Critically High Carboxyhemoglobin Level following Extensive Hysteroscopic Myomectomy

Abstract

Studies have demonstrated that during hysteroscopic myomectomy with bipolar diathermy, carbon monoxide is produced and enters the patient's circulation. However, little is known regarding the immediate or long-term sequelae of transient rises in carboxyhemoglobin levels during hysteroscopic surgery. This paper aims to suggest recommendations for acute evaluation, management, patient counseling, and future research. We present a case of a 36-year-old woman (Gravida 0, Para 0) with abnormal uterine bleeding-leiomyoma and resultant anemia, undergoing hysteroscopic resection of a large submucous myoma. During surgery, the patient was found to have a critically elevated level of carboxyhemoglobin and accompanying electrocardiogram derangements. She was managed with prolonged intubation, 100% O 2 , and trending of her carboxyhemoglobin levels before extubation. This demonstrates the importance of being cognizant of the potentially toxic gaseous byproducts of bipolar resection and of including intravasation of these byproducts in one's consideration of patient safety during extensive resections. Bipolar hysteroscopic resection of large leiomyomas may result in critically high carboxyhemoglobin levels, which can impair end-organ oxygen delivery with resultant ischemia; the risks of myocardial ischemia should be discussed with the anesthesia team before attempting an extensive resection. Electrocardiogram changes indicative of ischemia should prompt discontinuation of the case. Finally, carboxyhemoglobin poisoning should be included in the differential diagnosis of patients who demonstrate longer-than-expected anesthesia recovery times after bipolar resection of large submucous leiomyomas, and they should be managed with repeat evaluation of carboxyhemoglobin levels, supplemental oxygen, and cardiac monitoring.

Carbon Monoxide Poisoning Presenting With Neurological Signs During Hysteroscopic Bipolar Surgery With Spinal Anesthesia: Two Case Reports

“…2,9 The high affinity of CO for hemoglobin is responsible for rapid dissolution in the blood-forming COHb, leading to decreased oxygen delivery. CO poisoning causing hemodynamic disturbances and ST segment depression 4 has been reported during operative hysteroscopy. In our cases, no cardiovascular complications were observed.…”

“…1,2 There are only a few studies describing the production of carbon monoxide (CO) by electrosurgical vaporization. 3,4 CO intoxication can be responsible for cardiovascular complications but may also lead to neurological complications. 5 We describe 2 cases of probable CO poisoning with neurological signs during hysteroscopy performed with spinal anesthesia.…”

Comparison of outcomes of hysteroscopic myomectomy of type 2 submucous fibroids greater than 4 cm in diameter via pretreatment with HIFU or GnRH-a

“…to reduce the occurrence of intraoperative complications, and particularly, to reduce the absorption of hysteroscopic fluid distention media and thus decrease the risk of pulmonary edema, congestive heart failure, and electrolyte imbalances, it is important that hysteroscopy surgery should be completed within 60 min [7,26]. Therefore, pretreatment with HIFU can improve the safety and efficacy of hysteroscopic myomectomy.…”