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 Table of Contents  
LETTER TO THE EDITOR
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 379-380

Intraoperative cardiac arrest during hysteroscopyy


Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission15-Jan-2018
Date of Acceptance12-Dec-2018
Date of Web Publication29-Aug-2019

Correspondence Address:
DNB Nitu Puthenveettil
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi 682041
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_2_18

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How to cite this article:
Rajan S, Puthenveettil N, Paul J, Kumar L. Intraoperative cardiac arrest during hysteroscopyy. Res Opin Anesth Intensive Care 2019;6:379-80

How to cite this URL:
Rajan S, Puthenveettil N, Paul J, Kumar L. Intraoperative cardiac arrest during hysteroscopyy. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2019 Nov 18];6:379-80. Available from: http://www.roaic.eg.net/text.asp?2019/6/3/379/265713



A 59-year-old woman with a diagnosis of benign fibroid polyp was posted for hysteroscopy with dilatation and curettage under subarachnoid block. Clinical examination and investigations including a preoperative echocardiography were unremarkable. On the day of surgery, subarachnoid block was performed at L3–L4 space with bupivacaine 0.5% heavy 2.2 ml. After 5 min, surgery commenced with the patient in lithotomy position, and the vitals remained stable. One hour later, the patient complained of chest discomfort and suddenly became unresponsive. ECG and pulse oximetry were unrecordable. The surgery was stopped, the patient was moved back to the supine position and cardiopulmonary resuscitation was started. Following two cycles of cardiopulmonary resuscitation and 1 mg intravenous adrenaline, there was return of spontaneous circulation. ECG showed a normal sinus rhythm with a rate of 120/min, blood pressure (BP) of 130/86 mmHg, and oxygen saturation of 100%. Meanwhile, the patient was intubated; the right radial artery and internal jugular vein were cannulated. Random blood sugar was 103 mg/dl. By this time the patient had received 1 l of Ringer’s lactate solution, and 800 ml urine was drained when catheterized.

Ten minutes later, saturation started decreasing to 88%. The endotracheal tube showed frothy secretions. As signs suggestive of pulmonary oedema were present on auscultation, frusemide 80 mg and morphine 6 mg were given. She was shifted to the ICU with a heart rate of 120/min, BP of 200/110, oxygen saturation of 80%, and was put on pressure control ventilation (100% oxygen) with positive end-expiratory pressure of 16 cmH2O in view of pulmonary edema to push fluid back to the interstitial space to improve oxygenation. Morphine 6 mg bolus was given, and infusions of morphine 2 mg/h and frusemide 2 mg/h were started. Echocardiography, ECG, and cardiac enzymes remained normal.

After 4 h, the BP started decreasing. Morphine infusion was stopped, and noradrenaline 0.06 mcg/kg/min was started. Saturation remained between 78 and 82%. Urine output gradually decreased to less than 0.5 ml/h, and, after 2 h, the patient became anuric. Hyperkalemia evident in the arterial blood gas was managed with 100 ml sodium bicarbonate, glucose insulin bolus (100 ml of 50% dextrose with 10 U of insulin) and 10 ml of 10% calcium gluconate.

To remove the fluid overload, dialysis was decided, but, soon, the patient became hemodynamically unstable (BP 50/30 mmHg). Following intravenous adrenaline 1 mg, infusions of adrenaline (0.05–0.5 mcg/kg/min), dopamine (15–20 mcg/kg/min), vasopressin (0.01–0.05 U/min) and insulin (2–4 U/h) were started, and dialysis was deferred. The patient subsequently developed repeated cardiac arrests, and, despite managing hyperkalemia, bradycardia and ventricular fibrillation, the patient succumbed 2 h later.

Operative hysteroscopy is considered a relatively safe procedure with complications in only 0.95–3% of cases. Apart from the surgical complications, excessive fluid absorption with or without resultant hyponatremia is of concern [1],[2],[3]. It is recommended that the intrauterine pressures should be kept below the mean arterial pressure and that the fluid deficits should be carefully monitored. When deficits reach 1500 ml for nonelectrolyte fluids and 2500 ml for isotonic fluids, the surgery should be terminated [4]. Development of hyperchloremic metabolic acidosis with the use of normal saline has been reported. Severe hyperchloremic acidosis can impair myocardial contraction and, in the presence of fluid overload, can result in ventricular fibrillation or heart failure [5].

On re-evaluation of our case, it was noticed that 4.5 l of normal saline was used for irrigation in 1 h of surgical time. In addition, during hysteroscopy, polypectomy was also performed, which might have accelerated the systemic absorption of the irrigating fluid [6]. Along with sustained acidosis, hyperchloraemia was also evident in the serial arterial blood gases taken in the postoperative period ([Table 1]), indicating excess systemic absorption of the irrigation fluid (0.9% saline). Although the use of glycine could have prevented hyperchloremia, fluid overload still would have resulted because of the excess use. Proper optimization of medical conditions, careful monitoring and limiting undue intrauterine pressure rise by using devices with pressure set points, and limiting the volume of irrigation fluid and surgical time could avert the development of such adverse events during hysteroscopy.
Table 1 Serial arterial blood gases taken in the postoperative period

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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shveiky D, Rojansky N, Revel A, Benshushan A, Laufer N, Shushan A. Complications of hysteroscopic surgery: ‘Beyond the learning curve’. J Minim Invasive Gynecol 2007; 14:218–222.  Back to cited text no. 1
    
2.
Bradley LD. Complications in hysteroscopy: prevention, treatment and legal risk. Curr Opin Obstet Gynecol 2002; 14:409–415.  Back to cited text no. 2
    
3.
Sethi N, Chaturvedi R, Kumar K. Operative hysteroscopy intravascular absorption syndrome: a bolt from the blue. Indian J Anaesth 2012; 56:179–182.  Back to cited text no. 3
    
4.
Loffer FD, Bradley LD, Brill AI, Brooks PG, Cooper JM. Hysteroscopic fluid monitoring guidelines. J Am Assoc Gynecol Laparosc 2000; 7:438.  Back to cited text no. 4
    
5.
Schäfer M, Ungern-Sternberg BV, Wight E, Schneider MC. Isotonic fluid absorption during hysteroscopy resulting in severe hyperchloremic acidosis. Anesthesiology 2005; 103:203–204.  Back to cited text no. 5
    
6.
Munro MG. Complications of hysteroscopic and uterine resectoscopic surgery. Obstet Gynecol Clin North Am 2010; 37:399–425.  Back to cited text no. 6
    



 
 
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