Fluid Overload Prevention During Operative Hysteroscopic ...



Mercy Medical CenterPatient Care ServicesX Divisional □ Departmental □ Unit-based Fluid Overload Prevention During Operative Hysteroscopic Surgery□ Policy□ ProcedureX Protocol□ GuidelineNumber762-104-08Responsible Unit: Operating RoomEffective Date4/16/15Appropriate Clinical Areas: Operating RoomSupersedes10/11Archive DateKey words: fluid overload protocol, hysteroscopic surgeryDisclaimer: The information contained in this document is intended to set forth general information and considerations for patient care. However, the decisions concerning the care of any individual patient are subject to the presentation of each patient and the clinical judgment of the health care provider.PURPOSE: 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, hypoosmolality, and hypervolemia.Patients undergoing operative hysteroscopic procedures will be monitored closely via specialized equipment (Fluid Management System) for Distention Media Fluid Deficit to prevent fluid overload.Patients undergoing any procedure that will open a large number of vascular channels will be considered to be at high risk for intravasation.EXPECTED OUTCOME: The patient will have a normal serum sodium level post-operatively.DEFINITION OF TERM: 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.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.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:Roller Ball ablationResectoscopic submucous myomectomy / Hysteroscopic myomectomyResectoscopic polypectomyResectoscopic intrauterine adhesiolysis / Transection of intrauterine adhesionsTransection of intrauterine septum IV. RESPONSIBILITIES: (as indicated)RoleFUNCTIONOperative TeamKnowing roles and responsibilities of monitoring fluid volumes and any necessary treatments during operative procedure.PROTOCOL: 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 using mannitol or sorbitol as the distention media, and the patient experiences a Distention Media Fluid Deficit of 500 mL – 999 mL, the anesthesia provider shall administer Furosemide 20mg IV and a urinary drainage catheter shall be placed per physician’s order. 4. ………………….….If using mannitol or sorbitol as the distention media, and the patient reaches a Distention Media Fluid Deficit of 1,000 mL – 1,499 mL, the anesthesia provider shall perform hand held blood analysis to assess for hyponatremia, and completion of the procedure shall be planned. 5. ………………………If using 0.9% sodium chloride as the distention media, and the patient experiences a Distention Media Fluid Deficit of 1,000 mL, it is suggested that the physician and anesthesia provider consider administering Furosemide 20mg IV if the remaining surgical time is estimated at over 10 minutes, and a urinary drainage catheter shall be placed per physician’s order. 6. ………………………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. 7. ……………………..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. 8. …………………….If intra-operative sodium level is 120mEq/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:ApprehensionNauseaVomitingDisorientatinIrritabilityTwitchingShortness of BreathHypotensionBradycardiaLethargyConvulsionsConfusionDOCUMENTATION: 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.REFERENCES / LINKIndman, 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 Gynecologic Laparoscopists, 5 (1), 63-67.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.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.AAGL Advancing Minimally Invasive Gynecology Worldwide. (2013). AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000; 7: 167-168.) The Journal of Minimally Invasive Gynecology, 20 (2), 137-148. APPROVAL: Date ApprovedDeptApprover’ s NameApprover’s Signature11/2015Gynecology CenterFermin Barrueto, MD, DirectorSignature on File11/2015Obstetrics and Gynecology DeptRobert Atlas, MD, ChairmanSignature on File3/2015Patient Care ServicesKim Bushnell, Vice President, CNOSignature on File4/2015Nursing Practice Council Nursing Leadership Council-- ................
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