Anaesthetic Management of Pulmonary Edema and Metabolic Disorders Caused by Massive Absorption of Irrigation Fluid During Hysteroscopy: A Case Report of Multiple Uterine Myomectomy

Inside the human body, the uterus is a muscular chamber that can sometimes develop benign growths called fibroids. When these growths cause problems, doctors often use a procedure called hysteroscopy to remove them. This technique involves inserting a thin, lighted tube through the cervix to see inside the uterus. To make the view clear, the surgeon must fill the space with a liquid, much like inflating a balloon to see its walls. This liquid, usually a saltwater solution, keeps the cavity open so the doctor can work. However, this necessary step carries a hidden danger. If the liquid is absorbed into the bloodstream faster than the body can handle it, it can cause a dangerous buildup of fluid in the lungs and disrupt the delicate balance of salts and minerals in the blood. This condition, known as fluid overload or water intoxication, can happen quickly and is difficult to spot when a patient is asleep under general anesthesia.

A recent case report from Cangzhou Central Hospital in China details a dramatic instance where this risk became a reality, highlighting the critical role of the anesthesiologist in preventing disaster. The story involves a 44-year-old woman who arrived for surgery to remove several uterine fibroids. Before the operation, an ultrasound scan suggested the presence of a few specific growths. However, once the surgery began, the surgeon discovered that the actual situation inside the uterus was more complex than the images had shown. There were more fibroids than expected, and they were located in ways that required a much longer and more difficult procedure than originally planned. Because the surgery took far longer than anticipated, the volume of liquid used to keep the uterus inflated grew to an enormous amount. In total, the team used 15,000 milliliters of saline solution, a volume far exceeding what is typically seen in these operations.

As the surgery continued, the patient's body began to absorb this massive amount of fluid. The anesthesiologist, the doctor responsible for monitoring the patient's vital signs and keeping her asleep, noticed subtle but alarming changes. While the patient was unconscious, the doctor listened to her lungs and heard a change in the breathing sounds, a sign that fluid was beginning to fill the air sacs. This was the early warning signal of pulmonary edema, a condition where the lungs fill with fluid and struggle to exchange oxygen. At the same time, blood tests revealed that the patient's blood had become diluted, and her levels of potassium and calcium had dropped dangerously low. These electrolyte imbalances can cause the heart to beat irregularly and muscles to fail. The patient also developed a severe metabolic acidosis, meaning her blood had become too acidic, a sign that her body was under immense stress.

The turning point in this case was not a new machine or a miracle drug, but the decision-making of the medical team. The anesthesiologist recognized that the surgery had gone on too long and that the fluid absorption was becoming life-threatening. They urgently advised the surgeon to finish the procedure immediately. Once the surgery was over, the team acted swiftly. They administered a diuretic, a medication that helps the kidneys flush out excess water, and gave the patient potassium to restore the balance of salts in her blood. They also provided oxygen support as the patient woke up. Because the team detected the problem early and treated it decisively, the patient's lungs cleared, her blood chemistry returned to normal, and she was able to leave the hospital without lasting harm.

This case serves as a stark reminder of how quickly a routine surgery can turn dangerous when the unexpected happens. The report suggests that the main causes of the crisis were the mismatch between the preoperative ultrasound and the actual findings, which led to a prolonged operation, and a lack of communication between the surgical team and the anesthesiologist regarding the accumulating fluid risk. The authors note that while hysteroscopic surgery is generally safe, the risk of fluid overload is real and can escalate rapidly. They emphasize that no single person can manage this alone; it requires a team where the anesthesiologist is empowered to stop or alter the procedure the moment they see signs of trouble. The report concludes that better preoperative planning, stricter limits on how long a surgery should last, and constant monitoring of fluid intake and output are essential to keep patients safe. In this specific instance, the patient's survival was not guaranteed by the technology alone, but by the vigilance of the team watching over her.