Symptomatic absorption of isotonic saline during transcervical endometrial resection

Isotonic saline causes greater volume overload than electrolyte-free irrigating fluids

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.

Symptomatic absorption of normal saline during transurethral resection of the prostate: a case report

Background

Transurethral resection of the prostate (TUR-P) could incidentally cause hyponatremia, known as TUR syndrome due to intravascular absorption of non-electrolytic irrigation fluid. Recently, normal saline has been used as an irrigation fluid in a new system named TURis (TUR in saline) to prevent TUR syndrome. However, rapid massive absorption of normal saline can also cause other systemic adverse events.

Case presentation

A 71-year-old man underwent TURis for benign prostatic hyperplasia under spinal anesthesia. The patient lost consciousness which led upper airway obstruction and hypoxia 30 min after the surgery began. Blood gas test indicated hyperchloremic metabolic acidosis. While vasoactive agents were ineffective, the administration of bicarbonate significantly improved the symptoms and restored blood pressure.

Conclusion

We experienced a case of hyperchloremic metabolic acidosis with decreased level of consciousness and hypotension during TURis. Administration of bicarbonate, but not phenylephrine, was effective for recovering blood pressure.

Comparing volumetric and biochemical assessment of intravasation caused by hysteroscopic surgery

BACKGROUND

During hysteroscopic surgery intravasation of irrigation fluid occurs, leading to potentially dangerous intravascular fluid overload. Currently, intravasation is usually measured volumetrically as fluid deficit. Intravasation could also be calculated using the decrease in hemoglobin or increase in chloride ion concentration, both phenomena known to result from intravasation. We compared the values of intravasation measured volumetrically as fluid deficit versus calculated from the biochemical change in hemoglobin and chloride. We expected that these values would show strong correlation and agreement.

METHODS

In a retrospective data analysis of 51 patients who underwent hysteroscopic resection of myomas or endometrium a pre and post procedure concentration of haemoglobin and chloride was available. The fluid deficit was plotted against the two versions of calculated intravasation. Furthermore, we put the data into Bland-Altman plots to scrutinize their relationship.

RESULTS

The volumetric assessed fluid deficit and both versions of biochemically assessed intravasation, either using the change in hemoglobin or chloride ion concentration, turned out to be three totally different entities with weak correlation. Bland-Altman plots show too wide limits of agreement, and a striking difference between the two methods of calculated intravasation.

CONCLUSION

Our study shows significant differences and poor agreement between volumetric and biochemically assessed intravasation. Based on this study, routinely assessing intravasation by biochemical methods does not have additional benefit compared to the volumetric fluid deficit. It remains unclear which method resembles true intravasation.

The HYSTER study: the effect of intracervically administered terlipressin versus placebo on the number of gaseous emboli and fluid intravasation during hysteroscopic surgery: study protocol for a randomized controlled clinical trial

Background

Transcervical resection of myoma or endometrium is a safe, hysteroscopic, minimally invasive procedure. However, intravasation of distension fluid is a common phenomenon during these procedures. In a previous study we observed venous gas emboli in almost every patient. The severity of hysteroscopic-derived embolization has been shown to be correlated to the amount of intravasation. In addition, paradoxical gas embolism, which is potentially dangerous, was observed in several patients.

Studies have shown a reduction of intravasation by using intracervically administered vasopressin during hysteroscopy. We think that its analog, terlipressin, should have the same effect. In our previous research we observed more gaseous emboli as intravasation increased. Whether or not the insertion of intracervically administered terlipressin leads to a lower incidence and severity of gas embolism is unknown. We hypothesize that intracervically administered terlipressin leads to a reduction of intravasation with a lower incidence and severity of gas embolism. Terlipressin may be of benefit during hysteroscopic surgery.

Methods/design

Forty-eight patients (ASA 1 or 2) scheduled for transcervical resection of large, types 1–2 myoma or extensive endometrium resection will be included. In a double-blind fashion patients will be randomized 1:1 according to surgical treatment using either intracervically administered terlipressin or placebo. Transesophageal echocardiography will be used to observe and record embolic events. A pre- and post-procedure venous blood sample will be taken to calculate intravasation based on hemodilution. Our primary endpoint will be how terlipressin influences the severity of embolic events. Secondary endpoints include the effect of terlipressin on the amount of intravasation and on hemodynamic parameters.

Discussion

If terlipressin does indeed reduce the number of gaseous emboli and intravasation occurring during hysteroscopic surgery, it would be a simple method to minimize potential adverse events. It also allows for prolonged operating time before the threshold of intravasation is reached, thereby reducing the need for a second operation.

Trial registration

Nederlands Trial Register (Dutch Trial Register), ID: NTR5577. Registered retrospectively on 18 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2442-9) contains supplementary material, which is available to authorized users.