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Paradoxical gas embolism during hysteroscopy
- Bart M Rademaker (11 August 2008)
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Paradoxical gas embolism during hysteroscopy
- Susannah D Sherlock (20 July 2008)
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Bart M Rademaker
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Editor, In response to the two questions of Susannah D Sherlock I have the following comments; Firstly considering the question about the possibility of improper purging of air from the hysteroscopic instruments. We used normal saline as a distension medium and carefully purged air from all lines and hysteroscopic instruments. Following cervical dilation, the exposure of the open cervix to room air was kept to a minimum leaving the cervix closed using a tenaculum forceps. A continuous out-flow system was used so that the distension medium is refreshed actively and bubbles and debris are flushed away. We considered it therefore unlikely that air entrainment played an important role in our case. For that reason we think that the development of gas produced by the electrosurgical vaporization of myomas, fibroids, endometrial and or uterine tissue is much more important factor. Indeed Munro et al (1) demonstrated in vitro that hysteroscopic electrosurgical vaporization using either monopolar or bipolar diathermia results in the production of significant quantities of the highly soluble gasses hydrogen, carbon monoxide and carbon dioxide. The second question addressed the use of hyperbaric oxygen therapy (HBO) in the case of arterial embolism. Indeed HBO is considered the main stay of therapy in case arterialisiation of gas especially when cerebral gas embolism is accompanied by neurological deficits. Fortunately our patient did not develop neurological sequelae. She recovered uneventful after a period of supportive measures using an hour of mechanical ventilation with 100% of oxygen. As Susannah D Sherlock states correctly the use of HBO should always be considered when neurological deficits are present.(2) However, HBO treatment is not always available in every hospital and its apparent lack availability may hamper its use. Indeed in our hospital we do not have HBO and we have to transport the patient ten kilometres to the nearest HBO facility. In my opinion the need for HBO in a possibly instable patient has to be weighed against the risks of transportation and should therefore probably be restricted for patients having apparent neurological deficits. Specific measurements for the treatment of coronary artery emboli that have been advocated include; in addition to hyperbaric- oxygen therapy, bubble removal with a vacuum extraction catheter. (3,4) References 1. Munro MG, Weisberg M, Rubinstein E. Gas and air embolization during hysteroscopic electrosurgical vaporization: comparison of gas generation using bipolar and monopolar electrodes in an experimental model. J Am Assoc Gynecol Laparosc 2001;8:488-94. 2. Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. Ann Surg 1985;201:242-5. 3. Patterson MS, Kiemeneij F. Coronary air embolism treated with aspiration catheter. Heart 2005;91:e36. 4. Engelmann U, Minden H, Stock UA, et al. Late air embolism with interventional removal after isolated coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006;131:1403-4. Conflict of Interest:None declared |
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Susannah D Sherlock, Anaesthetist and Hyperbaric medical officer Royal hobart Hospital ,Tasmania ,Australia
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Editor- I read with great interest the report by Rademaker and colleaugues of paradoxical gas embolism during hysteroscopy.(1) I have two questions I wish to pose ,having had a similar case myself.(2) Firstly, since this was a hysteroscopy using normal saline as the distension medium (thought to lower the risk compared to CO2), where did the authors suspect the gas to have originated from. There have been suggestions that inadequate purging of air from the equipment can cause embolism. Did the authors supect this may have been the case? Secondly, and perhaps more importantly, I question why the authors did not consider hyperbaric oxygen therapy(HBO) Urgent exposure to HBO is the current accepted therapy for cerbral gas embolism (3)(4). With a confirmed diagnosis of arterialization of gas via TTE( transthoracic echocariography),it should have been considered. The consequenses of arterial embolism , as the authors pointed out, include hemiparesis,blindness and coma. A trial by Blanc et al (5) suggests that the outcome is worst when treatment is delayed( more than 6 hrs) and arterial gas embolism is worse than venous embolism ( recovery 35% v 67% ). Was hyperbaric therapy unavailable or discounted for some reason? Refences (1)Rademaker BMP, Groenman FA, van der Wouw PA,Bakkum EA. Paradoxical geas embolism by transpulmonary passage of venous emboli during hysteroscopic surgery : a case report and discussion. (2) Sherlock S, Shearer WA, Buist M, Rasiah R, Edwards A Carbon dixide embolism following diagnostic hysteroscopy. Anaesth Intensive Care 1998 Dec;26(6):674-6 (3) Jorgenson TB, SorensenAM, Jansen EC. Iatrogenic systemic air embolism treated with hyperbaric oxygen therapy.Acta Anaesthesiol Scand 2008 Apr;52(4):566-8 (4) Bitterman H, MelamedY. Delayed hyperbaric treatment of cerebral air embolism.Isr J Med Sci 1993 Jan;29(1):22-6 (5)Blanc P, Boussuges A, Henriette K, Sainty JM, Deleflie M. Iatrogenic cerebral air embolism:importance of an early hyperbaric oxygenation. Intensive Care Med 2002May;28(5):559-63 Conflict of Interest:None declared |
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