Fatal Acute Glycine and Sorbitol Toxicity During Operative Hysteroscopy

Abstract

Four cases of severe hyponatremia occurring during operative hysteroscopy and resulting in a 50% death rate are presented. Either glycine 1.5% or sorbitol 3% was used for uterine irrigation in each circumstance. Although careful monitoring of fluid intake and output is important, more precise methods of tracking medium intrusion into the vascular space may be required. Serial serum sodium, central venous pressure, and plasma osmolality determinations are recommended to establish a timely diagnosis of hyponatremia and hypoosmolality. Rapid and aggressive management of significant hyponatremia (Na < 120 mmol/liter) should be instituted using 3%-5% sodium chloride solution and furosemide to attain the goal of elevating serum sodium to 130\p=n-\135 mmol/liter with 24 h. Young women appear to be more susceptible to the sequelae of postoperative hyponatremia, e.g., cerebral edema, than are their male counterparts because of efficiency differences in their cerebral sodium pump function. Liquid distending media with osmolalities in the range of 280 mOsm/liter would offer a greater margin of patient safety than either sorbitol or glycine for operative hysteroscopy.(J GYNECOL SURG 9:137,1993)

Severe hyponatremia associated with transcervical resection of a uterine myoma

“…Dans la littérature ce chiffre d'hyponatrémie a été corrélé avec des cas de fatalité. 4,9,10,[15][16][17] Une revue des cas cliniques publiés montre que le retard dans l'administration du sérum salé hypertonique, 6,9,17 son omission dans la thérapie de l'hyponatrémie aigue, 4,16,18 ainsi que l'hypoxie associée, 19,20 sont les facteurs aggravant l'encéphalopathie hyponatrémique conduisant au décès.…”

Experience with Isotonic 2.2% Glycine as Distension Medium for Hysteroscopic Endomyometrial Resection

“…Further, some authors have postulated that not only hyponatremia, but the concomitant reduction in serum osmolality contributes to this; an association between osmolality and brainstem herniation has been described [1,5,9].…”

“…The cardiovascular and central nervous system symptoms resulting from this kind of absorption have been termed the transurethal resection syndrome [2,3]. Problems include volume overload, dilutional hyponatremia (electrolyte-free solutions), hypoosmolality (hypotonic fluids), pulmonary or cerebral edema, and even death [4][5][6][7]. Additionally, concerning hysteroscopic surgery, women appear to be more susceptible than men to central nervous system complications [8].…”

“…The distension media commonly used in hysteroscopic resection are not only electrolyte-free but hypotonic, although the use of isotonic solutions has been suggested [1,5,9].…”

“…Glycine, a non-conductive amino acid, has excellent optic qualities, but may have toxic effects when large amounts are absorbed [1,3,5,10]. Instead of isotonic glycine 2.2% (290 mosm/l), hypotonic glycine 1.5% (188 mosm/l) has been widely used to improve visualization and to reduce the concentration of glycine.…”