FLUID MANAGEMENT IN HYSTEROSCOPY.

MUNYAO JOSEPH.

Periop nurse

3rd Park Hospital.

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INTRODUCTION.

The development of hysteroscopy has provided a minimally invasive approach to common gynaecological problems, such as abnormal uterine bleeding.

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Increased clinician training, smaller diameter hysteroscopes, and increased emphasis on office-based procedures have led to a widespread use of this important technology.

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A hysteroscope is a telescope that is inserted into the uterus via the vagina and cervix to visualize the endometrial cavity, as well as the tubal ostia, endocervical canal, cervix, and vagina.

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Hysteroscopy can be performed for diagnostic or therapeutic indications.

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Hysteroscope.

DISTENSION MEDIA.

• Distension media is mandatory to allow visualization of the potential uterine cavity.
• Surgery could use cold scissors and graspers, mechanical energy or electrosurgery.
• Normal plasma osmolality 280mOsm/l.

GOOD MEDIA.

• Good view
• Readily available
• Isotonic
• Non-toxic
• Hypoallergenic
• Inexpensive
• Allows operative work

CLASSIFICATION OF MEDIA.

• Gas-carbon dioxide
• Liquids-high viscosity-dextran 32%.
• Low viscosity-iso-osmolar(electrolyte)-normal saline 0.9%,ringers lactate
• Hyperosmolar (non-electrolyte)-dextrose 5%, glycine 1.5%.

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FLUID SUPPLY.

• Gravity flow.
• 3-5 l bag at 90-100 cm above the pelvis height.
• Gives a pressure approx. 70 mmhg.
• Fluid bag with compression cuff.
• Set to 80-120 mmhg
• Not advisable-if the pressure exceeds MAP then absorption occurs.(70-100 mmhg).

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• Microprocessor controlled irrigation/suction pump.
• Maintains a constant i.u.p and adjusts flow according to this.
• Set the irrigation pressure at 50-80 mmhg –below or at MAP.
• Rate at 200-400ml/min.
• Gives an iup of 30-40mmhg IUP.

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SYSTEMIC FLUID ABSORPTION.

• How?
• Retrograde through the tubes.
• Through the endometrium.
• Open vessels and sinuses during resection.

When?

• High IUP >75 mmhg -fluids via the ostia.
• Low MAP.
• Depth of myometrial and endometrial penetration-submucosal resection of fibroids, metroplasty.
• Duration of surgery.
• Size of uterine cavity-larger surface area.

FLUID OVERLOAD.

• Fluid deficit of > 1000 ml when using hypotonic solution in healthy reproductive age.
• >2500ml when using isotonic solution.
• 750mls and 1500ml in elderly or women with comorbid like renal disease.
• Incidences<5% in operative cases.

SEVERITY AND NATURE OF COMPLICATIONS.

• Osmolality of fluids.
• Hypotonic –neurologic (hyponatremia, cerebral oedema, neurologic impairment and seizures).
• Isotonic –cardiovascular effects only-pulmonary oedema, heart failure.
• Premenopausal women at higher risk of neurologic complications due to suppressive effects of oestrogen on ATPase pump.

NEUROLOGIC�SYMPTOMS.

• Develop when sodium levels fall <125 mmol/l(135-145).
• Headache, nausea, vomiting and weakness.
• Further drop-brain oedema and increased ICP –confusion, agitation headache and blindness.
• <120- confusion,lethargic,seizures,coma,bradycardia,arrhythmias and arrest.

CARDIOVASCULAR� SYMPTOMS.

• Pulmonary oedema-low spo2, dyspnoea, palpitations etc.
• CCF –tissue oedema and poor tissue perfusion.

Management –�Multidisciplinary.

• Urinary catheter.
• Fluid restriction.
• Vitals signs.
• UEC, calcium levels and haemogram.
• Loop diuretics-furosemide.
• Echo.
• Iv slow 3% hypertonic saline until sodium >125 mmol/l

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SAFETY TIPS-�REDUCE ABSORPTION.

• Preop GnRH in premenopausal women before TCRF.
• Intracervical injection of dilute vasopressin before cervical dilatation.
• Maintain IUP as low as possible to allow adequate cavity visualization and below MAP.
• Pressure and flow in controlled pump within correct settings.
• Strict input and output chart.
• Use drapes with reservoir.

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