Fluid Overload Prevention During Operative Hysteroscopic ...



Operating Room

Fluid Overload Prevention during Operative Hysteroscopic Surgery

Policy #: 762-104-08 Issue/Reissue Date: 10/11

Distribution: Mercy Central Supersedes: 01/09

I. PURPOSE:

A. To establish guidelines and protocol for fluid overload prevention in the operating room during operative hysteroscopic and resectoscopic surgery. To promote recognition and intervention for signs and symptoms that could potentially lead to hyponatremia and hypoosmolality.

B. Patients undergoing operative hysteroscopic procedures will be monitored closely via specialized equipment (Fluid Management System) for Distention Media Fluid Deficit to prevent fluid overload.

C. Patients undergoing any procedure that will open a large number of vascular channels will be considered to be at high risk for intravasation.

II. DEFINITIONS:

A. Distention Media Fluid Deficit- the difference between the amount of distention media fluid infused into the patient and the amount of distention media fluid recovered from the patient.

B. Fluid Management System- any device used by surgeons and monitored by RNs to measure and control the inflow and measure the outflow of distention fluid used in operative hysteroscopic/resectoscopic surgeries.

C. Operative hysteroscopic surgery- a surgical procedure to correct abnormal uterine conditions, such as, polyps, fibroids, adhesions, and heavy bleeding. Examples of operative hysteroscopy/resectoscopic procedures include but may not be limited to:

1. Roller ball ablation

2. Resectoscopic submucous myomectomy/Hysteroscopic myomectomy

3. Resectoscopic polypectomy

4. Resectoscopic intrauterine adhesiolysis/Transection of intrauterine adhesions

5. Transection of intrauterine septum

III. EQUIPMENT:

▪ Fluid Management System (e.g., Olympus Hysterflow, Smith & Nephew TRUCLEAR) and related components

▪ Appropriate distention media

▪ Foley catheter

▪ Handheld blood analyzer (e.g., I-Stat)

▪ Sodium cartridge for blood analyzer (e.g., I-Stat E3+ red Cartridges)

IV. CONTENT:

A. Operating Room Protocol:

1. Utilization of an electronic Fluid Management System by the surgeon and RN is necessary for prompt recognition of Distention Media Fluid Deficit to prevent fluid overload.

2. The ideal distention media is 5% mannitol,or 0.9% sodium chloride. Sorbitol may also be used in certain cases at the discretion of the surgeon.

3. If the patient experiences a Distention Media Fluid Deficit of 500 mL – 999 mL, the anesthesia provider shall administer furosemide 20 mg IV and a urinary drainage catheter shall be placed per physicians order.

4. If the patient reaches a Distention Media Fluid Deficit of 1,000 mL – 1,499 mL or 1,999 mL (based on distention media, see 5. and 6. below), the anesthesia provider shall perform handheld blood analysis to assess for hyponatremia, and completion of procedure shall be planned.

5. If using mannitol or sorbitol as the distention media and the patient reaches a Distention Media Fluid Deficit of 1,500 mL, the procedure will be brought to an immediate conclusion.

6. If using 0.9% sodium chloride as the distention media and the patient reaches a Distention Media Fluid Deficit of 2,000 mL, the procedure will be brought to an immediate conclusion.

7. If intra-operative sodium level is 120 mEq/L or less, avoid waking up the patient until sodium reaches at least 125 mEq/L.

B. Post-Operative Protocol:

1. If furosemide is administered intra-operatively, an RN may discontinue the Foley catheter only after urinary output is over 1,000 mL, per physician’s order.

2. Monitor for signs and symptoms of hyponatremia if serum sodium is less than 135 mEq/L:

a. Apprehension

b. Nausea

c. Vomiting

d. Disorientation

e. Irritability

f. Twitching

g. Shortness of breath

h. Hypotension

i. Bradycardia

j. Lethargy

k. Convulsions

l. Confusion

V. EXPECTED OUTCOMES:

A. Patient will have a normal serum sodium level post-operatively.

VI. DOCUMENTATION:

A. Patient’s Distention Media Fluid Deficit will be documented in the OR record.

B. All interventions related to Distention Media Fluid Deficit will be documented in the OR record.

VII. REFERENCES:

A. Indman, P., Brooks, P., Cooper, J., Loffer, F., Valle, R., & Vancaillie, T. (1998). Complications of

fluid overload from resectoscopic surgery. The Journal of the American Association of Gynegologic

Laparoscopists, 5 (1), 63-67.

B. Nezhat, C., Fisher, D., & Datta, S. (2007). Investigation of often-reported ten percent hysteroscopy

fluid overfill: Is this accurate?. The Journal of Minimally Invasive Surgery, 14 (4), 489-493.

C. Sinha, M., Hedge, A., Sinha, R., & Goel, S. (2007). Parotid area sign: A clinical test for the diagnosis

of fluid overload in hysteroscopic surgery. The Journal of Minimally Invasive Surgery, 14 (2), 161-

168.

APPROVED BY:

_____________________________ ________________________________

Susan Finlayson, Sr. Vice President Nancy Hunt, R.N.

Patient Care Services Senior Director of Perioperative Services

________________________________

Dr. Robert Atlas, Chair

Obstetrics and Gynecology

NEW POLICY DATE: 10/11

REVIEW/REISSUE DATE: 10/13

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