Cardiovascular Catastrophe in Hysteroscopic Surgery: A Case of Diagnostic Dilemma, Arrest, and Recovery

TL;DR

A patient undergoing hysteroscopic surgery experienced severe cardiovascular collapse due to fluid overload and electrolyte imbalance, requiring emergency resuscitation and highlighting the need for vigilance during such procedures.

Contribution

This case report highlights the rare but life-threatening complication of fluid overload during hysteroscopic surgery and emphasizes the importance of rapid diagnosis and intervention.

Findings

The patient developed severe hyponatremia, hypokalemia, and metabolic acidosis during the procedure.

Point-of-care ultrasound and arterial blood gas analysis aided in diagnosing fluid overload and guiding resuscitation.

ROSC was achieved after 13 minutes of CPR, followed by ICU management for pulmonary edema and vasopressor support.

Abstract

Hysteroscopic surgery carries a risk of fluid overload and electrolyte imbalance. Although acute cardiovascular collapse due to excessive fluid absorption is rare, it can be life-threatening. A 36-year-old otherwise healthy female underwent hysteroscopic myomectomy under combined spinal-epidural anesthesia. She developed sudden bradycardia, hypotension, and unresponsiveness 50 minutes into the procedure, which responded to adrenaline and brief chest compressions (<1 minute). She was intubated and achieved return of spontaneous circulation (ROSC); however, elevated airway pressures complicated the case. The hysteroscopic procedure was continued for another 20 minutes, considering near-completion, but required conversion to an open approach. Meanwhile, desaturation was noted, and the patient had pulseless ventricular tachycardia requiring defibrillation and cardiopulmonary resuscitation (CPR). During CPR, arterial blood gas analysis revealed severe hyponatremia (sodium: 105 mmol/L), while point-of-care ultrasound demonstrated right ventricular distension and bilateral lung-field B-lines. ROSC was achieved after about 13 minutes of CPR. Additional findings included hypokalemia, metabolic acidosis, and elevated lactate levels. The patient was managed with mechanical ventilation, diuretics for pulmonary edema, and vasopressor support before transfer to the intensive care unit after completing surgery. This case underscores the importance of maintaining a high index of suspicion for fluid overload, glycine toxicity, and electrolyte disturbances during hysteroscopic procedures. Rapid deterioration can occur, and point-of-care evaluation during resuscitation may facilitate timely diagnosis and life-saving intervention.

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