Her preoperative laboratory tests were normal except the serum bilirubin level of 1. Electrocardiogram, non-invasive blood pressure, and pulse oximetry were applied for intra-anesthesia monitoring.
General anesthesia was induced with fentanyl, propofol, and rocuronium, followed by tracheal intubation and maintained with desflurane and remifentanil. The patient was placed in a lithotomy position. The difference between the fluid inflow and outflow increased over time. During the latter half of the surgery, a substantial spillage was observed on the floor. A mild decrease in blood pressure was observed throughout the surgery.
Premature ventricular contractions were observed 5 to 10 times per minute. The urinary catheter was inserted due to prolonged surgical time. After the drapes were removed, distention of the lower abdomen and navel was noticed. No abdominal fluid wave on palpitation, and no findings of intraperitoneal fluid retention by an abdominal ultrasound exam were observed. However, there were significant edemas in the conjunctiva, lip, and fingers Fig. Chest X-ray suggested mild pulmonary edema Fig.
With these findings, we diagnosed acute hyponatremia due to water intoxication. However, the second arterial blood gas test still indicated severe hyponatremia plasma sodium level She was admitted to the intensive care unit ICU under sedation and mechanical ventilation with tracheal intubation. Edema of lips a and conjunctiva b , and chest X-ray c at the end of the operation.
The details of correctional treatment, and transition of plasma sodium level and urine output are described in Fig. Sedation was maintained with propofol. For sodium correction, continuous administration of 1. A head computed tomography taken immediately after the attack showed mild cerebral edema Fig. At this time, the plasma sodium level was Treatments of 1.
Glasgow coma scale was E3V1M4 immediately after extubation. On the second postoperative day, her consciousness fully recovered. She was released from the hospital on the sixth postoperative day, following a physical examination by a neurologist and a second cerebral magnetic resonance imaging, which revealed no neurological deficits. Time courses of plasma sodium level, effective osmolality, blood pH, mean arterial pressure, urine output, and treatments for hyponatremia in intensive care unit.
Each symbol indicates each measurement and each black bar shows hourly urine output. For the treatments, each arrow indicates the duration of the treatment, and open circle indicates the time of furosemide administration. Head computed tomography immediately after the seizure attack.
In this case, severe hyponatremia occurred during a 2-h hysteroscopic myomectomy with electrolyte-free solution.
Although a seizure attack and mild brain edema occurred, the patient fully recovered on the second postoperative day. Hysteroscopic surgery is generally less invasive than laparoscopic or open surgery when the patient selection is appropriate. As this case had 3. However, excessive fluid absorption can be a life-threatening complication in a hysteroscopic surgery.
A previous study examined the relationship between the type of submucous leiomyoma and fluid absorption volume [ 3 ]. The result has shown a strong relationship between the absorption volume and the operation time. The interruption of the surgery should be considered with the assessment of the difference between the volume of inflow and outflow fluid [ 2 ].
Treatment of severe acute hyponatremia should be considered. A guideline proposes a treatment strategy for hyponatremia with severe symptoms 1D and 2D indicate strong and weak recommendations with low evidence [ 10 ]. In our case, plasma sodium level gradually increased since the ICU admission with a treatment of 1.
Sodium correction at a higher rate might have been better to avoid these symptoms. Overly rapid correction of hyponatremia can develop osmotic demyelination, where neurological findings improve in the early phase but are followed by a new progression of, sometimes permanent neurological deficits in one to several days later [ 11 ].
We treated hyponatremia with a mild increase in plasma sodium level and the patients fully recovered on postoperative day 2. Nowadays, isotonic fluid is also used in hysteroscopic surgery to avoid dilutional hyponatremia. Regardless of the fluid type for uterine distension, fluid balance monitoring is principal in the anesthesia management. One limitation of this report is the lack of the detailed irrigation fluid balance. As the significant edema and the difference between the fluid inflow and outflow indicated the absorption of irrigation fluid, we administered furosemide to excrete water from the body.
It should be noted that chronic furosemide intake can develop hyponatremia [ 11 , 14 ] due to the inhibition of sodium absorption in the kidney.
We experienced severe hyponatremia with a postoperative seizure attack and mild brain edema in a case undergoing a 2-h hysteroscopic procedure with electrolyte-free solution as irrigation fluid.
During the surgery, it is essential to monitor the fluid balance closely, and the interruption of the surgery should be considered by prolonged surgery and a large difference between inflow and outflow fluid. Under general anesthesia, caution should be exercised because the typical symptoms of hyponatremia such as nausea and confusion are blinded. Hyponatremia was treated with hypertonic saline administration and left no permanent neurological deficits.
Complications of hysteroscopy and how to avoid them. Best Pract Res Cl Ob. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update. Article Google Scholar. An analysis of fluid loss during transcervical resection of submucous myomas.
Fertil Steril. Severe intraoperative hyponatremia associated with the absorption of irrigation fluid during hysteroscopic myomectomy: a case report. J Clin Anesth. A multicenter survey of complications associated with 21, operative hysteroscopies. Rapid correction of severe hyponatremia after hysteroscopic surgery — a case report.
BMC Anesthesiol. Complications associated with the absorption of hysteroscopic fluid media. Sterns RH. Disorders of plasma sodium--causes, consequences, and correction. New Engl J Med. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas.
J Minim Invasive Gynecol. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant. Hyponatremia treatment guidelines expert panel recommendations. Am J Med. Smith CC, P. The syndrome of inappropriate secretion of antidiuretic hormone SIADH is a frequent cause of hyponatremia related to central nervous system disorders, neurosurgery, or the use of psychoactive drugs.
Fluid restriction is the standard of care for patients with SIADH who are asymptomatic or who have only mild symptoms, but patients with severe or symptomatic hyponatremia require more aggressive therapy. Infusion of hypertonic saline is the usual approach to the treatment of symptomatic hyponatremia, but patients require frequent monitoring. Pharmacologic agents such as demeclocycline and lithium may be effective in some patients but are associated with undesirable adverse events.
The AVPreceptor antagonists are a new therapeutic class for the treatment of hyponatremia.
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