AORN Journal
Volume 92, Issue 1 , Pages 103-109, July 2010

Clinical Issues—July 2010

Perioperative Nursing Specialist, AORN Center for Nursing Practice

Article Outline

This Month 

Intravasation and fluid deficit during hysteroscopy procedures

Key words: fluid management, fluid deficit, fluid overload, intravasation, hyponatremia, hysteroscopy.

Fluid selection during minimally invasive surgery

Key words: minimally invasive surgery, fluid selection, electrolyte solutions, distention media, irrigation solutions, fluid risks.

Comparing hysteroscopic insufflators and laparoscopic insufflators

Key words: insufflators, hysteroscopy, laparoscopy, minimally invasive surgery, distention media.

Using IV bags to position patients

Key words: patient positioning, positioning equipment, IV bags, burns.

Storage of disinfected laryngoscope blades

Key words: laryngoscope blades, high-level disinfection, packaging.

 

Back to Article Outline

Intravasation and fluid deficit during hysteroscopy procedures 

Question 

What is the cause of intravasation during hysteroscopy procedures? Is there a specific amount of fluid deficit that is indicative of fluid overload?

Answer 

During hysteroscopy procedures, fluid can be absorbed through the uterine vessels or through the bowel if there is a perforation. A fluid deficit also can occur if fluid egresses through patent fallopian tubes. Fluid deficit can lead to dilutional hyponatremia, which is associated with intravasation of nonelectrolyte solutions, and the rapid influx of hypotonic fluid, which increases circulation of free water and reduces the extracellular sodium concentration.1, 2

Measuring fluid volume can prevent complications when a deficit is identified early and the procedure is terminated.3 The critical volume of intravasation before symptoms are exhibited is not predictable.4 The American Congress of Obstetricians and Gynecologists suggests that 750 mL of fluid absorption implies excessive intravasation3 and advises terminating the procedure for patients who are elderly and for those with cardiovascular compromise when this occurs.3 The incidence and severity of symptoms from increased amounts of fluid absorbed intraoperatively or postoperatively have been documented during transurethral resection procedures and endometrial ablation procedures. In one study of transurethral resection procedures in which glycine was used as the fluid distention media, patients exhibited symptoms of excessive fluid absorption when 1 L to 2 L of fluid had been absorbed.5 Fluid absorption increases with increased procedure length. Completing procedures in one hour or less may help limit complications from fluid absorption.5

When the patient is at risk for hyponatremia, serum electrolyte or urine electrolyte testing often is performed. Normal serum sodium level is 135 mmol/L to 145 mmol/L. Hyponatremia occurs when serum sodium levels decrease to less than 135 mmol/L.6, 7 Perioperative nurses should be prepared to coordinate laboratory testing of serum electrolyte levels and report the results.

Back to Article Outline

Fluid selection during minimally invasive surgery 

Question 

We use our surgeon preference cards as standing orders for the solutions the surgeons prefer for specific procedures. I am a new preceptor and am having trouble explaining why surgeons select different solutions for particular procedures. Can you explain the rationale for fluid selection during minimally invasive surgery?

Answer 

The type of procedure being performed, the patient's condition, and the use of electrosurgery are the basis for fluid selection, whether the fluid is to be used for irrigation or as distention media. Perioperative nurses should be aware of the uses, contraindications, and risks associated with fluids used as distention media during minimally invasive surgery.

Normal saline (ie, 0.9% sodium chloride) and lactated Ringer's solution are examples of isotonic, electrolyte fluids that should not be used for irrigation or as a distention media when monopolar electrosurgery is planned for the procedure. Glycine, mannitol, and sorbitol are examples of nonelectrolyte solutions that do not dissipate the electrical current and can be infused when monopolar electrosurgical devices are to be used during a procedure. These solutions often are preferred for urologic procedures when monopolar electrosurgical devices are used. Normal saline is often used for arthroscopy procedures unless monopolar electrosurgery is planned.1

The American Congress of Obstetricians and Gynecologists considers isotonic electrolyte solutions to be the media of choice for diagnostic hysteroscopy or intraoperative hysteroscopy when mechanical, laser, or bipolar energy is used.2 Glycine 1.5%, sorbitol 3%, and mannitol 5% are low-viscosity, hyperosmolar, electrolyte-poor fluids that are compatible with monopolar radiofrequency energy but can cause hyponatremia and decrease serum osmolality. If these fluids are absorbed in excess, fatal complications such as cerebral edema and death can result.2 Mannitol 5% is iso-osmolar and causes diuresis, which can lead to excessive absorption. Dextran 70 is a high-viscosity fluid and a potent plasma expander. Anaphylaxis and disseminated intravascular coagulopathy have occurred when dextran 70 has been used for uterine distention.2 In addition, this solution crystallizes on instruments and is very difficult to remove. Dextran 70 is contraindicated for patients who are allergic to beet sugar.2

Glycine is the fluid medium commonly used with monopolar electrosurgical technology for urologic procedures.3 The complication known as transurethral resection syndrome may be observed when glycine is used as an irrigation or distention media. When blood vessels are exposed from tissue removal or elevated pressure is applied to the distention fluid, intravasation can occur (ie, distention fluid flows into the vascular system).4

Monopolar electrosurgical energy can cause temperatures up to 400° C (752° F) because of the resistance of surrounding tissue.5 Bipolar electrosurgical use has achieved clinical efficacy similar to monopolar electrosurgical use but results in shorter catheterization times and shorter hospital stays. For bipolar electrosurgical technology, normal saline, which reduces the risk of transurethral resection syndrome, may be used as the fluid medium rather than glycine.5

Back to Article Outline

Comparing hysteroscopic insufflators and laparoscopic insufflators 

Question 

We have been performing laparoscopic procedures at our ambulatory surgery center for several years, but we are now starting to perform hysteroscopy procedures. Can we use the same type of insufflator for both types of procedures? What are the standard ranges for intra-abdominal and intrauterine pressure?

Answer 

Insufflators designed for laparoscopic procedures should not be substituted for insufflators designed for hysteroscopy procedures.1 Laparoscopic insufflators supply large volumes at low pressures. Hysteroscopic insufflators supply low volume at high pressures.2

To reduce the risk of systemic hemodynamic changes, intra-abdominal pressure should be maintained at less than 12 mm Hg in adult patients.3, 4, 5, 6, 7 For heavier or taller patients, an intra-abdominal pressure of 20 mm Hg to 30 mm Hg may be necessary to establish the appropriate pneumoperitoneum.8 For pediatric patients, the insufflation pressures should be set as low as possible while still creating the pneumoperitoneum; however, there are no known studies that define standard ranges for intra-abdominal pressures in pediatric patients.9 Intrauterine pressures should be monitored to remain at less than 100 mm Hg to help minimize the risk of gas embolization.1

Insufflator pressures should be monitored throughout the procedure. Equipment for insufflations should be used according to the manufacturer's recommendations to ensure the equipment is designed to be used for the procedure that is planned.

Back to Article Outline

Using IV bags to position patients 

Question 

Traditionally, we have used IV bags at our facility to position patients, especially pediatric patients. The fluid seems to redistribute pressure, and they are more cost-effective to use than gel pads. Recently, we have heard that this is not the standard of practice. Does AORN have a recommendation specific to this practice?

Answer 

AORN recommends that equipment used for positioning be designed specifically for surgical procedure positioning, including, but not limited to, redistributing pressure.1 If items are not designed for positioning, there is no evidence that pressure is redistributed and the health care organization would be assuming the risk if a patient incurs an injury as a result of a failure in the performance of the positioning equipment.

A recent article reported that a 47-year-old woman was severely burned when an IV bag was used as a shoulder roll to extend her neck during a thyroid procedure.2 The saline-filled IV bag was covered with a blue towel, similar to the type of towels used for draping. The burn was discovered as the patient emerged from the general anesthetic. The size of the burn was similar to the size of the IV bag and was found in the area where the IV bag and towel had been in contact with the skin. The towel covering the IV bag had become saturated with the electrolyte solution from a small leak in the IV bag. The leak was not big enough to cause a change in the patient's positioning or to alert members of the surgical team during the procedure. The saturated towel may have acted as a ground for the electricity from the electrosurgical unit because it provided a large surface of less resistance than the patient return electrode.2

This is an example of the risk of using an item for positioning that has not been specifically designed for use as patient positioning equipment. It also serves as a reminder of the risk of leaving wet bed linen or other wet items next to the patient's skin while electrosurgery is used during surgical or other invasive procedures. Equipment used for patient positioning during surgery should be specifically designed for positioning and should be used according to the manufacturer's recommendations.

Back to Article Outline

Storage of disinfected laryngoscope blades 

Question 

After high-level disinfection, our laryngoscope blades are placed into the anesthesia carts. We have been told by a consultant that the scope blades must be packaged in either blue wrap or peel pouches before we place them on the cart. Is this correct?

Answer 

Items such as laryngoscope blades that have been processed by high-level disinfection should be protected from contamination until the item is to be used.1, 2, 3 Methods of protection during storage depend on the potential for contamination. When storage occurs in a location without a potential for contamination, such as in a clean equipment storage room, it is adequate to store the items in a cart (eg, laryngoscope blades) or a cabinet (eg, flexible endoscopes) with the drawers or doors closed.4

If the item is stored in a location where there is potential for contamination, the item should be wrapped or covered with an impermeable wrap before placement into the storage system. For example, contamination may result from a contaminated laryngoscope blade coming into contact with a disinfected blade. If the cart drawer is left open and a contaminated blade is passed over the open drawer, contaminants could fall off the contaminated blade onto the clean blades in the drawer.

The wrapping process should occur after the high-level disinfection process, including thorough drying, is complete. Wrapping the blades also provides a method to assist in recognizing a clean blade from one that is contaminated. A reclosable plastic bag or other impermeable wrap may be used as the covering because the blades require only high-level disinfection. Wrapping the blades in sterilization wrap or a sterilization peel pack is not recommended because this may lead the user to think that the blade is sterile rather than high-level disinfected.

Independent of the type of wrapping, the item should be clearly labeled as being high-level disinfected and not sterile. Labeling should also contain some method to indicate the date when the high-level disinfection occurred and the person responsible for completing the process.1, 4

The authors of this column have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

Back to Article Outline

Learner Evaluation. Continuing Education Program 

Clinical Issues 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.

Purpose/Goal 

To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High

2.Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High

3.Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High

Content 


4.To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High

5.To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

6.Will you be able to use the information from this article in your work setting? 1. Yes 2. No

7.Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)

7A.How will you change your practice? (Select all that apply)
1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other: ___________________________


7B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other: ___________________________


8.Our accrediting body requires that we verify the time you needed to complete the 0.9 continuing education contact hour (54-minute) program: __________

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #10052; Session: #4016 Fee: Members $4.50, Nonmembers $9

The deadline for this program is July 31, 2013.

Each applicant who successfully completes this program can immediately print a certificate of completion.

Back to Article Outline

References 

    Intravasation and fluid deficit during hysteroscopy procedures
  1. Haskal R. Current issues for nurse practitioners: hyponatremia. J Am Acad Nurse Pract. 2007;19(11):563–579
  2. Yeates KE, Singer M, Morton AR. Salt and water: a simple approach to hyponatremia. CMAJ. 2004;170(3):365–369
  3. American College of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol. 2005;106(2):439–442
  4. Morrison DM. Management of hysteroscopic surgery complications. AORN J. 1999;69(1):194–221
  5. Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth. 2006;96(1):8–20
  6. Singer GG, Brenner BM. Fluid and electrolyte disturbances. In:  Fauci AS,  Braunwald E,  Kasper DL,  Hauser SL editor. Harrison's Principles of Internal Medicine. 17th ed.. New York, NY: McGraw-Hill; 2008;
  7. Kaye AD, Riopelle JM. Intravascular fluid and electrolyte physiology. In:  Miller RD editors. Miller's Anesthesia. 7th ed.. Edinburgh: Churchill Livingstone; 2009;p. 1705–1737
    Fluid selection during minimally invasive surgery
  1. Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 139–173
  2. American College of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol. 2005;106(2):439–442
  3. Moharari RS, Khajavi MR, Khademhosseini P, Hosseini SR, Najafi A. Sterile water as an irrigating fluid for transurethral resection of the prostate: anesthetical view of the records of 1,600 cases. South Med J. 2008;101(4):373–375
  4. Collins JW, Macdermott S, Bradbrook RA, Drake B, Keeley FX, Timoney AG. The effect of the choice of irrigation fluid on cardiac stress during transurethral resection of the prostate: a comparison between 1.5% glycine and 5% glucose. J Urol. 2007;177(4):1369–1373
  5. Ho HS, Cheng CW. Bipolar transurethral resection of prostate: a new reference standard?. Curr Opin Urol. 2008;18(1):50–55
    Comparing hysteroscopic insufflators and laparoscopic insufflators
  1. American Congress of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol. 2005;106(2):439–442
  2. Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 139–173
  3. Gutt CN, Oniu T, Mehrabi A, et al. Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg. 2004;21(2):95–104
  4. Jacobs VR, Morrison JE, Kiechle M. Twenty-five simple ways to increase insufflation performance and patient safety in laparoscopy. J Am Assoc Gynecol Laparosc. 2004;11(3):410–423
  5. Mertens zur Borg IR, Lim A, Verbrugge SJ, IJzermans JN, Klein J. Effect of intraabdominal pressure elevation and positioning on hemodynamic responses during carbon dioxide pneumoperitoneum for laparoscopic donor nephrectomy: a prospective controlled clinical study. Surg Endosc. 2004;18(6):919–923
  6. Meierhenrich R, Gauss A, Vandenesch P, Georgieff M, Poch B, Schutz W. The effects of intraabdominally insufflated carbon dioxide on hepatic blood flow during laparoscopic surgery assessed by transesophageal echocardiography. Anesth Analg. 2005;100(2):340–347
  7. Koivusalo AM, Pere P, Valjus M, Scheinin T. Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum is safe even for high-risk patients. Surg Endosc. 2008;22(1):61–67
  8. Abu-Rafea B, Vilos GA, Vilos AG, Hollett-Caines J, Al-Omran M. Effect of body habitus and parity on insufflated CO2 volume at various intraabdominal pressures during laparoscopic access in women. J Minim Invasive Gynecol. 2006;13(3):205–210
  9. Harrington S, Simmons K, Thomas C, Scully S. Pediatric laparoscopy. AORN J. 2008;88(2):211–236
    Using IV bags to position patients
  1. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 327–350
  2. Pearlman RC. Use of a saline bag as a shoulder roll during surgery not recommended. Arch Surg. 2009;144(10):892;http://archsurg.ama-assn.org/content/vol144/issue10/index.dtlAccessed March 29, 2010
    Storage of disinfected laryngoscope blades
  1. Recommended practices for high-level disinfection. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 389–404
  2. ANSI/AAMI ST58:2005. Chemical sterilization and high-level disinfection in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006;33
  3. Rutala WA, Weber DJ The Healthcare Infection Control Practices Advisory Committee. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: Centers for Disease Control and Prevention; 2008;http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdfAccessed February 20, 2010
  4. Recommended practices for cleaning and processing flexible endoscopes and endoscope accessories. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 405–419

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire July 31, 2013.

PII: S0001-2092(10)00419-9

doi:10.1016/j.aorn.2010.04.009

AORN Journal
Volume 92, Issue 1 , Pages 103-109, July 2010

Article Tools