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CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 121-123

Air embolism during hysteroscopy: Case report of a catastrophic event


1 Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Sciences and Research, Chandigarh, India

Date of Web Publication21-Apr-2017

Correspondence Address:
Bhavana Girish
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2907.204668

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  Abstract 


Diagnostic hysteroscopy is one of the most commonly performed procedures in the evaluation of infertility. Air embolism is an extremely rare but catastrophic and often fatal complication occurring during hysteroscopy. We present a patient who developed massive air embolism during diagnostic hysteroscopy performed under general anesthesia. During the procedure, she developed sudden onset desaturation followed by cardiac arrest. The procedure was immediately stopped, cardiac massage and inotropic support were started, and the patient was shifted to the Intensive Care Unit on ventilator support. Positive end-expiratory pressure and heparin for emboli, midazolam for brain protection, and inotropes were administered. Despite extensive resuscitative efforts, the patient died 4 h after the event.

Keywords: Air embolism, hysteroscopy, infertility


How to cite this article:
Girish B, Singla R. Air embolism during hysteroscopy: Case report of a catastrophic event. IVF Lite 2016;3:121-3

How to cite this URL:
Girish B, Singla R. Air embolism during hysteroscopy: Case report of a catastrophic event. IVF Lite [serial online] 2016 [cited 2019 Sep 16];3:121-3. Available from: http://www.ivflite.org/text.asp?2016/3/3/121/204668




  Introduction Top


Hysteroscopy is widely used as a diagnostic and therapeutic tool in evaluation and management of women with infertility. It may be performed as an office procedure under sedation or under general anesthesia. In diagnostic hysteroscopy, the most commonly used distending media are normal saline and the earlier widely used carbon dioxide (CO2) has now largely been replaced due to increased incidence of complications such as gas embolism. Gas embolism with air or carbon dioxide (CO2) is a rare (3 per 17,000 procedures) but often fatal complication of hysteroscopy.[1] We report a fatal case of gas embolism occurring during diagnostic hysteroscopy performed under general anesthesia using normal saline as distending media in a young infertile female with no underlying medical disorder.


  Case Report Top


A 27-year-old woman with body mass index of 25.2 was admitted for diagnostic laparohysteroscopy for evaluation of primary infertility with bilateral tubal block. She had no known drug allergy. Her preoperative examination was normal and hematologic investigations including liver and renal functions were within normal limits. Chest X-ray and electrocardiogram (ECG) were also normal. After obtaining anesthetic clearance, she was taken up for diagnostic hysteroscopy and laparoscopy under general anesthesia.

After administering general anesthesia with induction agent: Intravenous (IV) propofol 100 mg and fentanyl 200 pg, her trachea was intubated following IV injection of 7 mg vecuronium. She was then placed in supine lithotomy position and cervix was dilated using graduated Hegar's dilators up to size 8. Normal saline was used for distending the uterus and due to nonavailability of hysteromat, gravity fall system was used to deliver the media. A 30° 5 mm hysteroscope was inserted and uterine cavity visualized. About 30 s after the procedure was started, the patient suddenly developed a fall in end-tidal carbon dioxide (PET CO2) from 38 to 10 mmHg and then to 3 mmHg, and pulse oximetric oxygen saturation (SpO2) declined from 98% to 87%, and then to 54%. The procedure was immediately stopped and hysteroscope was removed. Arterial blood pressure (BP) decreased from 132/75 mmHg to 72/36 mmHg, heart rate (HR) decreased from 91 to 31 bpm and was then impalpable. Pulmonary thromboembolism was suspected and cardiac massage was immediately started. FiO2 was changed to 1, IV fluid rate was increased, and sodium bicarbonate 50 mEq and epinephrine 1 mg were given IV with artificial ventilation. After 15 min of cardiac massage, pulse rate was 140 bpm, BP was still not recordable. The patient was started on inotropic support and shifted to the Intensive Care Unit. Heparin was given for the prevention of thrombotic embolism and midazolam was given for brain protection. Immediately postresuscitation, pupils were enlarged and the light reflex disappeared. She was declared dead 4 h after the event.


  Discussion Top


Diagnostic hysteroscopy is one of the commonly performed procedures for evaluation of infertility for the past 25 years. It may be performed under IV sedation as an office procedure or under general anesthesia. Although risks and complications during hysteroscopy are rare, gas embolism is a potentially life-threatening complication with incidence of fatal embolism around 3 per 17,000 procedures.[1]

The formation of gaseous emboli during hysteroscopic surgery is a common occurrence, and in one study, gas bubbles were seen in right atrium by transthoracic echocardiography in all patients and a continuous flow of bubbles was seen in 20 of 23 patients.[2] However, the cut off point between the occurrence of major catastrophic episode and subtle but unequivocally important symptoms is yet undefined. During operative hysteroscopy, due to increased volume of fluid used for distention and more extensive cervical dilatation, the risk of air embolism is higher. However, in our patient, the exact etiology of air embolism is unknown. Cervical dilatation may have caused a cervical laceration into which forced entry of air bubbles may have aggregated and caused a pulmonary embolus. Alternatively, removal and reintroduction of the hysteroscope may have facilitated air entry into the vascular compartment. The resultant pulmonary hypertension caused hypoxia, pulmonary vasoconstriction, and increased vascular permeability resulting in a drop in PET CO2.

This is the most important sign of intraoperative embolism, especially when accompanied by a decrease in BP.[3] The conscious patient experiencing an air embolus will often report dyspnea or chest pain and may display signs of acute bronchospasm and pulmonary edema. The other early signs include bradycardia, decrease in oxygen saturation, or a mill-wheel murmur by precordial auscultation.[3] However, the characteristic mill-wheel murmur is a late sign of cardiovascular collapse. The most sensitive method of detection is a transesophageal echo, but it is not routinely used because of its expense, technical demands, and relatively invasive nature.[4] Although central venous pressure and pulmonary arterial pressure are useful to detect gas embolism, these are also invasive. Therefore, PET CO2 concentration, HR (or ECG), and oxygen saturation may be the common choice for detecting gas embolism during hysteroscopy.[5]

Sources of pulmonary embolism during hysteroscopy include air bubbles in the tubing of irrigation solution entering open venous sinuses under pressure or venous absorption of the bubbles produced by vaporization of tissue. Residual debris and blood clots can also enter open venous sinuses under high-pressure irrigating solution. Inappropriate insufflation equipment can drive gas into the intravascular space such as when a laparoscopic CO2 insufflator (maximum insufflation rate: 16 L/min) is inadvertently used instead of a hysteroscopic CO2 insufflator (maximum insufflation rate: 100 ml/min). If the patient is in Trendelenburg position, the pressure differential between the endometrial cavity and the right heart can cause passage of air from the endometrial cavity to the uterine veins and subsequently the systemic venous circulation.

If air embolism (or clinically significant gas embolism) is suspected, the location of suspected gas entry should be identified and closed, which generally means removing any instrument from the uterus and clamping closed the cervical canal. The patient should be placed in left lateral position (called Durant maneuver) as this elevates the right ventricle above the level of the diaphragm and prevents embolism. The patient should be administered 100% oxygen and insertion of central venous line should be considered. Inotropic support and cardiopulmonary resuscitation may be frequently required if the patient develops cardiovascular collapse.[6]

Prevention of air embolism involves efforts of all the staff involved in the procedure including the surgeon, anesthetist, OT technician, and other staff. Steep Trendelenburg position should be avoided whenever possible. Measures should be taken to minimize effort needed to dilate the cervix, office hysteroscopy is preferred if available. Before inserting the hysteroscopic system into the endometrial cavity, the tubing and hysteroscope should be purged of air. The number of instrument exchanges should be minimized, as, for example, each removal and reinsertion of the resectoscope provides an additional opportunity for the piston-like action of the hysteroscope assembly to push air into the systemic circulation.[7] Furthermore, leaving the cervical canal open to air may facilitate access of room air to the systemic circulation, so a dilator should be left in the canal after dilatation before insertion of the hysteroscope.[8]





A fatal case of gas embolism during diagnostic hysteroscopy is reported. Although a rare event, the possibility of this complication should be kept in mind while performing any procedure and all the necessary precautions should be undertaken. All diagnostic hysteroscopies should be performed with the appropriate monitoring and preferably under anesthetic monitoring. Operating surgeon and staff should be sensitized to signs, symptoms, and management of this catastrophic event to prevent adverse outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no confl icts of interest.



 
  References Top

1.
Corson SL, Brooks PG, Soderstrom RM. Gynecologic endoscopic gas embolism. Fertil Steril 1996;65:529-33.  Back to cited text no. 1
    
2.
Leibowitz D, Benshalom N, Kaganov Y, Rott D, Hurwitz A, Hamani Y. The incidence and haemodynamic significance of gas emboli during operative hysteroscopy: A prospective echocardiographic study. Eur J Echocardiogr 2010;11:429-31.  Back to cited text no. 2
    
3.
Brooks PG. Venous air embolism during operative hysteroscopy. J Am Assoc Gynecol Laparosc 1997;4:399-402.  Back to cited text no. 3
    
4.
Groenman FA, Peters LW, Rademaker BM, Bakkum EA. Embolism of air and gas in hysteroscopic procedures: Pathophysiology and implication for daily practice. J Minim Invasive Gynecol 2008;15:241-7.  Back to cited text no. 4
    
5.
Nishiyama T, Hanaoka K. Gas embolism during hysteroscopy. Can J Anaesth 1999;46:379-81.  Back to cited text no. 5
    
6.
Munro MG. Complications of hysteroscopic and uterine resectoscopic surgery. Obstet Gynecol Clin North Am 2010;37:399-425.  Back to cited text no. 6
    
7.
Rademaker BM, van Kesteren PJ, de Haan P, Rademaker D, France C. How safe is the intravasation limit in hysteroscopic surgery? J Minim Invasive Gynecol 2011;18:355-61.  Back to cited text no. 7
    
8.
Behnia R, Holley HS, Milad M. Successful early intervention in air embolism during hysteroscopy. J Clin Anesth 1997;9:248-50.  Back to cited text no. 8
    

 
  Authors Top


Dr. Bhavana Girish completed her MD from the All India Institute of Medical Sciences in 2015. She worked as Senior Resident at the Post Graduate Institute of Medical Sciences and Research, Chandigarh, India for 8 months following which she returned to All India Institute of Medical Sciences as Senior Resident.




 

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