Fluid management: A closer look at a vital element of hysteroscopy

Michael D. Randell

In this guest commentary, Michael D. Randell, MD, FACOG, from the department of surgery in the division of gynecology at Emory Saint Joseph’s Hospital, Atlanta, discusses how to properly manage fluids when performing hysteroscopy.

It is well known within the gynecological community that optimal fluid management is an essential function of any successful hysteroscopy and hysteroscopically-directed procedure. In fact, the effectiveness of hysteroscopy is directly dependent on the quality and accuracy of the fluid management system used.

Additionally, while hysteroscopy is considered a safe procedure performed by many gynecologists, we must be aware that too much absorption of hysteroscopic distention media during a procedure can cause serious adverse events in patients, including life-threatening complications. The essential nature of distention media and its potential for associated complications make it vital that health care providers take a close look at the way we work with currently available fluid management systems, as well as the ways they work for us.

A common and invaluable procedure for treating many intrauterine abnormalities, such as fibroids, polyps, adhesions and uterine septa, hysteroscopy is performed with an endoscope, often with an attached video system. These procedures require distention media to ensure optimal visualization throughout the procedure.

Vigilant monitoring of fluid is essential during procedures to accurately measure fluid deficit and ensure the safety of the patient. Clinicians face a higher rate of fluid absorption and associated risk in procedures that require dissection into the myometrium, such as in a myomectomy or resection of uterine septa, making timely and efficient measurement of fluid deficit extremely important in these cases.

The key to effective fluid management lies in working with a system best equipped to minimize and recognize systemic absorption of fluid during the procedure. The American Association of Gynecological Laparoscopists (AAGL) has a particularly robust set of guidelines around fluid management that serve as helpful best practices for physicians. Of course, there exist several fluid delivery and management systems, ranging from basic manual tools to automated pumps designed to maintain a preset intrauterine pressure level.

The limitations of manual fluid management systems make it most desirable to use an automated fluid management system, which allows for more accurate measurement of fluid deficit to ensure the maximum deficit limit (eg, 2,500 cc for normal saline) is not exceeded. Automated systems also better maintain stable uterine cavity distention pressure to support optimal visualization throughout the procedure.

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Ultimately, the importance and function of fluid management systems are twofold: to maintain patient safety and to promote procedural effectiveness. Without successful fluid management, a myomectomy procedure could be stopped prior to a complete resection of the fibroid due to excessive fluid absorption or risk for complications because of fluid overload.

Keeping this in mind, it becomes vital to carefully evaluate the systems we use for their ability to help us accurately measure and manage fluid deficits while maintaining a high level of visualization. Even when performing a routine hysteroscopy, as surgeons, we can only be as impactful as the quality of the instruments we use.

There is, of course, room for improvement among even the automated fluid management systems that surgeons are currently using. For example, many systems involve complicated set up and breakdown that proves time consuming for a busy nursing staff. Operation room nurses are often rotating between specialties and may go several weeks without needing to use a fluid management system, necessitating a steeper learning curve in getting familiar with complex equipment.

Additionally, nonintuitive and complex user interfaces can make it difficult to quickly understand and troubleshoot unexpected deficit and pressure levels. Tissue and fluid collection can also be messy or imprecise across existing systems. Automated fluid management systems that feature simplicity and accuracy will go a long way in improving the ways we manage fluid absorption during hysteroscopy.

With thousands of hysteroscopic myomectomies performed annually each year in the U.S., it can feel easy to take the supporting equipment we use at face value, leaving it on the sidelines. But, I would challenge the users of fluid management systems — and the companies who develop them — to continuously evaluate and re-evaluate where we could make room for advancements in the ways we work with our fluid management systems.

After all, fluid management systems provide a function vital to the integrity of hysteroscopies, which have saved many women from having to undergo major, more invasive surgical procedures.

References:

AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media. The Journal of Minimally Invasive Gynecology. Accessed on January 29, 2018. http://www.aquilex.co.uk/resources/2013-US-AAGL-FM-Guidelines.pdf.

The FIBROID Registry. U.S. Department of Health and Human Services. Accessed on January 29, 2018. https://archive.ahrq.gov/research/fibroid/fibreg.htm.

Disclosure: Randell reports being a paid consultant for Hologic Inc. for the NovaSure and Myosure procedures.