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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.54 no.6 Campinas Nov./Dec. 2004
Water intoxication during hysteroscopy. Case report*
Intoxicación hídrica durante histeroscopia. Relato de caso
Triga Argiro, MDI; Paraskeva Antia, MD; Dimitrios K Filippou, MDII
of Anaesthesiology, Athens Anticancer Hospital "Agios Savvas", Athens,
IIDept. of Surgery, Athens Oncological Hospital "Agii Anargiri", Athens, Greece
OBJECTIVES: Water intoxication and electrolyte disturbances that produce
systemic toxicity can be developed during transurethral prostatic resection
procedures and hysteroscopic surgery. Usual causes are considered the fluid
load and the duration of the operation.
CASE REPORT: We present an unusual case of water intoxication in a 42 years old, female patient who underwent endoscopic resection of uterine submucuous myoma. The diagnosis and treatment is also described.
CONCLUSIONS: Water intoxication may develop as a result of distending fluid overload, therefore careful fluid measurement and monitoring is crucial.
Key Words: COMPLICATIONS: water intoxication; SURGERY, Gynaecological
Y OBJETIVOS: Intoxicación hídrica y disturbios electrolíticos
produciendo toxicidad sistémica pueden acontecer durante resección
prostática transuretral y cirugía histeroscópica, siendo
en general causados por el volumen de líquido y por la duración
RELATO DEL CASO: Se presenta un caso no frecuente de intoxicación hídrica en una paciente de 42 años sometida a resección endoscópica de un mioma uterino submucoso, con la descripción del diagnóstico y del tratamiento.
CONCLUSIONES: La intoxicación hídrica puede ser resultado de recargo líquido, siendo importante el control cuidadoso de los líquidos empleados y monitorización clínica.
Fluid overload, water intoxication, electrolyte disturbances and systemic toxicity can occur after absorption of large amounts of a hypotonic irrigating solution during endoscopic surgery. This syndrome is well recognized during transurethral prostatic resection procedures, but can also occur during hysteroscopic surgery 1,2. The development of fluid overload is influenced by several factors such as type of irrigation fluid, infusion pressure, type and duration of surgery and results in serious complications from cardiovascular, respiratory and central nervous system.
A 42 years-old, 60 kg female, physical status ASA I, was presented for endoscopic resection of uterine submucuous myoma. Preoperative physical examination and laboratory tests were normal. In the operating room standard monitoring was applied. At that time patient's blood pressure and heart rate were 110/70 mmHg and 72 bpm respectively. A 18-gauge IV catheter was placed and Ringer's lactated solution was administrated at a rate of 150 mL/h. After administration of 10 mg of metoclopramide IV the patient was preoxygenated, and anesthesia was induced with fentanyl 150 µg IV and propofol 180 mg IV. Laryngeal mask (number 4) insertion was facilitated by 40 mg of rocuronium. Anesthesia was maintained with 60% nitrous oxide and 2% sevoflurane in oxygen. The patient was placed in the lithotomy position and the side port of a Hysteromat 3700, Wiest hysteroscope was connected to an infusion of distilled water under hydrostatic pressure of 70-100 mmHg.
The procedure went on uneventful for 40 minutes and during that time the patient's blood pressure ranged about 120/70 mmHg, whereas heart rate ranged from 60-70 beats/min. Ten minutes before the end of the procedure, the patient developed hypertension and tachycardia (systolic blood pressure 170 mmHg, diastolic blood pressure 110 mmHg and heart rate 110 beats/min). Supplemental fentanyl of 150 µg was administered IV, as the incidence was first attributed to pain. Nevertheless, the patient remained hypertensive and tachycardic. That fact raised suspicions of excessive hypotonic fluid absorption. After the operation completed, patient was placed in head up supine position and a urine catheter was placed. Auscultation revealed pulmonary rales and furosemide 20 mg was administrated immediately IV. At the same time patient's urine was bloody probably due to hemolysis. After stabilization and removal of laryngeal mask, we managed to transfer our patient in postanaesthesia care unit.
Blood analysis revealed a decrease in serum concentration of potassium, sodium, and calcium and hemodilution. More specifically sodium concentration estimated in 130 mmol/L (139 mmol/L), potassium in 3.6 mmol/L (4.1 mmol/L), calcium in 7,2 mg/dL (8,2 mg/dL), and hematocrit in 28.8% (39.2%). Preoperative values are referred in brackets. Hemolysis was confirmed by elevated blood bilirubin concentration 1,61 mg/dL (0.42 mg/dL) and elevated urine hemoglobin. Plasma osmolality estimated in 267 mOsmol/L. Blood glucose levels were slightly elevated (150 mg/dL) compared to normal preoperative values. At the PACU the patient started to complain for paresthesias and muscle weakness, which was attributed to the low plasma calcium concentration. Immediately 500 mg of calcium gluconate was administrated IV within one hour. The patient remained in the PACU for two hours and following diuresis, blood pressure decreased to normal values and pulmonary auscultation showed marked improvement. After the symptoms disappeared, patient was transferred to the ward, where new laboratory tests revealed an increase in hematocrit and serum sodium, potassium and calcium concentrations. Laboratory results returned to normal during the next day.
Hysteroscopy has gained popularity in diagnostic and therapeutic gynecological procedures. Although hysteroscopic techniques require less operating time they are not devoid of complications, especially when hysteroscopy is combined with endometrial resection or ablation using electrodiathermy 3. The irrigation fluid can be absorbed through the open vessels, or through the patents fallopian tubes into the peritoneal cavity and produce a syndrome similar to the transurethral resection syndrome of the prostate (TURP). The incidence of fluid overload in hysteroscopic endometrial ablation procedures is 1%-5% 4-6. Large amounts of irrigation fluid (2 L or more) must be absorbed before symptoms or signs appear.
Electrolyte solutions can not be used for irrigation because they disperse the electrocautery current. Water provides great visibility but large amounts can be absorbed due to its hypotonicity. The most commonly used irrigation fluid is glycine 1.5% (230 mOsmol/L) or a mixture of sorbitol 2.7% and mannitol 0.54% (195 mOsmol/L) 7. Because all fluids are hypotonic absorption and water intoxication can still occur. The surgeon in our case used distilled water because of deprivation of glycine solution.
Hypertension is an early sign of fluid overload and indeed a sudden hypertensive response was seen in our patient. The absorption of fluid dilutes the serum protein concentration therefore lowers the plasma oncotic pressure and results in accumulation of fluid in the interstitial space of the lungs. In this case the patient didnt complain for dyspnoea although there were auscultation findings. Acute water intoxication results also in dilutional hyponatremia, which leads to serious ECG changes (bradycardia, nodal rhythm, widened QRS complex, ST - T wave changes and ventricular tachycardia) or brain oedema when the plasma sodium concentration is <120 mmol/L. In our case hyponatremia was mild and had no adverse ECG effects. The fall in potassium level was also mild and had no clinical impact. Mild hyper glycemia was attributed to stress response. Dilutional hypocalcemia has been described in the literature as an adverse effect of fluid overload during TURP or hysteroscopic procedures and can lead in tetany or even cardiac arrest 8,9. In our case hypocalcemia resulted in symptoms of muscle weakness, fatigue, and numbness in the hands, which imply latent tetany. Hypotonic fluid absorption can also lead to acute hemolysis, which was apparent in this case, by the appearance of hemoglobin in the urine and the elevation of serum bilirubin concentration. Mild hyperglycemia was attributed to surgical stress.
Hysteroscopic surgery can have serious complications as a result of distending fluid overload, therefore careful fluid measurement and monitoring is crucial.
"Written consent was obtained from the patient for publication of the study".
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Dimitrios K Filippou, MD, PhD
Address: 19 G.Moschopoulou str
ZIP: 17342 City: Agios Dimitrios, Athens, Greece
Submitted for publication
March 17, 2004
Accepted for publication August 17, 2004
* Received from Hospital Anticancer de Atenas