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Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice President/Medical Director A A G L “Advancing Minimally.

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Presentation on theme: "Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice President/Medical Director A A G L “Advancing Minimally."— Presentation transcript:

1 Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice President/Medical Director A A G L “Advancing Minimally Invasive Gynecology Worldwide”

2 Franklin D. Loffer, M.D.

3 Uterine Perforation Diagnostic (1° in office)1/ % Ablation/resection69/ % Submucous myoma7/9680.7% Adhesions1.0% Septum1.0% AAGL survey 1988/1991/ / 1.1 / 1.4% F D Loffer literature review

4 Franklin D. Loffer, M.D. Prevention 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

5 Franklin D. Loffer, M.D. Problems from Perforation During Hysteroscopy PartialPartial - increased fluid intravesation - increased fluid intravesation - lost orientation - lost orientation CompleteComplete - 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.

6 Franklin D. Loffer, M.D. Hemorrhages Submucous myomas2.2% Endometrial ablation/resection0.5%*- 0.8% AAGL survey 1988/1991/ /0.03/0.25% FD Loffer literature review

7 Franklin D. Loffer, M.D. Causes of Hemorrhage Deep myometrial vesselsDeep myometrial vessels Uterine or cervical artery and branchesUterine or cervical artery and branches Intraabdominal vesselsIntraabdominal vessels Not from:- superficial myometrial vessels - transection of submucous fibroids - fundal perforationNot from:- superficial myometrial vessels - transection of submucous fibroids - fundal perforation

8 Franklin D. Loffer, M.D. Managing 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

9 Franklin D. Loffer, M.D. Types of Distention Media Gas: CO 2Gas: CO 2 High viscosity fluidHigh viscosity fluid –Dextran 70 Low viscosity fluidLow viscosity fluid –Glycine –Sorbitol –Mannitol –Saline / Ringers Lactate

10 Franklin D. Loffer, M.D. Problems From Fluid Overload Congestive heart failure (all media)Congestive heart failure (all media) Hyperammonemia (glycine)Hyperammonemia (glycine) Coagulopathies and/or allergic reactions (dextran)Coagulopathies and/or allergic reactions (dextran) Hyponatremia/hypo-osmolarity → death (electrolyte free media)Hyponatremia/hypo-osmolarity → death (electrolyte free media)

11 Franklin D. Loffer, M.D. Fluid Intravasation Is : The loss of uterine distending media intoThe loss of uterine distending media into open uterine vessels open uterine vessels Most critical with electrolyte free mediaMost critical with electrolyte free media Less critical with electrolyte mediaLess critical with electrolyte media

12 Franklin D. Loffer, M.D. Frequency of Fluid Overload AAGL survey % % %AAGL survey % % % Submucous myoma1.1%Submucous myoma1.1% Endometrial ablation / resection1.5%Endometrial ablation / resection1.5% FD Loffer Literature Review

13 Franklin D. Loffer, M.D. Direction of Flow Relates to Pressure lessAmoreB equalC moreless equal (in fluid at rest the pressure is equal everywhere in the system) Pressure in: Uterus Blood Vessel

14 Franklin D. Loffer, M.D. Amount of Flow Relates to Pressure (with equal hole size) Pressure = 2x Pressure = 4x

15 Franklin D. Loffer, M.D. Amount of Flow Relates to Hole Size (with equal pressure) Pressure = 4x

16 Franklin D. Loffer, M.D. Relation Between Fluid Loss, Operative Time & Myomas Emanual, et al., “An analysis of fluid loss during transcervical resection of submucous myomas”, Fertility & Sterility. 68:5, 1997 pp

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18 Relative Pressures (approximate) Uterine distension- 50 – 70 mm HgUterine distension- 50 – 70 mm Hg Fallopian tubes open- 55 – 110 mm HgFallopian tubes open- 55 – 110 mm Hg Mean arterial blood pressureMean arterial blood pressure - 120/70 mm Hg - 120/70 mm Hg

19 Franklin D. Loffer, M.D. Use only in diagnostic cases

20 Franklin D. Loffer, M.D. Fluid Management Fluid management is required for operativeFluid management is required for operative hysteroscope hysteroscope Manual calculation is inadequateManual calculation is inadequate -Approximately 10% error in fluid packaging -Time delays -Nursing calculation errors

21 Franklin D. Loffer, M.D. Fluid Delivery / Monitoring Systems Gravity vs. mechanical pumps (pressure is pressure)Gravity vs. mechanical pumps (pressure is pressure) Eyeball vs. measuring (seeing is not believing)Eyeball vs. measuring (seeing is not believing)

22 Franklin D. Loffer, M.D. Fluid Delivery / Monitoring Systems Pumps– ConveniencePumps– Convenience Monitoring – Early warning – Exact amounts – Evaluating rapidityMonitoring – Early warning – Exact amounts – Evaluating rapidity Value of:

23 Franklin D. Loffer, M.D. Osmolality of Distending Media Glycine 1.5%200 mOsmol/lGlycine 1.5%200 mOsmol/l Sorbitol 3% - Mannitol 0.5%178 mOsmol/lSorbitol 3% - Mannitol 0.5%178 mOsmol/l Mannitol 5%280 mOsmol/lMannitol 5%280 mOsmol/l (Normal serum osmolality290 mOsmol/l)

24 Cerebral Edema Following Absorption of Glycine Irrigating Solution [H 2 O] Vascular space Interstitial space Intracellular space AB [H 2 O] CD Brain Skull Interstitial space Intracellular space Brain Skull [H 2 O] H 2 O crosses blood-brain barrier Intravascular half-life 85 minutes

25 Franklin D. Loffer, M.D. Is Mannitol A Better Media Than Glycine? 1½% Glycine5% Mannitol pt 1pt 2pt 1pt 2 Vol. Deficit (L) P.O. Na (mmol/L) Na diff (mmol/L) Serum osmolality diff (mmol/L) Nausea & vomiting++00 Phillips, DR et al. JAAGL 1997;4:567

26 Franklin D. Loffer, M.D. 5% Mannitol MetabolismMetabolism –Absorption6-10% –Excretion90-94% –Plasma half life min Excessive intravasationExcessive intravasation –Hypervolemia –Hyponatremia –Normal plasma osmolality Metabolism

27 Franklin D. Loffer, M.D. Intravasation Increased By Open vascular channelsOpen vascular channels High infusion pressureHigh infusion pressure High flow rateHigh flow rate Long operative timeLong operative time

28 Franklin D. Loffer, M.D. Gaseous Embolization

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30 Trendelenberg positioning is not necessary and should be avoided in hysteroscopy Trendelenberg positioning is not necessary and should be avoided in hysteroscopy

31 Franklin D. Loffer, M.D. Diagnosing Gas Embolism  end tidal CO 2 Millwheel murmur  central venous pressure  cardiac output Doppler echocardiography

32 Franklin D. Loffer, M.D. Hysteroscopic Venous Gas Embolization - Critical Issues Room airRoom air Products of combustionProducts of combustion VolumeVolume

33 Franklin D. Loffer, M.D. Carbon Dioxide Embolism Following Diagnostic Hysteroscopy 33 y/o - diagnosis: ectopic vs. SAB L/S  150 mm Hg ml/min 4 min H/S  D&C Cardiac arrest from gas embolism 4 min after H/S Brink, DM. Brit J OBG. 1994;101:717.

34 Franklin D. Loffer, M.D. Compostion 1 of Gases Found by Hysteroscopic Electrosurgical Vaporization BipolarUnipolarAir (normal saline)(glycine) Hydrogen CO CO O N C 2 H CH Misc Munro et al. JAAGL Nov Measured in mole percent 2 - Acetylene, Propane, C3 Olefin, Isobutane, n-Butane, C4 Alkene, C5 Hydrocarbon -- --

35 Franklin D. Loffer, M.D. Toxicology and Solubility of Gases Formed By Electrosurgical Vaporization Solubility Toxicin BloodRisk to Pt Hydrogenlowmoderatevolume only CO highhighdepends on amount CO 2 low highlittle Nlowlowvolume only O 2 none high volume only Munro et al. JAAGL Nov 2001 Munro et al. JAAGL Nov 2001

36 Franklin D. Loffer, M.D. Frequency of Gas Embolization - Monopolar Resectoscope Using Glycine Detected in hepatic vein or right heart - 3 control patients operative patients 10/11Detected in hepatic vein or right heart - 3 control patients operative patients 10/11 No significant patient problemsNo significant patient problems Hepatic vein traps gas firstHepatic vein traps gas first Bloomstone et al. JAAGL Feb 2001 Bloomstone et al. JAAGL Feb 2001

37 Franklin D. Loffer, M.D. Avoiding Risks of Gaseous Intravesation 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

38 Franklin D. Loffer, M.D. Preventing 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 agonists?Use of oxytocin, vasopression or GnRh agonists? Accurate intake & outputAccurate intake & output

39 Franklin D. Loffer, M.D. Conclusions Fudal perferations carry a low risk unlessFudal perferations carry a low risk unless accompanied by thermal injury. accompanied by thermal injury. Fluid intravesation is a major risk ofFluid 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.

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43 Thank You For Your Attention

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