Dilutional Hyponatremia During Intrauterine Adhesion

Dilutional Hyponatremia During Intrauterine AdhesionSevere dilutional hyponatremia in a forbearing during hysteroscopic of intrauterineadhesion A fibre reportYE Yuzhu, LIN LinaAbstract Hysteroscopy is a stripped-downly invasive procedure for the perseverings of intrauterin adhesion, barely may result in potentially disastrous complicatedness labeled transurethral resection of the prostate (TURP) syndrome. Excessive preoccupancy of large scale of dilatation media under high inflow wring by openings of venous channels in endometrium, the large volume of transfusion fluid that is beyond the modulation ability of body may educate the most dangerous situation of severe hyponatremia, hypervolemia and hypoosmolality. The consequence of hysteroscopy is chiefly determined by the type of distention medium, irrigation pressure,condition of endometrium, preoperative catheterization, type of electrode ashes of rules and duration of the mental process. A case of hysteroscopic resecti on of intrauterine adhesion in which ill symptomatic hyponatremia and hypervolemia happended with epidural anesthesia is presented.Key words Hysteroscopy, hyponatremia, distension medium, excerpt pressure, TURP (transurethral resection of the prostate ) syndrome.IntroductionHysteroscopy technique in the sensing and treatment of intrauterine diseases plays an dominant role because of its unique feature of minimal invasion and remains the gold standard mean for the diagnosis of uterine disease, but may result in potentially disastrous complication known as TURP syndrome or hyponatremia and hypervolemia. A hysteroscopy precdure requires an intrauterin installation inserting into the uterine st peerless accompanied by a suitable type of distention medium including dextrose 5% in water (D5W), 2.7% sorbitol, 0.54% mannitol and saline solution for the opticalization of intrauterine situation. The most common fluid utilize clinically is D5W for its distinct features of low-viscosity, electrolyte-free, safety and lower cost. TURP syndrome appears when large scale of distension media (D5W) is overly absorbed including the following clinical signs dyspnea, headache, nausea and vomiting, coma, and veritable(a) brush aside progress to cerebaral and pneumonic edema. Signs and syndromes are nonspecific when the conditon is in its early stages and, as a result, its easy to be ignored. Vigilance and communication of the all medical team is extremely required to avoid state of ailment aggravating. Early management must be rendered as soon as possible for the critically ill tolerants by anesthetists. We report a case of a 36-year-old woman who developed TURP syndrome during hysteroscopic of intrauterine adhesion herein.2. eccentric ReportA 36-year-old, weight 62 kg , no medicinal drug or coexisting diseases, ASA physical status II , underwent hysteroscopy treatment because of her iterative intrauterin adhesion during epidural anesthesia. Past functional history r evealed four time of previous hysteroscopies within the year, both of which were aimed to remedy for her secondary infertility but failed in acquiring satisfactory therapeutic efficacy. There were no irresponsible fingds on the preoperative physical examination and normal values in laborarory results included roue routine test and plasmic electrolytes, and the concerntrations of sodium ion, potassium ion and rail line glucose level were 139 mmol/L, 3.47 mmol/L and 4.0 mmol/L, respectively. A 12-lead electrocardiogram showed sinus rhythm.Upon arrival to surgical operating room, 500 ml lactated Ringers solution was dripped intravenously as tending fluid by and by standard monitors were placed. The heart rate was 76 beat generation per minute, respiratory rate was 18 breathes per minute and the oxygen saturation was 99%. Contiuous epidural anesthesia was performed successfully with 0.5% lidocaine and 0.375% ropivacaine 15ml totally within 15 minutes. accordingly the patient was placed in lithotomy position and no catheterization was offered because of the short carrying into action period we had anticipated preoperatively although she expressed her micturition desire. The surgery initially proceeded unevenfully with actually steady state of hemodynamics. 8,000 mL D5W as the irrigation fluid was delivered throught the hysteroscope by soberness pressure (60cm above the patient), and the irrigation pressure for uterine quarry distending was 150 mmHg. Monopolar electrode remains was selected for endometrium resection, and controled the watts of electroresection and electrocoagulation within 40 60 watts and 60 80 watts, respectively. Simultaneous ultrasonographic supervise was used to identify the sickness of uterus wall and uterine cavity size. A total of 1,000 mL of lactated Ringers solution was infused during the 70 minutes of surgery, with a total blood loss of 20 mL. Twenty minutes in the beginning the termination of surgery , the patient complain ted of difficulty in breathing with synchronous polypnea, shiver, and sensations of vertigo and nausea. Oxygen saturation dropped from 98% to 90% and recoverd soon after mask oxygen inhalation. Thereupon tramadol 50 mg was administered intravenously, and excellent effect obtained. virtually 300 mL output of urine when the bladder was squeezed incautiously by ultrasound probe and the patient vomited once just the procedure completed. The patient appeared haziness of spirit-mind but responded appropriately to verbal stimulate. A dorsalis pedis artery blood try on was obtained from the patient, and electrolytes were reported using a blood- gaseous state analyzing device. Results as follows PH 7.31 Na+, 115 mmol/L K+, 3.0mmol/L ionized Ca2+, 0.93 mmol/L Glucose, 27.8 mmol/L HCO3, 18.6 mmol/L. Based on the symptoms mentioned above, TURP syndrome was suspected. An indwelling urinary catheter was inserted immediately and 1,800 mL urine output was collected totlly at twice. A mixture of 50ml 10% saline and 100ml 0.9% saline was dripped to raise sodium concentration, meanwhile metoclopramide 10 mg was used for anti-nausea. But there were no diuretic and insulin used in case of aggravating of hypokalemia. Oxygen saturation exerted in 92% after oxygen mask was removed and with a progressive rise. vital signs on permission to PACU were as follows blood pressure, 126/79 mmHg heart rate, 79 beats per minute breathing rate, 20 breaths per minute and oxygen saturation, 96%. The patient was transported to postanesthesia care unit (PACU) for continued treatments and review of blood gas analysis. On our arrival into PACU, arterial blood gas (ABG) analysis was performed when the venous transfusion of the hypertonic saline solution ended, revealing PH 7.36 Na+, 127 mmol/L K+, 3.0mmol/L ionized Ca2+, 1.0 mmol/L glucose, 22.9 mmol/L HCO3, 21.5 mmol/L BE, -3.6 mmol/L. The patient still had low sodium and potassium level from ABG, a mixture of 100ml 10% saline and 100ml 0.9% sali ne containing potassium chloride 0.5 g was supplemented in low-speed intravenously. Nurse anesthetist was asked to record vital signs every 15 minutes. 16151805, the patient got her vital signs stablized gradually and oxygen staturation could maintain over 95%. Review of her blood gas analysis showed PH 7.36 Na+, 137 mmol/L K+, 3.4mmol/L ionized Ca2+, 1.0 mmol/L glucose, 7.2 mmol/L HCO3, 23.2 mmol/L BE, -3.6 mmol/L. The patient recieved 500 ml lactated Ringers solution totally in PACU, with a total urine output of 850 mL(data from PACU anesthetic chart), and sent hind end to the ordinary ward without any complaints and Alderete scores 10.2. DiscussionHysteroscopy has gained widely used in diagnostic and therapeutic in gynecologic surgery for umteen special advantages, but is not devoid of risks especially when hysteroscopy is applied to resection of extensively endometrial lesion. Excessive absorption of irrigation fluid during hysteroscopic surgery from uterine cavity is the main cause of TURP syndrome or water intoxication, of which reported incidence is 0.2% 1. The TURP syndrome mainly has clinical symptoms in cardiovascular system, respiratory system and nervous system including elevation of blood pressure, bradycardia, dyspnea, pulmonary edema, cerebral hemia and even death. The severity of consequence is associated with multiple factors, analysis of this case were as follows. The patients uterine cavity has low compliance and severe adhesion, so an intrauterine pressure (IUP) of 150 mmHg is required to obtain excellent visual conditions of bilateral tubal orifices. 8,000 mL D5W as the irrigation fluid is delivered into uterine for uterine distension in 70 minutes operation time. Based on clinical research, the absorptivity of distension media by body is within the weave of 10 30 ml/min only when the irrigation pressure is less(prenominal) than 100 mmHg 2. Therefore, we estimated 700 2,100 mL D5W is absorbed into circulatory system approximately, alo ng with an infusion of 1,000 mL lactated Ringers solution. As a result, 1,700 3,100 mL is administered into blood intravenously at least, and even more. Hyperglycemia caused by excessive absorption of D5W produces hyperglycemic hyperosmolar status and thence makes intracellular fluid transfers to outside the cell, which bings about exacerbating of hyponatremia status. The patient accepted high frequency hysteroscopy procedure in the short term leads to big and severe damage of endometrium, allowing the distension fluid entrance into blood circulation more easily, which contributes to hypervolemia in a more faster pace. As one of essential factors, excessive irrigation pressure plays a crucial role in distension fuild over absorption in the condition that endometrial venous sinus are widely open in hysteroscopic electric resection. In our case, we have to raise the pressure to 150 mmHg for a clear surgical vision of uterine cavity, therefore, rendering excellent chance for fluid entering into body. No catheterization was performed preoperatively, thus a large amount of fluid accumulates in bladder and circulation system. To sum up, in this case, fluid overburden, hyperglycemic hyperosmolar status, high intrauterine pressure, mental disturbance of endometrial vessles and lack of preoperative catheterization lead to a significant increasement of locomote volume and a sharply reduce of plasma colloid osmotic pressure. extracellular free water in brain are transported from the outside to the inwardly of the cell, which results in cerebral edema and causes intracranial hypertension. A serious of neurologic syndromes develop including dizziness, headache, nausea, vomiting, and haziness of spirit-mind. Likewise, as a consequence of irrigation fluid overload and dilution of the plasma protein concentration, pulmonary hydrostatic pressure elevated, leading to the accurrence of acute pulmonary edema and pulmonary interstitial edema. The ventilation/perfusion imb alance occurs, and then manifests in dyspnea, hypoxemia and a sustained downward trend of oxygen saturation, etc. seasonably recognition and urgent corresponding treatment measures should be taken in the early course of water intoxication to prevent the condition deteriorated. In a general way, for every liter of hypotonic fluid absorbed, the blood serum sodium concentration will decrease by 10 mmol/L(10 milliequivalent/L) 3. The result of ABG analysis of the patients dorsalis pedis artery blood sample indicates severe hyponatremia (Na+ --(--(-) (- 280-320 mmol/L) (limiting correction to )3%5%-----------20%--27.8 mmol/L-20 mmol/L,--4----- -1------------2 5,80100mmHg6--60minanaethestic considertion90min3 1.5L-1.0L(Issacson 1000 ml 10 mmol/L1000 2000 ml -Issacson KB Complications of hysteroscopyJ Obstet Gynecol Clin matrimony Am199926(1)3951)4--------5---TURP---- lengthiness1 Jansen FW, Verdevoogd CB, Ulzen KV, et al. Complications of hysteroscopyaprospective multicenter study J, O bstet Gynecol, 2000, 96 (2) 266 270.2 Rhymer JS, Bell TS, Perry KC, et al. Hyponatremia following transurethralresection of the postate J.Br Jurol, 1985, 57(4) 450452.3 Prost AM, Liberman RF, Harlow BL, Ginsburg ES. Complication ofhysteroscopic surgery predincting patients at risk. Obster Gynccol. 200096517-5204 Cooper JM Brady RM. Intraoperative and early post-operative complicationsof operative hysteroscopy. Obstetric and gynaecology Clinics of North America2000 27 347-3655Romer T. Benefit of GnRH analogene treatment for hysteroscopicsurgery in patients with bleeding disorders J.Gynecol.ObstetInvest,2003,50112-120.6Murdoch JA. Tong JG. Anesthesia for hysteroscopy. Anesthesiol ClinNorth Am. 200119125-140 J .--,2009,9(12)1097-109Witz CA, Silverberg KM, Burns WN, Schenken RS, olive DL.Complications associated with the absorption of hysteroscopic fluidmedia. Fertil Steril 199360745-56.