Crisis management during anaesthesia: water intoxication

Area of Science:

• Anesthesiology
• Perioperative Medicine
• Patient Safety

Background:

• Irrigation of closed body spaces can cause perioperative fluid and electrolyte shifts.
• Water intoxication syndrome, characterized by hyponatremia to death, occurs during procedures like transurethral resection of prostate (TURP) and transcervical endometrial ablation (TCEA).
• Prompt recognition and management are crucial for this potentially fatal "water intoxication" syndrome.

Purpose of the Study:

• To evaluate a core crisis management algorithm supplemented with a water intoxication sub-algorithm for managing this syndrome during anesthesia.
• To assess the effectiveness of the "COVER ABCD-A SWIFT CHECK" algorithm and a specific water intoxication protocol.

Main Methods:

• The study retrospectively analyzed 4000 incidents reported to the Australian Incident Monitoring Study (AIMS).
• The performance of a structured crisis management approach was compared against actual management by anesthesiologists.
• Ten cases of water intoxication were identified for analysis.

Main Results:

• Ten cases of water intoxication were identified: two from endometrial ablations and eight from urological procedures.
• The core algorithm identified issues in seven cases but was insufficient for neurological presentations.
• A specific water intoxication sub-algorithm was required for diagnosis in eight cases and for corrective strategies in eight cases.

Conclusions:

• The standard "core" crisis management algorithm is inadequate for managing perioperative water intoxication.
• A dedicated, simple sub-algorithm for water intoxication is necessary for improved patient outcomes.
• This approach enhances the management of a rare but serious complication.