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Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 187-190

Severe hyponatremia and cerebral edema after laparoscopic salpingectomy, hysteroscopy myomectomy, and adenomyosis resection: A case report

Department of Anesthesiology and Intensive Care, Ciptomangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Indonesia

Date of Submission23-Jan-2022
Date of Decision14-May-2022
Date of Acceptance28-May-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Andy Omega
Department of Anesthesiology and Intensive Care, Ciptomangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_29_22

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The usage of hypotonic irrigation solution during hysteroscopy and laparoscopy can cause systemic fluid absorption and complications such as hyponatremia, fluid overload, and cerebral edema. Moreover, Trendelenburg position on gynecologic laparoscopy with a long duration can increase intracranial pressure and decrease cerebral perfusion pressure. A woman, 39 years old, suffered from severe hyponatremia and cerebral edema after hysteroscopy myomectomy, laparoscopic salpingectomy, adenomyosis resection, and adhesiolysis procedure. Water for injection was used as an irrigation solution during the procedure, totaling 20 L. The position of the procedure was supine, Trendelenburg, with a procedure duration of 4 h 50 min. A spontaneous respiratory trigger was not found for about 1 h during extubation. We found anisochoric pupil 5/4 mm without direct and indirect light reflex on physical examination. From the laboratory result, the sodium level was 118. Brain CT scan with contrast showed cerebral edema. Sodium correction was given using NaCl 3%, 500 mL/24 h IV drip. Sodium was corrected slowly and cautiously to prevent cerebral pontine myelinolysis. In the ICU, the sodium level was increased to a normal level. But, the light reflex was still absent, and the pupil was anisochoric. Brain MRI showed diffuse cerebral edema.

Keywords: Cerebral edema, hypotonic irrigation solution, severe hyponatremia, Trendelenburg position

How to cite this article:
Nugroho AM, Omega A, Danneto C. Severe hyponatremia and cerebral edema after laparoscopic salpingectomy, hysteroscopy myomectomy, and adenomyosis resection: A case report. Bali J Anaesthesiol 2022;6:187-90

How to cite this URL:
Nugroho AM, Omega A, Danneto C. Severe hyponatremia and cerebral edema after laparoscopic salpingectomy, hysteroscopy myomectomy, and adenomyosis resection: A case report. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Nov 26];6:187-90. Available from: https://www.bjoaonline.com/text.asp?2022/6/3/187/352404

  Introduction Top

Hysteroscopy procedure requires irrigation solution to distend the uterine, wash out the bleeding, and then improve visualization of the endometrium. Fluid irrigation (especially hypotonic solution) can cause systemic fluid absorption and complications such as hyponatremia, fluid overload, lung edema, and brain edema. This mechanism is similar to Transurethral Resection of Prostate (TURP) syndrome. During hysteroscopy, symptoms will appear when the natrium level is below 125 mmol/L. In the standard procedure, the volume of irrigation solution is about 3–6 L, with a fluid deficit (fluid intake–fluid output) of less than 2 L. Irrigation fluid deficit is one of the determinant factors for dilution and fluid overload. Besides that, operation duration, absorption area, and irrigation solution pressure also determine total fluid absorption.[1],[2],[3],[4]

If untreated, this can cause severe complications such as respiratory distress, cardiovascular collapse, seizure, coma, and death. Trendelenburg position during laparoscopy and hysteroscopy can cause an increase in mean arterial pressure (MAP) and central venous pressure (CVP). Increased MAP and CVP levels will increase cerebral blood flow and reduce cerebral venous drainage. The process will cause the elevation of intracranial pressure and decrease cerebral perfusion pressure. We report cerebral edema due to severe hyponatremia due to hypotonic irrigation solution (water for injection) absorption and Trendelenburg position.[5],[6],[7]

  Case Report Top

A woman, 39 years old, undergone hysteroscopy operative myomectomy, laparoscopy salpingectomy, adenomyosis resection, and adhesiolysis because of submucosal uterine myoma and hydrosalpinx. Preoperatively, the patient was assessed with ASA 2, uterine myoma, clinically with heavy menstruation, without abdominal distension, and anemia with hemoglobin level 10. Before the procedure, the sodium level was 138.

In the operating room, the patient’s blood pressure was 110/70 mmHg, heart rate was 78x/min, respiratory rate was 16x/min, temperature was 36.6°C, and oxygen saturation was 99% room air. General anesthesia was given using coinduction agent fentanyl 100 microgram IV, induction agent propofol 100 mg IV, and muscle relaxant rocuronium 50 mg IV. The patient was intubated with cuff endotracheal tube (ETT) number 7.5. The patient’s breathing was supported with ventilator mode pressure control 12/12/5/50%, with ETCO2 30–35 mmHg.

Initially, the patient was placed in lithotomy position during hysteroscopy operative myomectomy. The procedure continued with laparoscopy for unilateral salpingectomy, adenomyosis resection, and adhesiolysis. The position during laparoscopy is supine up to 30° of Trendelenburg. Because of limited facility, the surgeon used a monopolar cauter during the procedure. With monopolar cauter, the irrigation solution used is water for injection.

Intraoperative hemodynamic blood pressure was 100–120 in systolic and 60–80 mmHg in diastolic, without vasopressor. The heart rate was 70–120x/min, and oxygen saturation was 99% on ventilator mode pressure control 16/12/5/50%, with ETCO2 in the 28–33 mmHg range. During the procedure, there were no periods of hypotension or desaturation. Anesthesia duration was 5 h and 30 min; surgery duration was 4 h and 50 min. Trendelenburg position duration was about 3 h. The total fluid intake was 2400 mL (1500 mL of crystalloid, 500 mL of colloid, and 400 mL of packed red cell (PRC)). Intraoperative bleeding was 400 mL. Urine output was 400 mL (diuresis 1.7 mL/kg/h). During the procedure, about 20 L of water for injection was used as an irrigation solution, but unfortunately, the intake and output fluid deficit was not measured during irrigation.

After the procedure, the patient was planned to do extubation. Blood pressure was 110/62 mmHg, heart rate was 94x/min, oxygen saturation was 99% with ventilator mode pressure control 14/12/5/50%, ETCO2 level was 30 mmHg, and temperature was 36°C. Ventilator mode was changed to spontaneous mode, and oxygen flow and airflow were increased. For about 1 h, spontaneous ventilation and respiratory trigger were still absent, although a total dosage of neostigmine and naloxone had already been given.

On physical examination, pupils were anisochoric 5/4 mm, absent from direct and indirect light reflexes. iStat result showed sodium level as 118, hemoglobin level as 8.2, hematocrit level as 24, and BGA: 7.305/34.5/326/17.2/-9/100%. The patient was transferred to the ICU without extubation. From ultrasonography, there was no free fluid in the abdominal cavity. Subclavian central venous catheter (CVC) was inserted for sodium correction. Hyponatremia was corrected with NaCl 3%, 500 mL/24 h. Noncontrast brain CT scan showed cerebral edema. The patient has been given mannitol 100 mL drip IV.

On the second day of ICU admission, the sodium level was increased to 122. Patient diuresis was 2.2 mL/kg/h, with a negative fluid balance of 609.6 mL. The pupil was anisochoric 5/4 mm, without light reflexes and respiratory triggers. On the third day of ICU admission, the sodium level was 144. NaCl 3% was stopped, and Ringer acetate 30 mL/h was given maintenance fluid. The patient’s diuresis was 2.3 mL/kg/h, with a negative fluid balance of 1294.7 mL. The patient’s pupil was anisochoric 5/4 mm, without light reflexes or respiratory triggers.

Brain MRI showed the appearance of diffuse brain edema. Although close monitoring and adequate therapy were given in the ICU, there were no signs of improvement from the patient. The brain death test was done by an intensivist, a neurologist, an internist until the thirteenth day of ICU admission, and the results were positive. One day later, the patient’s clinical condition deteriorated, and the patient was dead.

  Discussion Top

Hysteroscopy procedures have become more frequent because of their noninvasive properties and have numerous advantages over traditional surgery procedures. Although becoming more familiar, the knowledge about the importance of irrigation fluid monitoring (type and amount) has not yet become a serious concern. Fluid irrigation absorption can cause numerous serious complications, such as fluid overload, dilutional hyponatremia, water intoxication, and cerebral edema. Absorption can occur through a uterine cavity or uterine blood vessels. Absorption happens because of differences in hydrostatic pressure between irrigation solution and blood vessel. The intraperitoneal accumulation of irrigation solution will decrease extracellular electrolytes through diffusion. Uterine wall perforation can worsen this condition. Complications depend on the speed, volume, and property of irrigation fluid. The pressure given is expected to be as minimum as possible to visualize a clear operation field. But unfortunately, the thick and stiff wall of the uterine needs high pressure of fluid irrigation to distend its cavity. The procedure must be stopped if the fluid deficit is between 1000 and 2000 mL. The duration of surgery also increases the risk of fluid absorption.[4],[5]

Generally, 10 mmol of sodium will decrease for every 1 L hypotonic fluid absorption. The total absorption of irrigation fluid is affected by procedure duration, irrigator pressure, and fluid volume.[4],[5] Dilutional hyponatremia is an electrolyte abnormality that can cause cerebral edema, seizure, coma, and other permanent and lethal complications. Irrigation solution can cross the cell membrane and blood–brain barrier. Irrigation solution can shift because of osmotic gap between intracellular and extracellular compartments.[4]

In our case, the patient suffered from severe hyponatremia (sodium level: 118) and cerebral edema due to large volumes of absorption of hypotonic irrigation fluid. This process was known only after surgery completion when the patient was on extubation preparation. Hyponatremia due to absorption of irrigation fluid can be prevented by using an isotonic irrigation solution. The allowable maximum fluid deficit is 2500 mL when using isotonic irrigation fluid (sodium chloride 0.9%). Otherwise, for hypotonic irrigation fluid (water for injection, glycine 1.5%, sorbitol 3%, and mannitol 5%), the allowable maximum fluid deficit is 1000 mL. Isotonic irrigation fluid necessitates a bipolar cautery device. Moreover, hyperchloremic acidosis can be a complication of using sodium chloride 0.9% as an irrigation fluid. Electrolyte and blood gas analysis must be evaluated when giving more than 3 L of irrigation fluid or a fluid deficit of more than 2 L. Furthermore, it must be reconsidered if the procedure should be continued or not.[3],[4]

In our case, the surgeon used monopolar cautery, making isotonic fluid irrigation could not be used. It caused a less allowable maximum fluid deficit. The knowledge about irrigation fluid has not become a particular concern for the surgeons and anesthesia team in the operating room. There were no communications between the surgeon and anesthesia team when using hypotonic irrigation fluid. Moreover, the fluid deficit was not calculated carefully. Therefore, electrolyte and blood analyses were not taken to prevent complications after using 3 L of irrigation fluid.

The cornerstone of treatment in such cases is to remove excess fluid and correct the sodium level.[4] Sodium should not be corrected rapidly to prevent cerebral pontine myelinolysis. It should not exceed 25 mmol/L in 48 h, and sodium level must be monitored cautiously. In our case, hyponatremia was corrected with NaCl 3% 20 mL/h during 24 h. The anesthesia method for hysteroscopy is still controversial. General anesthesia can obscure the early signs of hyponatremia and fluid intoxication, such as bradycardia, hypertension, headache, nausea, and altered mental status. Neurological status cannot be evaluated. Because of general anesthesia, our patient’s signs of hyponatremia were not noticed until the end of the procedure.[3],[4]

Cerebral edema can also be happened due to Trendelenburg position. The Trendelenburg position increases brain venous pressure because of the gravitation effect to venous drainage, further increasing intracranial pressure, cerebral blood flow, and cerebral blood volume. These processes decrease cerebral perfusion pressure and impair cerebral tissue oxygenation.[5],[6],[7],[8]

A study found a decrease in cerebral autoregulation mechanism after Trendelenburg position exceeded 170 min. The duration was correlated with the reduction in neuronal function and cerebral edema. It is suggested to return to normal position when the surgeon does not need Trendelenburg position anymore.[7],[8],[9] In our case, the total duration of the Trendelenburg position was 3 h. Although theoretically autoregulation is still maintained during 3 h of Trendelenburg position, severe hyponatremia causes cerebral edema, and Trendelenburg position worsens cerebral edema and further decreases the cerebral perfusion. In 45° of Trendelenburg position for more than 3 h, it is suggested to do noninvasive monitoring every hour to assess cerebral oxygenation and intracranial pressure. There are several monitoring tools, such as near-infrared spectroscopy (NIRS) and optic nerve sheath diameter (ONSD).[10],[11],[12]

By using NIRS, the cerebral regional oxygen saturation index (rSO2) can be monitored during surgery. NIRS compares oxyhemoglobin to total hemoglobin level by measuring the difference in relative transparency to near-infrared light. NIRS can provide real-time data about cerebral tissue oxygenation. A decrease in rSO2 level of more than 10 units or rSO2 less than 50 indicates cerebral ischemia.[10],[11] ONSD parameters can be measured by ocular ultrasonography to detect increasing intracranial pressure. There is a positive correlation between ONSD and intracranial pressure. ONSD more than 5.8 mmHg indicates an elevation of intracranial pressure above 20 mmHg.[10] In our patient, NIRS and ONSD were not measured because cerebral edema was identified lately after surgery, and both monitoring tools were not available.

  Conclusion Top

Our case showed severe hyponatremia due to hypotonic irrigation fluid absorption during surgery. Moreover, cerebral edema was worsened by the Trendelenburg position, which further increased intracranial pressure. Therefore, the knowledge and concern about choosing and counting irrigation fluid deficit, communication between surgeon and anesthesia team, early detection, and suitable treatment become essential to prevent further complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Woo YC, Kang H, Cha SM, Jung YH, Kim JY, Koo GH, et al. Severe intraoperative hyponatremia associated with the absorption of irrigation fluid during hysteroscopic myomectomy: A case report. J Clin Anesth 2011;23:649-52.  Back to cited text no. 1
Jo YY, Jeon HJ, Choi E, Choi YS Extreme hyponatremia with moderate metabolic acidosis during hysteroscopic myomectomy—A case report. Korean J Anesthesiol 2011;60:440-3.  Back to cited text no. 2
Elegante MF, Hamera JA, Xiao J, Berger DA Operative hysteroscopy intravascular absorption syndrome causing hyponatremia with associated cerebral and pulmonary edema. Clin Pract Cases Emerg Med 2019;3:252-5.  Back to cited text no. 3
Liao CY, Lo CH, Yu MX, Chan WH, Wei KY, Tseng MF, et al. Life-threatening acute water intoxication in a woman undergoing hysteroscopic myomectomy: A case report and review of the literature. BMC Womens Health 2020;20:52.  Back to cited text no. 4
Kalmar AF, Dewaele F, Foubert L, Hendrickx JF, Heeremans EH, Struys MM, et al. Cerebral haemodynamic physiology during steep Trendelenburg position and Co(2) pneumoperitoneum. Br J Anaesth 2012;108:478-84.  Back to cited text no. 5
Schramm P, Treiber AH, Berres M, Pestel G, Engelhard K, Werner C, et al. Time course of cerebrovascular autoregulation during extreme Trendelenburg position for robotic-assisted prostatic surgery. Anaesthesia 2014;69:58-63.  Back to cited text no. 6
Lee JR, Lee PB, Do SH, Jeon YT, Lee JM, Hwang JY, et al. The effect of gynaecological laparoscopic surgery on cerebral oxygenation. J Int Med Res 2006;34:531-6.  Back to cited text no. 7
Lee KH, Jeon YG, Cho DW, Kim MH, Lim HK Hemisphere cerebral infarction after total laparoscopic hysterectomy in the Trendelenburg position. Anesth Pain Med 2016;11:362-5.  Back to cited text no. 8
Madsen PL, Secher NH Postoperative confusion preceded by decreased frontal lobe haemoglobin oxygen saturation. Anaesth Intensive Care 2000;28:308-10.  Back to cited text no. 9
Moretti R, Pizzi B Ultrasonography of the optic nerve in neurocritically ill patients. Acta Anaesthesiol Scand 2011;55:644-52.  Back to cited text no. 10
Cho H, Nemoto EM, Yonas H, Balzer J, Sclabassi RJ Cerebral monitoring by means of oximetry and somatosensory evoked potentials during carotid endarterectomy. J Neurosurg 1998;89:533-8.  Back to cited text no. 11
Samra SK, Dy EA, Welch K, Dorje P, Zelenock GB, Stanley JC Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy. Anesthesiology 2000;93:964-70.  Back to cited text no. 12


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