Visual disturbances in TUR reaction

A comparison of the influence of 2.7% sorbitol-0.54% mannitol and 5% glucose irrigating fluids on plasma serum physiology during hysteroscopic procedures

Background

2.7% sorbitol-0.54% mannitol has been selected as an alternative irrigating fluid during endoscopic surgery for its theoretical advantages. We compared the influence of 2.7% sorbitol-0.54% mannitol (Urosol™, CJ Pharma, Seoul, Korea) and 5% glucose as an irrigating solution for hysteroscopic myomectomy & polypectomy in the occurrence of associated complications.

Methods

Thirty patients scheduled for a hysteroscopic operation were included in a prospective randomized trial comparing 2.7% sorbitol-0.54% mannitol solution (Group S, n = 15) and 5% glucose (Group G, n = 15) as an irrigating fluid. We recorded the amount of the irrigating fluids, the amount of fluid intake, and the duration of the procedure. Serum sodium, chloride, potassium, glucose values, and serum osmolality were measured before (just after the induction, T1), during (when 2 L of irrigation fluid was infused, T2), and after (1 h after the end of the operation, T3) the hysteroscopic procedure.

Results

The mean volume of absorbed irrigating fluid was 185.0 ± 73.5 ml in Group G and 175.4 ± 50.5 ml in Group S. Transient hyperglycemia occurred in one patient of Group G. No differences were found in the intraoperative and postoperative levels of serum sodium, potassium, chloride, glucose and osmolality in both groups.

Conclusions

There was no clinical evidence of hyponatremic hypoosmolality in any of the patients. We found no difference between 2.7% sorbitol-0.54% mannitol and 5% glucose as an irrigating fluid for hysteroscopic procedures with mild to moderate irrigant absorption.

Hysteroscopy and anaesthesia

PURPOSE AND SOURCE

Hysteroscopy has become a widely accepted technique in the diagnosis and treatment of various gynaecological conditions. The advent of the fibreoptic endoscope and distending media has largely been responsible for the increasing use of hysteroscopy. It is our aim in this article to review the literature on the frequently used distending media such as carbon dioxide, glycine, dextran, dextrose, sorbitol and mannitol and their anaesthetic implications.

PRINCIPAL FINDINGS

The endoscopist chooses the particular medium. Complications due to the distending media occur in < 4% of cases. Dilutional hyponatraemia and hypothermia are commonly encountered complications and, in addition, hyperglycaemia and volume expansion can occur. Less commonly encountered complications are embolism with carbon dioxide and pulmonary oedema, renal failure and in rare cases anaphylaxis and encephalopathy. Regional anaesthesia may offer an advantage over general anaesthesia in early recognition of fluid accumulation. Apropriate monitoring should include fluid balance, routine monitoring as well as temperature, electrolytes and blood sugar measurements. Precordial Doppler measurement, central venous and/or pulmonary artery pressure measurement may be of help in detecting as well as treating carbon dioxide and/or air embolism and fluid balance in high risk patients.

CONCLUSIONS

There is no one commonly used medium and no one medium is devoid of complications. There have been no controlled studies comparing different anaesthetic techniques. Positioning of the patient can give rise to complications such as peripheral neuropathy. Hysteroscopy is a non invasive procedure which entails a short hospital course with minimal postoperative sequelae and may be cost saving.

Eye symptoms, visual evoked potentials and EEG during intravenous infusion of glycine

Disturbance of vision is a complication that may occur from absorption of the glycine solution used to irrigate the bladder during transurethral operations. We examined for a possible dose-response relationship between glycine dose, eye symptoms and neurophysiological changes after repeated intermittent intravenous infusions of 4.4 g of glycine for up to 22 g over 1 h in 10 male volunteers. The serum glycine concentration increased from 230 +/- 75 to 5,232 +/- 1,088 mumol/l (mean +/- s.d.) during the infusions. We found an increase in diastolic arterial pressure but no significant changes in systolic pressure, heart rate or mental status. Five of the volunteers developed blurring of vision which lasted for 10-30 min. The visual evoked potentials (VEP) of these subjects showed an increase of the P100 and N70 latencies which started after no more than 4.4 g of glycine had been administered. The amplitude of the VEP was preserved and the main frequency of the EEG did not change, indicating that VEP changes were not due to cortical dysfunction. There was no dose-response relationship between glycine infusion and eye symptoms but a sub-group of volunteers responded with both visual disturbances and VEP changes.

The transurethral resection syndrome

The transurethral resection syndrome ("TUR syndrome") is caused by absorption of electrolyte-free irrigating fluid, and consists of symptoms from the circulatory and nervous systems. The clinical picture is inconsistent and the syndrome is easily confused with other acute disorders. Mild forms are common and often go undiagnosed, while severe forms of the TUR syndrome are rare and potentially life-threatening. The pathophysiology is complex but includes four mechanisms: circulatory distress from the rapid absorption of electrolyte-free irrigating fluid, adverse effects of glycine, dilution of the protein and electrolyte concentrations of the body fluids, and disturbance of renal function. The treatment of the TUR syndrome consists of general life support and in specific treatment directed towards hypotension, hyponatraemia and anuria. Methods to lower the uptake of irrigating fluid are widely used and probably reduce the incidence of the TUR syndrome. However, patient safety can be guaranteed only if the absorption is monitored. An irrigating fluid containing tracer amounts of ethanol can be used for this purpose. This permits the uptake of fluid to be indicated by measuring the concentration of ethanol in the patient's exhaled breath.

The physiologic basis of the TUR syndrome

To better assess the role of hyperammonemia versus hypoosmolarity versus hyponatremia in the TUR syndrome, we developed a rat model. Sprague-Dawley female rats received an intraperitoneal injection (250 cc/kg body weight) of either 1.5% glycine, 2.0% glycine, 2.0% glycine plus 1.5% mannitol, 3.0% mannitol, 5.0% mannitol, or 2.0% glycine plus 0.25% saline. Arterial blood samples were obtained prior to injection, at 2, 8, 16, and 24 hr and analyzed for osmolarity, sodium, and ammonia. Those animals receiving 2.0% glycine, 2.0% glycine plus 1.5% mannitol, and 5.0% mannitol all died within 24 hr with lethargy, convulsions, and coma. Hyponatremia developed in all animals; death, however, occurred only when the sodium concentration declined to 90-95 meq/dl. Mannitol maintained serum osmolarity but did not prevent coma and death. Including 0.25% saline in the initial injection, or an iv injection of 5.0% saline delayed 8 hr achieved 100% survival. Ammonia concentrations increased 15-fold by 8 hr in groups receiving 2.0% glycine; it rapidly decreased to near normal by 24 hr. Decreasing the rise in ammonia by 50% with iv arginine had no effect on survival. Our results suggest that hyponatremia rather than hyperammonemia or hypoosmolarity accounts for the major morbidity and mortality secondary to the TUR syndrome.