A literature review and update on the prevention and management of fluid overload in endometrial resection and hysteroscopic surgery

Abstract

Objective The purpose of this study is to provide safe guidelines to minimize the risk of fluid absorption and its complications at operative hysteroscopy. Design Retrospective review of the literature. Results Two of the major complications of fluid intravasation at hysteroscopic surgery are hyponatraemic encephalopathy and death. Fluid intravasation remains a risk despite optimal instrumentation and the use of minimal pressures to distend the uterus. While multiple factors affect the amount of fluid absorption and significant variability can exist between very similar cases, monitoring of fluid balance remains the most important issue. Techniques relying on volume measurements are less accurate than those using weight measurements and can potentially lead to significant underestimation of fluid absorption. A continuous automated weighing system provides an easy, less time‐consuming and valid method of monitoring fluid deficit. We believe the safe limit for accurately measured fluid loss should be 800 mL, as 1000 mL of glycine intravasation results in a very significant decrease in serum sodium which is sufficient to bring a normonatraemic patient into the abnormal range. It is safer to perform hysteroscopic surgery under local anaesthesia as the earliest symptoms of encephalopathy, i.e. nausea, vomiting, weakness, will alert the surgeon and anaesthesist about impending serious complications, and corrective measures can be taken earlier than when the patient is under general anaesthesia. Conclusion Fluid overload with subsequent hyponatraemic encephalopathy and death is one of the most significant complications in operative hysteroscopy. Following a protocol which entails the use of local anaesthesia and accurate fluid monitoring and sets a limit to fluid deficit will minimize this risk.

BSGE/ESGE guideline on management of fluid distension media in operative hysteroscopy

“…However, despite requiring more instilled fluid, high intrauterine pressures to allow adequate visualisation are harder to achieve [2]. …”

“…Intravenous infusion of a slow 3 % hypertonic sodium chloride infusion (typically 1–2 mmol/L/h to prevent pontine myelinolysis) is indicated until serum sodium rises to 125 mmol/ [2, 18, 22, 23] correcting any cerebral oedema and reducing the risk of systemic complications. Acute hyponatraemia below 120 mm/l and/or acute symptomatic hyponatraemia should be treated with a 100 ml bolus of 3 % saline over 10 min and this can be repeated up to three times, followed by an infusion as described above.…”

“…Isotonic electrolyte-containing solutions cannot be used with monopolar energy because this leads to activation of ions that disperse the electric current and reduce the power density. Hence the heat generated in tissues is insufficient to destroy or have a tissue effect [2]. …”

Response to “Complications during hysteroscopy for gynecological procedures: prevention is better than cure!”

“…A variety of recommendations have been made in prior publications. Local and/or neuraxial anesthesia to detect symptomatology in awake patients is a reported recommendation [5]. The aforementioned cited case summary includes patients receiving this modality.…”

Predictors of fluid intravasation during operative hysteroscopy: a preplanned prospective observational study with 200 cases

“…sodium) because of the risk of cerebral edema and dilutional hyponatremia [15][16][17] , condition in which immediate intensive approach is necessary 18 . In endoscopic resections, both monopolar (which needs non-electrolytic solutions as distension fluid) or bipolar (more expensive technique, which accepts electrolytic/ ionic solutions 19,20 ) probes can be used for performing hysteroscopic adhesiolysis, resection of uterine septum, endometrium, polyps and fibroids 10,13,[21][22][23][24] . In fact, both techniques have been widely used over the last decade 14,25,26 .…”