Critically High Carboxyhemoglobin Level following Extensive Hysteroscopic Myomectomy.

Studies have demonstrated that during hysteroscopic myomectomy with bipolar diathermy, carbon monoxide is produced and enters the patient's circulation. However, little is known regarding the immediate or long-term sequelae of transient rises in carboxyhemoglobin levels during hysteroscopic surgery. This paper seeks to suggest recommendations for acute evaluation, management, patient counseling, and future research. We present a case of a 36-year-old G0P0 with Abnormal Uterine Bleeding-Leiomyoma and resultant anemia undergoing hysteroscopic resection of a large, submucous fibroid. During surgery, the patient was found to have a critically elevated level of carboxyhemoglobin, and accompanying ECG derangements. She was managed with prolonged intubation, 100% O2, and trending of her carboxyhemoglobin levels before extubation. This demonstrates the importance of being cognizant of the potentially toxic gaseous byproducts of bipolar resection, and to include intravasation of these byproducts in one's consideration of patient safety during extensive resections. Bipolar hysteroscopic resection of large leiomyomas may result in critically high carboxyhemoglobin levels, which can impair end-organ oxygen delivery with resultant ischemia; the risks of myocardial ischemia should be discussed with the anesthesia team prior to attempting an extensive resection. EKG changes indicative of ischemia should prompt discontinuation of the case. Finally, carboxyhemoglobin poisoning should be included in the differential diagnosis of patients who demonstrate longer than expected anesthesia recovery times following bipolar resection of large submucous leiomyomas, and should be managed with repeat evaluation of carboxyhemoglobin levels, supplemental oxygen, and cardiac monitoring. Copyright (c) 2019. Published by Elsevier Inc.

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