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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 112-114

Operative hysteroscopy intravascular absorption syndrome: The gynecological transurethral resection syndrome


Department of Anesthesia, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Web Publication3-Oct-2018

Correspondence Address:
Dr. Rajeev Chauhan
Department of Anesthesia, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_22_18

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  Abstract 


Hysteroscopy is becoming fairly common in most centers these days, both as a diagnostic and therapeutic tool especially for short day-care procedures, reducing unnecessary hospital admissions and overuse of resources. However, these procedures are not without complications, and some could be delayed and potentially fatal if a high index of suspicion is not maintained. One such rare yet one with a high mortality among urological patients is the transurethral resection syndrome on which there is a cornucopia of literature in the form of articles and chapters. There are very few highlighting a similar syndrome of sorts called the operative hysteroscopy intravascular absorption syndrome. Here, we describe one such case, and in brief, the anesthetic management options for hysteroscopic procedures to prevent such a complication.

Keywords: Hyponatremia, hysteroscope, operative hysteroscopy intravascular absorption


How to cite this article:
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

How to cite this URL:
Chauhan R, Ganesan V, Luthra A. Operative hysteroscopy intravascular absorption syndrome: The gynecological transurethral resection syndrome. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2018 Dec 16];8:112-4. Available from: http://www.joacc.com/text.asp?2018/8/2/112/242623




  Introduction Top


Resectoscopic surgeries are increasingly being used for gynecological procedures in current practice. These procedures range from simple polypectomy to complicated hysteroscopic myomectomies. Although these surgeries have decreased the requirement for laparotomies, they have their own list of complications, including uterine perforation, hemorrhage, gas embolism, sepsis, and fluid overload. Absorption of excessive amounts of irrigation fluids may lead to an entity similar to the transurethral resection syndrome (TURS), called operative hysteroscopy intravascular absorption (OHIA) syndrome. Here, we describe one such case and outline its management.


  Case Report Top


A 36-year-old, 60 kg American Society of Anesthesiologist (ASA) I female, presented for endoscopic resection of uterine submucous myoma. Preoperative examination and laboratory investigations were normal. In the operating room standard monitors were applied. Baseline blood pressure and heart rate were 110/70 mm Hg, 65 mm Hg mean, and 72 beats/min (bpm), respectively. A 20-gauge intravenous (i.v.) catheter was placed and normal saline solution was administrated slowly. The patient was preoxygenated, and anesthesia was induced with morphine 4.5 mg i.v. and propofol 200 mg i.v. Proseal laryngeal mask (number 4) insertion was facilitated by administering 25 mg succinylcholine. Anesthesia was maintained with 60% nitrous oxide and 1.2% isoflurane in oxygen. Patient was kept on spontaneous ventilation after the effect of succinylcholine weaned off. Thereafter Foley's catheter was placed, the patient was placed in the lithotomy position, and the side port of a Hysteromat 3700, Wiest hysteroscope was connected to an irrigating fluid of glycine 1.5% (230 mosm/l) under hydrostatic pressure of 70–100 mm Hg. The procedure of 120 min was uneventful when the patient's blood pressure ranged about 120/70 to 130/85 (mean 65–75) mm Hg and heart rate ranged from 60 to 70 bpm. About 5 min before the end of surgery, isoflurane was stopped and 100% oxygen was given. The patient responded to commands after about 22–25 min of end of surgery when the laryngeal mask was removed, and the patient was transferred to the post anesthesia care unit. There was swelling of the face and puffiness in the eyes and in the parotid region. The delayed awakening in this patient raised suspicion of electrolyte imbalance. The patient was placed in head-up supine position, arterial blood gas (ABG) was sent, and conjunctival examination also showed evidence of fluid overload. Auscultation revealed no crepitations and i.v. furosemide 5 mg was administrated. At the same time, patient's urine was high colored probably due to hemolysis. When inquired about visual disturbances patient complained of partial loss of vision.

Initial ABG revealed pH 7.174, PO288, PCO239, BE 4.5, SO294.6%, Na+ 111, K+ 4.09, Hct 30%. Serial ABGs were taken and in next 4 h urine output was about 3.5 l. Level of Na+ also improved to 129 and the patient was counseled about fluid overload and side effect of glycine manifesting as ocular disturbances. The patient's vision returned to normal in 2 h.


  Discussion Top


OHIA syndrome has a similar pathogenesis to TURS in that both have symptoms due to fluid overload, acute hypoosmolality, glycine toxicity, and dyselectrolytemia. Hysteroscopy surgery are fairly common these days and the rate of complications is reported to be as low as 0.24%, but may go up to 10% with more complicated surgeries such as hysteroscopic myomectomy.[1],[2] Fluid overload with hyponatremia and hypo-osmolality occurs in up to 6% of cases and it can be fatal.[3] The possible mortality of clinically significant OHIA syndrome is unknown and may for practical purposes be considered to be similar to TURS, which has been reported to be as high as 25%.[4]

Intrauterine distending pressures greater than mean arterial pressures, especially more than 80 mm Hg, can cause rapid absorption of the irrigation fluid,[4] which is most commonly 1.5% glycine, leading to fluid overload, pulmonary edema, hyponatremia, neurotoxicity, and visual disturbances. The amount of fluid absorbed is further enhanced by the number of vascular channels opened during myomectomy and prolonged duration of surgery.

Patients under general anesthesia, as in our case, will not manifest the early symptoms of OHIA, which include perioral numbness/prickling sensation, altered sensorium, restlessness, and respiratory difficulty. Bradycardia, hypotension, and oxygen desaturation are consistent signs,[5] but these did not manifest in our case as well.

The delayed awakening, facial swelling, and decreased vision that presented in the postoperative period classic of this syndrome prompted further investigation and the management as outlined above. This further reinforces the need for standardized methods to assess amount of fluid absorbed in such resectoscopic surgeries, the use of isotonic solutions with bipolar/laser resection techniques, lower distending pressures, and protocolized monitoring under general anesthesia such as serial electrolyte measurements, echocardiographic or lung ultrasound monitoring of fluid status, ethanol breath test (ethanol mixed in irrigation fluid), the parotid area sign[6] (intraoperative increase in philtrum-mastoid prominence distance), etc., when the patients are under general anesthesia.

Regional anesthesia may be safer and beneficial to detect the early warning symptoms of this syndrome in awake patients as this facilitates continuous neurological monitoring. The management of hyponatremia involves fluid restriction, 3% saline with correction rates traditionally not to exceed more than 0.5 mEq/l/h of sodium, to avoid central pontine myelinolysis, targeting to keep it north of 120 mEq/l with serial sodium concentration. Central pontine myelinolysis, however, is more common in the setting of rapid correction of chronic hyponatremia, but considering the fact that once it occurs this devastating complication has no treatment, it would be prudent to avoid rapid correction in all possible cases. Diuretics with frusemide also aids in this as well as to correct fluid overload. Pulmonary edema should be managed with oxygen supplementation, diuretics, morphine, head-up position to facilitate ventilation and in severe cases may also necessitate mechanical ventilation.


  Conclusion Top


The purpose of this case report was to highlight the importance of considering the possibility of OHIA/TURS in all resectoscopic surgeries emphasizing on early detection and intervention to avoid preventable complications from occurring. Thus with a high index of suspicion, it should be possible to decrease morbidity and potential mortality due to this infrequent but dangerous syndrome.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D, et al. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol 2002;104:160-4.  Back to cited text no. 1
    
2.
Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: Predicting patients at risk. Obstet Gynecol 2000;96:517-20.  Back to cited text no. 2
    
3.
Mushambi MC, Williamson K. Anaesthetic considerations for hysteroscopic surgery. Best Pract Res Clin Anaesthesiol 2002;16:35-52.  Back to cited text no. 3
    
4.
Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth 2006;96:8-20.  Back to cited text no. 4
    
5.
Sethi N, Chaturvedi R, Kumar K. Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue. Indian J Anaesth 2012;56:179-82.  Back to cited text no. 5
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6.
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.  Back to cited text no. 6
    




 

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