demanding cases for the resectoscopic surgeon-the treatment of post-ablation failures and the removal of intramural leiomyomas-which are clinical scenarios that require ultrasound guidance and well-honed resectoscopic surgical skills.
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Vilos GA, Hutson JR, Singh IS, Giannakopoulos F, Rafea BA, Vilos AG. Venous Gas Embolism during Hysteroscopic Endometrial Ablation: Report of 5 Cases and Review of the Literature. J Minim Invasive Gynecol 2020; 27:748-754. [DOI: 10.1016/j.jmig.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 01/05/2023]
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Palancsai Siftar J, Sobocan M, Takac I. The passage of fluid into the peritoneal cavity during hysteroscopy in pre-menopausal and post-menopausal patients. J OBSTET GYNAECOL 2018; 38:956-960. [PMID: 29557212 DOI: 10.1080/01443615.2017.1420047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The present study aimed to determine the amount of fluid medium passing through the Fallopian tubes into the peritoneal cavity during a hysteroscopy. This was done to understand the pathophysiology of complications related to the hysteroscopy. Conducted in a general hospital setting, the study examined the fluid inflow-outflow during a hysteroscopy both in pre- and post-menopausal women. A hysteroscopy was performed vaginoscopically for both diagnostic and therapeutic procedures. The study involved 117 patients. 84 (71.8%) of them were pre-menopausal and 33 (28.2%) were classified as post-menopausal. The fluid volume difference in the peritoneal cavity prior to hysteroscopy was 26.0 ± 4.2 mL in the pre-menopausal and 7.7 ± 2.4 mL (p = .001) in the post-menopausal group. The pre-menopausal group's flow rate through the Fallopian tubes was 1.5 ± 0.2 mL/min. In the post-menopausal group, it was 0.4 ± 0.1 mL/min (p < .05). It was found that during the hysteroscopy in the pre-menopausal patients, more fluid flows through the Fallopian tubes and at a higher flow rate. Impact statement What is already known on this subject? The complications during a hysteroscopy (HSC) are usually fluid-related and can result in adverse events such as a fluid overload, the dissemination of malignant cells, or electrolyte misbalance. Currently, there is a poor understanding of how HSC fluid behaviour impacts on the pathophysiology of these adverse procedure effects. What do the results of this study add? There have been no quantitative studies of the behaviour of fluid inside the uterine cavity during HSC, which means a quantification of fluid inflow and absorption is required. Our study adds a quantitative understanding of fluid behaviour during HSC. It shows increased rates of fluid passage, as well as fluid speed, into the peritoneal cavity in pre-menopausal patients. What are the implications of these findings for clinical practice and/or further research? Due to the higher rates of fluid passage and speed in pre-menstrual patients, caution regarding the complications during hysteroscopy and further studies are needed on the impact of different fluid distribution.
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Affiliation(s)
- Janka Palancsai Siftar
- a Department of Obstetrics and Gynecology , General Hospital Izola, Izola , Slovenia.,b Faculty of Medicine , University of Maribor, Maribor , Slovenia
| | - Monika Sobocan
- b Faculty of Medicine , University of Maribor, Maribor , Slovenia.,c University Department of Gynecology and Perinatology , University Medical Center Maribor , Maribor , Slovenia
| | - Iztok Takac
- b Faculty of Medicine , University of Maribor, Maribor , Slovenia.,c University Department of Gynecology and Perinatology , University Medical Center Maribor , Maribor , Slovenia
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Umranikar S, Clark TJ, Saridogan E, Miligkos D, Arambage K, Torbe E, Campo R, Sardo ADS, Tanos V, Grimbizis G, British Society for Gynaecological Endoscopy /European Society for Gynaecological Endoscopy Guideline Development Group for Management of Fluid Distension Media in Operative Hysteroscopy. BSGE/ESGE guideline on management of fluid distension media in operative hysteroscopy. ACTA ACUST UNITED AC 2016; 13:289-303. [PMID: 28003797 PMCID: PMC5133285 DOI: 10.1007/s10397-016-0983-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Vasilios Tanos
- St’ Georges Med School, Nicosia University and Aretaeio Hospital, Nicosia, Cyprus
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Ablación-resección endometrial con resectoscopio monopolar: resultados. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2016. [DOI: 10.1016/j.gine.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hahn RG. Fluid absorption and the ethanol monitoring method. Acta Anaesthesiol Scand 2015; 59:1081-93. [PMID: 25952458 DOI: 10.1111/aas.12550] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/04/2015] [Accepted: 04/13/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Fluid absorption is a well-known complication of endoscopic surgeries, such as transurethral prostatic resection and transcervical endometrial resection. Absorption of electrolyte-free fluid in excess of 1 L, which occurs in 5% to 10% of the operations, markedly increases the risk of adverse effects from the cardiovascular and neurological systems. Absorption of isotonic saline, which is used with the new bipolar resection technique, will change the scenario of adverse effects in a yet unknown way. Hyponatremia no longer occurs, but marking the saline with ethanol reveals that fluid absorption occurs just as much as with monopolar prostate resections. METHODS Ethanol monitoring is a method for non-invasive indication and quantification of fluid absorption that has been well evaluated. By using an irrigating fluid that contains 1% of ethanol, updated information about fluid absorption can be obtained at any time perioperatively by letting the patient breathe into a hand-held alcolmeter. RESULTS Regression equations and nomograms with variable complexity are available for estimating how much fluid has been absorbed, both when the alcolmeter is calibrated to show the blood ethanol level and when it is calibrated to show the breath ethanol concentration. Examples of how such estimations should be performed are given in this review article. CONCLUSIONS The difficulty is that the anesthesiologist must be aware of how the alcolmeter is calibrated (for blood or breath) and be able to distinguish between the intravascular and extravascular absorption routes, which give rise to different patterns and levels of breath ethanol concentrations.
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Affiliation(s)
- R. G. Hahn
- Research Unit; Södertälje Hospital and Department of Anesthesiology; Linköping University; Linköping Sweden
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14
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Costalonga EC, Costa e Silva VT, Caires R, Hung J, Yu L, Burdmann EA. Prostatic surgery associated acute kidney injury. World J Nephrol 2014; 3:198-209. [PMID: 25374813 PMCID: PMC4220352 DOI: 10.5527/wjn.v3.i4.198] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/07/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury (AKI) is associated with extended hospital stays, high risks of in-hospital and long-term mortality, and increased risk of incident and progressive chronic kidney disease. Patients with urological diseases are a high-risk group for AKI owing to the coexistence of obstructive uropathy, older age, and preexistent chronic kidney disease. Nonetheless, precise data on the incidence and outcomes of postoperative AKI in urological procedures are lacking. Benign prostatic hyperplasia and prostate cancer are common diagnoses in older men and are frequently treated with surgical procedures. Whereas severe AKI after prostate surgery in general appears to be unusual, AKI associated with transurethral resection of the prostate (TURP) syndrome and with rhabdomyolysis (RM) after radical prostatectomy have been frequently described. The purpose of this review is to discuss the current knowledge regarding the epidemiology, risk factors, outcomes, prevention, and treatment of AKI associated with prostatic surgery. The mechanisms of TURP syndrome and RM following prostatic surgeries will be emphasized.
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15
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[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]. ACTA ACUST UNITED AC 2013; 42:1032-49. [PMID: 24210234 DOI: 10.1016/j.jgyn.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide clinical practice guidelines (CPGs) from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning the adverse events related to hysteroscopy. MATERIALS AND METHODS Review of literature using following Keywords: hysteroscopy; vaginoscopy; infection; perforation; intrauterine adhesions RESULTS Vaginoscopy should be the standard technique for outpatient hysteroscopy (grade A) using a miniature (≤ 3.5mm sheath) (grade A) rigid hysteroscope (grade C), using normal saline solution distension medium (grade C), without any anesthesia (conscious sedation should not be routinely used), without cervical preparation (grade B), without vaginal disinfection and without antibiotic prophylaxy (grade B). Misoprostol (grade A), vaginal estrogens (grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120 mmHg. The maximum fluid deficit of 2000 mL is suggested when using normal saline solution and 1000 mL is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (grade B). CONCLUSION Implementation of this guideline should decrease the prevalence of complications related to office and operative hysteroscopy.
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Bahar R, Shimonovitz M, Benshushan A, Shushan A. Case-Control Study of Complications Associated With Bipolar and Monopolar Hysteroscopic Operations. J Minim Invasive Gynecol 2013; 20:376-80. [DOI: 10.1016/j.jmig.2012.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/29/2012] [Accepted: 12/31/2012] [Indexed: 11/25/2022]
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AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media. J Minim Invasive Gynecol 2013; 20:137-48. [DOI: 10.1016/j.jmig.2012.12.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/05/2012] [Indexed: 11/20/2022]
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Sabsovich I, Abel M, Lee CJ, Spinelli AD, Abramowicz AE. Air embolism during operative hysteroscopy: TEE-guided resuscitation. J Clin Anesth 2012; 24:480-6. [DOI: 10.1016/j.jclinane.2012.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 01/03/2012] [Accepted: 01/16/2012] [Indexed: 01/05/2023]
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Park JT, Lim HK, Kim SG, Um DJ. A comparison of the influence of 2.7% sorbitol-0.54% mannitol and 5% glucose irrigating fluids on plasma serum physiology during hysteroscopic procedures. Korean J Anesthesiol 2011; 61:394-8. [PMID: 22148088 PMCID: PMC3229018 DOI: 10.4097/kjae.2011.61.5.394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 05/09/2011] [Accepted: 05/10/2011] [Indexed: 11/10/2022] Open
Abstract
Background 2.7% sorbitol-0.54% mannitol has been selected as an alternative irrigating fluid during endoscopic surgery for its theoretical advantages. We compared the influence of 2.7% sorbitol-0.54% mannitol (Urosol™, CJ Pharma, Seoul, Korea) and 5% glucose as an irrigating solution for hysteroscopic myomectomy & polypectomy in the occurrence of associated complications. Methods Thirty patients scheduled for a hysteroscopic operation were included in a prospective randomized trial comparing 2.7% sorbitol-0.54% mannitol solution (Group S, n = 15) and 5% glucose (Group G, n = 15) as an irrigating fluid. We recorded the amount of the irrigating fluids, the amount of fluid intake, and the duration of the procedure. Serum sodium, chloride, potassium, glucose values, and serum osmolality were measured before (just after the induction, T1), during (when 2 L of irrigation fluid was infused, T2), and after (1 h after the end of the operation, T3) the hysteroscopic procedure. Results The mean volume of absorbed irrigating fluid was 185.0 ± 73.5 ml in Group G and 175.4 ± 50.5 ml in Group S. Transient hyperglycemia occurred in one patient of Group G. No differences were found in the intraoperative and postoperative levels of serum sodium, potassium, chloride, glucose and osmolality in both groups. Conclusions There was no clinical evidence of hyponatremic hypoosmolality in any of the patients. We found no difference between 2.7% sorbitol-0.54% mannitol and 5% glucose as an irrigating fluid for hysteroscopic procedures with mild to moderate irrigant absorption.
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Affiliation(s)
- Jong Taek Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Michielsen DPJ, Coomans D, Peeters I, Braeckman JG. Conventional monopolar resection or bipolar resection in saline for the management of large (>60 g) benign prostatic hyperplasia: An evaluation of morbidity. MINIM INVASIV THER 2010; 19:207-13. [DOI: 10.3109/13645706.2010.496963] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Michielsen DPJ, Coomans D, Braeckman JG, Umbrain V. Bipolar transurethral resection in saline: The solution to avoid hyponatraemia and transurethral resection syndrome. ACTA ACUST UNITED AC 2010; 44:228-35. [DOI: 10.3109/00365591003720275] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Danny Coomans
- Department of Biostatistics and Medical Informatics, Faculty of Medicine and Pharmacy
| | | | - Vincent Umbrain
- Department of Anesthesia, UZBrussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Piros D, Fagerström T, Collins JW, Hahn RG. Glucose as a marker of fluid absorption in bipolar transurethral surgery. Anesth Analg 2009; 109:1850-5. [PMID: 19923514 DOI: 10.1213/ane.0b013e3181b0843b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Historically, a reduced serum sodium concentration has been used to diagnose absorption of electrolyte-free irrigating fluid during transurethral resection of the prostate (TURP). In bipolar TURP, the irrigating solution contains electrolytes, thus invalidating the serum sodium method. In this study, we investigated whether glucose can be used to diagnose the absorption of irrigating fluid during TURP procedures. METHODS The serum glucose and sodium concentrations were measured in 250 patients undergoing monopolar TURP using either 1.5% glycine or 5% glucose for urinary bladder irrigation. The glucose kinetics was analyzed in 10 volunteers receiving a 30-min infusion of 20 mL/kg of acetated Ringer's solution with 1% glucose. These data were then used in computer simulations of different absorption patterns that were summarized in a nomogram for the relationship between the glucose level and administered fluid volume. RESULTS There was a statistically significant inverse linear relationship between the decrease in serum sodium and the increase in glucose levels after absorption of 5% glucose during TURP (r(2) = 0.80). The glucose concentration increased, from 4.6 (sd 0.4) to 8.3 (0.9) mmol/L, during the experimental infusions. Regardless of the absorption pattern, all simulations indicated that the uptake of 1 L of fluid containing 1% glucose corresponded to an increase in the glucose level of 3.7 (sd 1.6) mmol/L at the end of surgery, whereas 2 L yielded an increase of 6.9 (1.7) mmol/L. CONCLUSIONS In bipolar TURP, the addition of glucose to a concentration of 1% in the electrolyte-containing irrigation fluid can be used as a tracer of absorption that is comparable with measuring serum sodium after monopolar TURP.
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Affiliation(s)
- David Piros
- Department of Anesthesiology, Karolinska Institutet at Söder Hospital, S-118 83 Stockholm, Sweden.
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Kim KO, Shin HI, Lee JH, Lee Y, Choi JG, Yoon DI. Pulmonary edema during hysteroscopic surgery: Three cases report. Korean J Anesthesiol 2009; 57:117-122. [PMID: 30625842 DOI: 10.4097/kjae.2009.57.1.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Hysteroscopic surgery has become a routine gynecologic procedure. The advantages are associated with more accurate removal of lesion, its short operating time, rapid post-operative recovery and low morbidity. However, there are potentially serious complications which can be occured during and following hysteroscopic surgery. The complications are uterine perforation, fluid overload and electrolyte disturbance due to intravasation and absorption of uterine distention media, hemorrhage and, rarely, gas or air embolism. We experienced pulmonary edema during hysteroscopic surgery in three consecutive patients. Therefore, we report these cases of fluid overload with uterine distention media resulting acute pulmonary edema during hysteroscopic surgery.
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Affiliation(s)
- Kyoung Ok Kim
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
| | - Hong Il Shin
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
| | - Jeoung Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
| | - Younsuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
| | - Jun Gwon Choi
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
| | - Dong Il Yoon
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea.
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Hsieh MH, Chen TL, Lin YH, Chang CC, Lin CS, Lee YW. Acute pulmonary edema from unrecognized high irrigation pressure in hysteroscopy: a report of two cases. J Clin Anesth 2008; 20:614-7. [DOI: 10.1016/j.jclinane.2008.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 05/23/2008] [Accepted: 05/29/2008] [Indexed: 11/30/2022]
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Groenman FA, Peters LW, Rademaker BM, Bakkum EA. Embolism of Air and Gas in Hysteroscopic Procedures: Pathophysiology and Implication for Daily Practice. J Minim Invasive Gynecol 2008; 15:241-7. [DOI: 10.1016/j.jmig.2007.10.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 10/24/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
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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. [PMID: 17368250 DOI: 10.1016/j.jmig.2006.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 08/30/2006] [Accepted: 09/02/2006] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To describe the clinical test parotid area sign, which is used to assess fluid absorption during resectoscopic surgery and to compare the test with volumetric fluid balance method with respect to its ability to detect fluid overload. DESIGN Historical cohort study (Canadian Task Force classification II-1). SETTING Tertiary endoscopy center. PATIENTS Eighty-six women who underwent resectoscopic surgery between 1999 and 2004 at our center. INTERVENTION The volumetric fluid balance method was used to evaluate glycine absorption (glycine deficit) during the surgery. A flexometallic ruler was placed on the left cheek of the patient between 2 fixed points: the midpoint of the philtrum and a point on the mastoid prominence, and this distance (philtrum-mastoid prominence distance) was measured at the beginning of every 3 minutes during, and at the end of the procedure. MEASUREMENTS AND MAIN RESULTS Eighty-six patients were divided into 2 groups: Group A, which included patients with absorption less than 1000 mL as measured by the volumetric method; and Group B, which included patients with absorption of 1000 mL or more. The results of the parotid area sign test in the 2 groups were compared. The 2 groups were comparable with respect to the age, weight, preoperative measured philtrum-mastoid prominence distance, and hospital stay. The median (and average absolute deviation) operating time in group A (15 minutes [and 6.79]; range 8-60 minutes; 95% CI of the median, 15-20 minutes) was significantly lower than the median (and average absolute deviation) operating time in group B (25 minutes [and 8.96]; range 9-60 minutes; 95% CI of the median, 20-25 minutes; p <.001). The mean postoperative philtrum-mastoid prominence distance measured in patients of group A (14.23 +/- 0.396 cm [range 14-16 cm, 95% CI 14.10-14.36 cm]) was significantly lower than that in group B [14.76 +/- 0.622 cm (range 14-17 cm, 95% CI 14.58-15.12 cm]; p <.001). By paired t test, the change in the philtrum-mastoid prominence distance after surgery as compared with the value before surgery in each patient was found to be insignificant in group A (p =.86). However, it was found to be significant in group B (p <.001). The increase in the measured philtrum-mastoid prominence distance (i.e., postoperative measurement minus the preoperative measurement) in each patient after surgery was significantly more in group B (mean +/- SD, 0.54 +/- 0.362 cm [range 0-2 cm, 95% CI 0.43-0.65 cm]) than that in group A (mean +/- SD, 0.03 +/- 0.091 cm [range 0-0.4 cm, 95% CI 0.008-0.06 cm]; p <.001). The correlation coefficient for the increase in the philtrum-mastoid prominence distance as the glycine deficit increased in the 2 groups considered together was significant (r = 0.937, p <.01). The partial regression coefficient b value for the effect of duration of surgery while controlling for the effect of fluid deficit was 0.008 (p <.001), and the b value for the effect of fluid deficit while controlling for the effect of duration of surgery was 0.437 (p <.001). The regression coefficient r value (0.727) for the goodness of the fit of the regression line to the data sets was also significant (p <.001). The sensitivity of the test with respect to the volumetric fluid balance is 97.8% (95% CI, 87.28%-99.88%) and specificity is 92.3% (95% CI, 78.03%-97.99%). The negative predictive value is 97.30% (95% CI, 84.19%-99.85%) and positive predictive value is 93.87 (95% CI, 82.13%-98.40%). The conventional positive likelihood ratio for the test is 12.72 (95% CI 4.28-37.77). The conventional negative likelihood ratio is 0.023 (95% CI 0.003-0.16). CONCLUSION The parotid area sign is a simple, effective, and easy-to-perform test (in real time continuously) that requires minimal equipment or training. It supplements the volumetric fluid balance method in the detection of fluid overload (1.5% glycine) during resectoscopic surgery. It may also enable us to detect fluid overload when volumetric fluid balance method fails to detect extraneous losses caused by spillage.
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Affiliation(s)
- Manju Sinha
- Bombay Endoscopy Academy and Centre for Minimally Invasive Surgery, BEAMS Hospital for Women, Khar, Mumbai, India
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Stewart RH, Quick CM, Zawieja DC, Cox CS, Allen SJ, Laine GA. Pulmonary Air Embolization Inhibits Lung Lymph Flow by Increasing Lymphatic Outflow Pressure. Lymphat Res Biol 2006; 4:18-22. [PMID: 16569202 DOI: 10.1089/lrb.2006.4.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Air embolization of the pulmonary vascular tree increases pulmonary microvascular filtration and induces pulmonary edema formation. Flow from cannulated pulmonary lymphatic vessels increases significantly following air embolization. However, in the intact animal, lymph flows into the venous system and the magnitude of lymph flow is directly affected by systemic venous pressure. We hypothesized that pulmonary air embolization would lead to systemic venous hypertension and that this increase in lymphatic outflow pressure would prevent an increase in pulmonary lymph flow. METHODS AND RESULTS Pulmonary air embolization was induced in dogs under general anesthesia. Flow from cannulated pulmonary lymphatic vessels was recorded for lymphatic outflow pressure set equal to atmospheric pressure (Q(LA)) and for outflow pressure set equal to systemic venous pressure (Q(LV)) both before and after embolization. Air embolization resulted in significant increases in systemic venous pressure from 6.4 +/- 0.3 to 12.4 +/- 1.2 mm Hg and in QLA from 48 +/- 9 to 175 +/- 29 microL . min(1). However, embolization did not increase Q(LV) (10 +/- 2 vs. 3 +/- 3 microl . min(1)). CONCLUSIONS Pulmonary air embolization impedes pulmonary lymph flow by increasing systemic venous pressure and, thereby, contributes to pulmonary edema formation.
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Affiliation(s)
- Randolph H Stewart
- Michael E. DeBakey Institute, Texas A&M University, College Station, 77843-4466, USA.
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Abstract
Fluid absorption is an unpredictable complication of endoscopic surgery. Absorption of small amounts of fluid (1-2 litre) occurs in 5-10% of patients undergoing transurethral prostatic resection and results in an easily overlooked mild transurethral resection (TUR) syndrome. Large-scale fluid absorption is rare but leads to symptoms severe enough to require intensive care. Pathophysiological mechanisms consist of pharmacological effects of the irrigant solutes, the volume effect of the irrigant water, dilutional hyponatraemia and brain oedema. Other less widely known factors include absolute losses of sodium by urinary excretion and morphological changes in the heart muscle, both of which promote a hypokinetic circulation. Studies in animals, volunteers and patients show that irrigation with glycine solution should be avoided. Preventive measures, such as low-pressure irrigation, might reduce the extent of fluid absorption but does not eliminate this complication. Monitoring the extent of absorption during surgery allows control of the fluid balance in the individual patient, but such monitoring is not used widely. However, the anaesthetist must be aware of the symptoms and be able to diagnose this complication. Treatment should be based on administration of hypertonic saline rather than on diuretics. New techniques, such as bipolar resectoscopes and vaporizing instead of resecting tissue, result in a continuous change of the prerequisites for fluid absorption and its consequences.
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Affiliation(s)
- R G Hahn
- Department of Anaesthesia, Karolinska Institute, South Hospital, SE-118 83, Stockholm, Sweden.
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