Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice...
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Transcript of Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice...
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Complications of HysteroscopyComplications of Hysteroscopy
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.Executive Vice President/Medical DirectorExecutive Vice President/Medical Director
A A G L A A G L “Advancing Minimally Invasive Gynecology Worldwide”“Advancing Minimally Invasive Gynecology Worldwide”
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Uterine PerforationUterine Perforation
Diagnostic (1° in office)Diagnostic (1° in office) 1/40001/4000 0.03%0.03%
Ablation/resectionAblation/resection 69/574869/5748 1.2%1.2%
Submucous myomaSubmucous myoma 7/9687/968 0.7%0.7%
AdhesionsAdhesions 1.0%1.0%
SeptumSeptum 1.0%1.0%
AAGL survey 1988/1991/1993AAGL survey 1988/1991/1993 1.3 / 1.1 / 1.4%1.3 / 1.1 / 1.4%
F D Loffer literature reviewF D Loffer literature review
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Prevention of Uterine PerforationsPrevention of Uterine Perforations
• Good visualizationGood visualization
• Adequate distensionAdequate distension
• Not resecting below uterine cavityNot resecting below uterine cavity
• Ultrasound or laparoscopy monitoringUltrasound or laparoscopy monitoring
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Problems from PerforationProblems from PerforationDuring HysteroscopyDuring Hysteroscopy
• Partial Partial
- increased fluid intravesation- increased fluid intravesation
- lost orientation- lost orientation• Complete Complete
- procedure discontinued- procedure discontinued
- bleeding (vaginal and/or abdominal)- bleeding (vaginal and/or abdominal)
- intrabdominal organ injury higher with - intrabdominal organ injury higher with
thermal energy sources than mechanical.thermal energy sources than mechanical.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Hemorrhages Hemorrhages
Submucous myomasSubmucous myomas 2.2%2.2%
Endometrial ablation/resectionEndometrial ablation/resection 0.5%*- 0.8%0.5%*- 0.8%
AAGL survey 1988/1991/1993AAGL survey 1988/1991/1993 0.1/0.03/0.25%0.1/0.03/0.25%
FD Loffer literature reviewFD Loffer literature review
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Causes of HemorrhageCauses of Hemorrhage
• Deep myometrial vesselsDeep myometrial vessels
• Uterine or cervical artery and branchesUterine or cervical artery and branches
• Intraabdominal vesselsIntraabdominal vessels
• Not from:Not from: - superficial myometrial vessels- superficial myometrial vessels
- transection of submucous - transection of submucous
fibroidsfibroids
- fundal perforation- fundal perforation
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Managing P.O. HemorrhageManaging P.O. Hemorrhage
• Tincture of time (wait and see)Tincture of time (wait and see)
• Dilute pitressin (3 mgm / 10 cc)Dilute pitressin (3 mgm / 10 cc)
• Balloon / FoleyBalloon / Foley
• Pitressin packPitressin pack
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Types of Distention MediaTypes of Distention Media
• Gas: COGas: CO22
• High viscosity fluidHigh viscosity fluid– Dextran 70Dextran 70
• Low viscosity fluidLow viscosity fluid– GlycineGlycine– SorbitolSorbitol– MannitolMannitol– Saline / Ringers LactateSaline / Ringers Lactate
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Problems From Fluid OverloadProblems From Fluid Overload
• Congestive heart failure (all media)Congestive heart failure (all media)• Hyperammonemia (glycine)Hyperammonemia (glycine)• Coagulopathies and/or allergic reactions Coagulopathies and/or allergic reactions
(dextran)(dextran)• Hyponatremia/hypo-osmolarity Hyponatremia/hypo-osmolarity → death → death
(electrolyte free media)(electrolyte free media)
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Fluid Intravasation Is : Fluid Intravasation Is :
• The loss of uterine distending media into The loss of uterine distending media into
open uterine vesselsopen uterine vessels
• Most critical with electrolyte free mediaMost critical with electrolyte free media
• Less critical with electrolyte mediaLess critical with electrolyte media
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Frequency of Fluid Overload Frequency of Fluid Overload
• AAGL surveyAAGL survey - 1988- 1988 0.34%0.34%- 1991- 1991 0.14%0.14%- 1993- 1993 0.2%0.2%
• Submucous myomaSubmucous myoma 1.1%1.1%
• Endometrial ablation / resectionEndometrial ablation / resection 1.5%1.5%
FD Loffer Literature ReviewFD Loffer Literature Review
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Direction of Flow Relates to PressureDirection of Flow Relates to Pressure
lessless
AA
moremore
BB
equalequal
CC
moremore lessless equalequal
(in fluid at rest the pressure is equal (in fluid at rest the pressure is equal everywhere in the system)everywhere in the system)
Pressure in:Pressure in:
UterusUterus
BloodBloodVesselVessel
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Amount of Flow Relates to PressureAmount of Flow Relates to Pressure(with equal hole size)(with equal hole size)
Pressure = 2xPressure = 2x Pressure = 4xPressure = 4x
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Amount of Flow Relates to Hole SizeAmount of Flow Relates to Hole Size(with equal pressure)(with equal pressure)
Pressure = 4xPressure = 4x Pressure = 4xPressure = 4x
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Relation Between Fluid Loss, Relation Between Fluid Loss, Operative Time & MyomasOperative Time & Myomas
0
500
1000
1500
2000
2500
10 20 30 40 50 60 70 80 90 100
Type 0
Type I
Type II
Emanual, et al., “An analysis of fluid loss during transcervical resection of Emanual, et al., “An analysis of fluid loss during transcervical resection of submucous myomas”, Fertility & Sterility. 68:5, 1997 pp. 881-886submucous myomas”, Fertility & Sterility. 68:5, 1997 pp. 881-886
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Relative PressuresRelative Pressures(approximate)(approximate)
• Uterine distensionUterine distension - 50 – 70 mm Hg- 50 – 70 mm Hg
• Fallopian tubes openFallopian tubes open - 55 – 110 mm Hg- 55 – 110 mm Hg
• Mean arterial blood pressure Mean arterial blood pressure
- 120/70 mm Hg- 120/70 mm Hg
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Use only in Use only in diagnostic diagnostic
casescases
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Fluid ManagementFluid Management
• Fluid management is required for operative Fluid management is required for operative
hysteroscopehysteroscope
• Manual calculation is inadequateManual calculation is inadequate
-- Approximately 10% error in fluid Approximately 10% error in fluid packagingpackaging
-- Time delaysTime delays
-- Nursing calculation errorsNursing calculation errors
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Fluid Delivery /Fluid Delivery /Monitoring SystemsMonitoring Systems
• Gravity vs. mechanical pumpsGravity vs. mechanical pumps(pressure is pressure)(pressure is pressure)
• Eyeball vs. measuringEyeball vs. measuring(seeing is not believing)(seeing is not believing)
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Fluid Delivery /Fluid Delivery /Monitoring SystemsMonitoring Systems
• PumpsPumps – Convenience– Convenience
• Monitoring Monitoring – Early warning– Early warning– Exact amounts– Exact amounts– Evaluating rapidity – Evaluating rapidity
Value of:Value of:
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Osmolality of Distending MediaOsmolality of Distending Media
• Glycine 1.5%Glycine 1.5% 200 mOsmol/l200 mOsmol/l
• Sorbitol 3% - Mannitol 0.5%Sorbitol 3% - Mannitol 0.5% 178 mOsmol/l178 mOsmol/l
• Mannitol 5%Mannitol 5% 280 mOsmol/l280 mOsmol/l
(Normal serum osmolality(Normal serum osmolality 290 mOsmol/l)290 mOsmol/l)
Cerebral Edema Following Absorption of Glycine Irrigating SolutionCerebral Edema Following Absorption of Glycine Irrigating Solution
[H2O][H2O]
Vascular space
Interstitial space
Intracellular space
AA BB
[H2O][H2O]
CC DD
[H2O]
[H2O]
Brain
Skull
Interstitial space
Intracellular space
BrainSkull
[H2O]
[H2O]
H2O crossesblood-brain barrier
Intravascular half-life
85 minutes
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Is Mannitol A BetterIs Mannitol A BetterMedia Than Glycine?Media Than Glycine?
1½% Glycine1½% Glycine 5% Mannitol5% Mannitolpt 1pt 1 pt 2pt 2 pt 1pt 1 pt 2pt 2
Vol. Deficit (L)Vol. Deficit (L) 2.1242.124 2.4482.448 3.6403.640 2.7352.735
P.O. Na (mmol/L)P.O. Na (mmol/L) 124124 124124 105105 110110
Na diff (mmol/L)Na diff (mmol/L) 1818 1515 3636 3131
Serum osmolality diff (mmol/L)Serum osmolality diff (mmol/L) -13-13 -11-11 11 -3-3
Nausea & vomitingNausea & vomiting ++ ++ 00 00
Phillips, DR et al. JAAGL 1997;4:567Phillips, DR et al. JAAGL 1997;4:567
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
5% Mannitol5% Mannitol
• MetabolismMetabolism– AbsorptionAbsorption 6-10%6-10%– ExcretionExcretion 90-94%90-94%– Plasma half lifePlasma half life 15-102 min15-102 min
• Excessive intravasationExcessive intravasation– HypervolemiaHypervolemia– HyponatremiaHyponatremia– Normal plasma osmolalityNormal plasma osmolality
MetabolismMetabolism
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Intravasation Increased ByIntravasation Increased By
• Open vascular channelsOpen vascular channels
• High infusion pressureHigh infusion pressure
• High flow rateHigh flow rate
• Long operative timeLong operative time
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Gaseous EmbolizationGaseous Embolization
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Trendelenberg positioning is Trendelenberg positioning is not necessary and should be not necessary and should be
avoided in hysteroscopyavoided in hysteroscopy
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Diagnosing Gas Embolism
end tidal CO2
• Millwheel murmur
central venous pressure
cardiac output
• Doppler echocardiography
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Hysteroscopic Venous Gas EmbolizationHysteroscopic Venous Gas Embolization- Critical Issues- Critical Issues
• Room airRoom air
• Products of combustionProducts of combustion
• VolumeVolume
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Carbon Dioxide Embolism FollowingDiagnostic Hysteroscopy
• 33 y/o - diagnosis: ectopic vs. SAB
• L/S H/S @ 150 mm Hg + 100 ml/min
• 4 min H/S D&C
• Cardiac arrest from gas embolism4 min after H/S
Brink, DM. Brit J OBG. 1994;101:717.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
CompostionCompostion11 of Gases Found by of Gases Found byHysteroscopic Electrosurgical VaporizationHysteroscopic Electrosurgical Vaporization
BipolarBipolar UnipolarUnipolar AirAir(normal saline)(normal saline) (glycine)(glycine)
HydrogenHydrogen 51.051.0 49.049.0 0.000050.00005
COCO 25.725.7 26.126.1 0.000010.00001
COCO22 6.56.5 7.57.5 0.03140.0314
OO22 2.92.9 3.03.0 20.947620.9476
NN 1.41.4 2.32.3 78.08478.084
CC22HH22 3.63.6 4.14.1
CHCH44 2.82.8 2.52.5 0.00020.0002
MiscMisc22 6.06.0 5.6 5.6
Munro et al. JAAGL Nov 2001Munro et al. JAAGL Nov 2001
1 - Measured in mole percent1 - Measured in mole percent2 - Acetylene, Propane, C3 Olefin, Isobutane, n-Butane, C4 Alkene, C5 Hydrocarbon2 - Acetylene, Propane, C3 Olefin, Isobutane, n-Butane, C4 Alkene, C5 Hydrocarbon
----
----
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Toxicology and Solubility of Gases Formed Toxicology and Solubility of Gases Formed By Electrosurgical VaporizationBy Electrosurgical Vaporization
SolubilitySolubilityToxicToxic in Bloodin Blood Risk to PtRisk to Pt
HydrogenHydrogen lowlow moderatemoderate volume onlyvolume only
COCO high high highhigh dependsdependson amounton amount
COCO22 low low highhigh littlelittle
NN lowlow lowlow volume onlyvolume only
OO2 2 none high volume onlynone high volume only
Munro et al. JAAGL Nov 2001Munro et al. JAAGL Nov 2001
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Frequency of Gas Embolization -Frequency of Gas Embolization -Monopolar Resectoscope Using GlycineMonopolar Resectoscope Using Glycine
• Detected in hepatic vein or right heartDetected in hepatic vein or right heart
- 3 control patients- 3 control patients 00
- 11 operative patients - 11 operative patients 10/1110/11
• No significant patient problemsNo significant patient problems
• Hepatic vein traps gas firstHepatic vein traps gas first
Bloomstone et al. JAAGL Feb 2001Bloomstone et al. JAAGL Feb 2001
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Avoiding Risks of Gaseous Avoiding Risks of Gaseous IntravesationIntravesation
• Purge air from linesPurge air from lines
• No TrendelenbergNo Trendelenberg
• Alert anesthesiologistAlert anesthesiologist
• Protect open cervixProtect open cervix
• Avoid high pressures (intravasation)Avoid high pressures (intravasation)
• Inadequate uterine flushingInadequate uterine flushing
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Preventing Fluid OverloadPreventing Fluid Overload
• Anticipate possibility of problemAnticipate possibility of problem
• Minimal distension pressuresMinimal distension pressures
• Operate quicklyOperate quickly
• Use mannitol solution?Use mannitol solution?
• Use of oxytocin, vasopression or GnRh Use of oxytocin, vasopression or GnRh agonists?agonists?
• Accurate intake & outputAccurate intake & output
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
ConclusionsConclusions
• Fudal perferations carry a low risk unless Fudal perferations carry a low risk unless
accompanied by thermal injury.accompanied by thermal injury.
• Fluid intravesation is a major risk of Fluid intravesation is a major risk of
hysteroscopy.hysteroscopy.
• It occurs primarily in operative cases.It occurs primarily in operative cases.
• 5% Mannitol may be a better media.5% Mannitol may be a better media.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
ThankThank You For You For
Your AttentionYour Attention
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.
Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.