Cases & Commentaries

Making Do

Commentary By Linda D. Bradley, MD

The Case

A 56-year-old female with dysfunctional uterine
bleeding and possible retained intrauterine device (IUD) was
scheduled for elective hysteroscopy and dilation and curettage
(D&C). Of note, she had recently completed a course of
tetracycline for an asymptomatic infection with Actinomyces
israelii
discovered on Pap smear.

After the patient was in the operating room and
prepared for the procedure, the team discovered that the equipment
typically used for hysteroscopy was unavailable—the case had
been listed only as a "D&C" on the operating room (OR)
schedule, so the hysteroscopy set had not yet been sterilized after
use earlier in the day. To avoid cancelling the procedure, the team
borrowed sterile parts from various other hysteroscopy sets.

During insufflation of the uterus, the patient
suffered cardiac arrest presumably related to air embolus. The
patient was successfully resuscitated. After an 8-day stay in the
intensive care unit, the patient was discharged home with no
permanent sequelae.

Initially the team attributed the patient’s
decompensation to air introduced from the "makeshift" hysteroscopy
set, which may not have been a truly "closed" system. However,
post-operatively, the patient developed fevers, and blood cultures
grew Actinomyces. The team then concluded that the event was
more likely caused by intraoperative introduction of
Actinomyces, due to incomplete eradication of this infection
pre-operatively.

The Commentary

Operative hysteroscopy permits evaluation of
women with menstrual disorders, infertility, postmenopausal
bleeding, and recurrent pregnancy loss. It is particularly useful
when ultrasound is equivocal. In general, it is a safe, easily
learned procedure that has excellent surgical outcomes.(1,2)

Initially, this patient presented with
postmenopausal bleeding and "possible" imbedded IUD. In such
situations, if the IUD cannot be located by visualization of the
IUD string, then imaging studies are necessary before offering
intrauterine manipulation. Transvaginal ultrasound provides the
least invasive means to detect the presence and location of an
IUD.(3) If
equivocal, then hysteroscopy permits direct inspection of the
endometrial cavity. In this case, office-based retrieval should
probably have been attempted first.(2) If
impossible or impractical, the patient should then have been
scheduled in the OR for IUD removal with hysteroscopic
visualization.

Unfortunately, this case had several problems
that led to a major adverse event.

Most obviously, it is mandatory that the
operating room, equipment, and team be fully prepared for scheduled
cases. Present-day standards in gynecology emphasize the critical
role of diagnostic hysteroscopy (with or without biopsy) in the
evaluation and panoramic inspection of the endometrium. Although
previously a popular method, a "blind D&C" is now seen as
antiquated unless the patient has had a miscarriage.(4) Therefore, a schedule listing only a D&C should
have raised a red flag in this 56-year-old patient. The nurses
should have recognized the high probability that the patient was
not pregnant and checked the pre-operative note to ascertain
whether additional equipment was necessary. Moreover, the surgeon
should have reviewed the OR schedule to ensure that the case was
listed correctly and that hysteroscopic equipment and supplies were
requested.

Newer hospital policies and federal requirements
mandate that patients confirm the proposed surgery with critical
hospital team members (nurse, anesthesiologists, and surgeon) on
the day of the procedure. An informed and knowledgeable patient is
an invaluable asset. If what the patient says and what the schedule
reflects differ, then the situation can be clarified before the
patient is anesthetized. Thus, an informed patient, astute nursing
team, and vigilant surgeon increase the likelihood that the
proposed procedure and available equipment match. Nevertheless, as
depicted by Reason in his "Swiss Cheese
Model," these safety mechanisms each have enough "holes" that
sometimes all three protections will fail.(5)

In this case, recognizing that the appropriate
equipment was not available before the patient was anesthetized
could have been managed in several ways. The procedure could have
been rescheduled, delayed, or postponed. Alternatively, if the
patient were already anesthetized before the problem was detected,
then a blind D&C might have been attempted with the aim of
retrieving the IUD. If the IUD could be removed blindly, but
hysteroscopy could not be completed to evaluate the endometrium for
other causes of bleeding, then the patient could have been
scheduled at a later date for office saline infusion sonography
(SIS) or office hysteroscopy.(3,6)
If the IUD could not be removed by blind D&C and if a working
hysteroscope was not available, then the patient should have been
awakened and informed about the situation.

In this case, the team constructed a makeshift
hysteroscope. When this sort of improvisation occurs, the surgeon
must ensure that the system provides the same level of safety and
efficacy as the prototype. Ingenuity is admirable if the
hysteroscope works; however, if there is any doubt then the
procedure should be abandoned and the patient rescheduled. Any
malfunction of equipment should be documented. Most importantly, an
incident report and full discussion of the technical problems
should be reviewed with the operating room nurse manager. In so
doing, similar errors may be prevented in the future.

Cardiac arrest occurred "during the insufflation
of the uterus." Most likely, the arrest was caused by either air
embolism or CO2 gas embolization.(7,8,9)
Could it have been that, in the chaotic operating room environment
(likely in this mis-scheduled procedure), the laparoscopic
insufflator—instead of the hysteroinsufflator—was used
to distend the uterus? The laparoscopic insufflator flows at 1-15
L/minute; whereas, the hysteroscopic insufflator will maximally
distend the uterus with 100 mL/minute. If the wrong
insufflator were used, the patient could have received greater than
ten times the normal flow rate, which can be hazardous, or even
fatal. Another cause of cardiac arrest could have been air
remaining in the hysteroscopic tubing, if it had not been purged
prior to attaching it to the patient. Surgeons should make a habit
of informing the circulating nurse of the appropriate connections
needed. Additionally, the operative note should reflect which
instruments and equipment were used.

The safest sequence of events in removing an IUD
is as follows: make sure that all ambient air in the tubing is
de-aerated by flushing the tubing copiously and ensuring that all
bubbles are purged, use a fluid-based system (compatible with the
electrosurgical device that may be needed), and perform the
diagnostic hysteroscopy to localize the IUD. If CO2 is preferred,
it should be used only for diagnostic purposes. After
instrumentation and removal of the IUD, I recommend switching from
CO2 to a fluid medium if further endometrial inspection is
necessary. In this case, since the patient experienced
postmenopausal bleeding, thorough inspection and endometrial
sampling were necessary to exclude other causes of postmenopausal
bleeding.

The caregivers in this case came to believe that
the cause of the patient’s deterioration was an introduced
infection. Operative hysteroscopy may in fact stimulate a latent
infection. However, postoperative infection is uncommon; most
studies place the risk at 0.92% and 2.7%.(10) Generally, antibiotic prophylaxis is not indicated
for operative hysteroscopy unless the patient has had a joint
replacement, prior history of pelvic inflammatory disease, mitral
valve prolapse, or residual tissue that remains after surgery.

Even though infection is possible, sepsis rarely
occurs after operative hysteroscopy. While an unfortunate
occurrence after this procedure, I believe that it was
coincidental, and that the team’s initial hypothesis for the
cause of the deterioration—air embolism—was more
likely. There was no evidence of cervical motion tenderness, fever,
or pelvic pain prior to the procedure. Although localized
endometritis due to the IUD may have caused the patient’s
bleeding (11),
an antecedent pelvic inflammatory process (particularly with
actinomycosis, usually a commensal pathogen [12]) is highly unlikely. It is also improbable that the
makeshift hysteroscopy system itself led to sepsis, unless the
equipment was not sterilized at all.

Take-Home Points

Gynecologists can improve outcomes and enhance
patient safety with comprehensive pre-operative evaluation, patient
education, and appropriate scheduling of planned surgical
procedures. Adherence to absolute and relative contraindications is
mandatory. The astute physician will remember that expertise lies
not just in manual dexterity, careful surgical planning, and
communication with the entire surgical team, but also in prompt
evaluation and intervention of complications.

Linda D.
Bradley, MD
Director of Hysteroscopic Services
Department Obstetrics & Gynecology
Cleveland Clinic Foundation
Cleveland, Ohio

References

1. Bradley LD. Complications in hysteroscopy:
prevention, treatment and legal risk. Curr Opin Obstet Gynecol.
2002;14:409-15.[ go to PubMed ]

2. Bradley LD, Widrich T. State-of-the-art
flexible hysteroscopy for office gynecologic evaluation. J Am Assoc
Gynecol Laparosc. 1995;2:263-7.[ go to PubMed ]

3. Bradley LD, Falcone, T, Magen AB. Radiographic
imaging techniques for the diagnosis of abnormal uterine bleeding.
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4. Bettocchi S, Ceci O, Vicino M, Marello F,
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5. Reason J. Human error: models and management.
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6. Widrich T, Bradley LD, Mitchinson AR, Collins
R. Comparison of saline infusion sonography with office
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7. Neis KJ, Brandner P, Lindemann HJ. Room air as
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8. Brandner P, Neis KJ, Ehmer C. The etiology,
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9. Munro, MG, Weisberg M, Rubinstein E. Gas and
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10. Agostini A, Cravello L, Shojai R, Ronda I,
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hysteroscopy. Fert Steril. 2002;77:766-8.[ go to PubMed ]

11. Chatwani A, Amin-Hanjani S. Incidence of
actinomycosis is associated with intrauterine devices. J Reprod
Med. 1994;39:585-87.[ go to PubMed ]

12. Lippes J. Pelvic actinomycosis: a review and
preliminary look at prevalence. Am J Obstet Gynecol.
1999;180:265-9.[ go to PubMed ]