Original ContributionsDetection of fluid volume absorption by end-tidal alcohol monitoring in patients undergoing endoscopic renal pelvic surgery
Introduction
Endoscopic techniques for surgical procedures are increasing steadily. At the same time, new side effects of these techniques are on the rise. Therefore, awareness of potential harm is essential in treating patients with new techniques. The fluid absorption of hypotonic irrigation solution is a well-known complication during transurethral resection of the prostate (TURP). Such a syndrome can occur during any procedure in which large amounts of irrigation fluids are used. Excessive absorption may lead to hypervolemia and life-threatening complications such as hypervolemia, electrolyte disturbances, and consequent cardiorespiratory collapse. Cardiovascular morbidity and mortality were shown to increase with fluid absorption.1 In the past, various methods such as electrolytes monitoring, monitoring of hemoglobin (Hb) concentration, or measuring the weight of the patient, as well as tracing the irrigation fluid with radioactive isotopes, were suggested as ways to detect fluid absorption.2, 3 Then, measurement of end-tidal breath alcohol levels was successfully introduced into clinical practice. Measuring end-tidal breath alcohol levels became standard in many institutions.4 This monitoring tool significantly improved the process quality, resulting in a better outcome with fewer complications after TURP.5
Endoscopic renal pelvic surgery using large amounts of irrigating fluid also may pose a high risk for fluid absorption. Therefore, we applied the monitoring with tracing the irrigation fluid with alcohol to endoscopic renal pelvic surgery. The aim of this study was to investigate consecutive patients scheduled for elective surgery on the renal pelvis (nephrolithopalaxy, endopyeloplasty) regarding practicability and clinical relevance of findings using the described monitoring.
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Material and methods
After institutional approval from the Kantonsspital Ethics Committee, 62 consecutive patients scheduled for endoscopic renal pelvic surgery were investigated. This study was a part of a quality control program with special focus on process quality improvement using an interdisciplinary approach. General anesthesia was chosen in all patients because of patient positioning (prone) and the need for repeated tilt maneuvers. After oral premedication with midazolam (7.5 mg), anesthesia was induced
Results
Demographic data are summarized in Table 1.
In this series, time to maximum fluid absorption occured after a minimum of 30 minutes. Less than 500 ml of irrigation fluid was absorbed in 94% of all cases (Figure 1). Maximal calculated fluid absorption was 2,236 ml after a duration of 30 minutes. Two patients showed a calculated fluid absorption above 1,000 ml. One of these patient showed severe clinical signs of volume overload (lung edema, myocardial ischemia) and was successfully treated in
Discussion
During any endoscopic procedure using irrigation fluids, significant fluid absorption can occur. To reduce morbidity and mortality, breath alcohol measurement has been verified to be a quality management tool for TURP.5 Recently published data and our own results also demonstrate the usefulness of this monitoring in endoscopic renal pelvic surgery.
In contrast to TURP, absorption of fluid can occur rapidly by perirenal vessels as well as more gradually by the retroperitoneal route during
Acknowledgements
For his technical assistance we would like to thank Beat Kaiser, CRNA; for his editorial support, Dr. Stefan Zbinden, Head of Department of Anesthesiology, Wolhusen and Uli Schneider, MD, Munich, for creating the database.
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