If you’ve ever found yourself rushing through the halls of your hospital or institution, prepping for your fourth or fifth consecutive surgery of the day, you’re not alone.
Many OR nurses will be faced with burnout at some point in their careers, as a result of long shifts and the physically and mentally demanding nature of our work. With all that goes on in a single day, optimum fluid management during hysteroscopic procedures might not always be top-of-mind – but it remains a critical element of responsibility in the OR.
Maintaining appropriate fluid management during hysteroscopic procedures is crucial to ensuring patient safety. Excess fluid deficit, which the American Association of Gynecologic Laparoscopists defines as exceeding 2,500 ML for isotonic solutions, can lead to serious complications, such as pulmonary edema, hyponatremia or even death.1 More frequently, reaching maximum fluid deficit limits results in an unsuccessful resection of the tissue or a prematurely terminated procedure. 1 The importance of the OR nurse’s role in appropriate fluid management therefore cannot be overstated – the very integrity of the operation depends on it.
However, as many OR nurses can agree, fluid management has not always been made easy. At the recent Association of periOperative Registered Nurses annual conference, I had the opportunity to speak with four OR nurses about the importance of our role in hysteroscopic procedures, and the challenges with current fluid management systems. Many OR nurses are contending with somewhat dated approaches to fluid management, having to rely on manual equipment that can result in inexact measurements of fluid deficit.1 A manual pressure bag, for instance, requires physical control of the pressure that distends the uterine cavity, which not only creates a situation of cramping and exhaustion for the nurse, and oftentimes insufficient distention for the surgeon, but also can result in inaccurate measurement. With manual fluid management systems, nurses must manually calculate the fluid deficit, while also managing the case. One must take into consideration all the possible sources of outflow, which can include spill from the vagina, and the amount of fluid on the OR floor for both manual and automatic systems. Naturally, the manual estimation can result in an inexact approach that causes variables in estimation. This can make it highly possible that the maximum fluid deficit is reached or exceeded rather quickly or entirely unknown for certain.
Automated fluid management systems come with their own set of challenges. Oftentimes these devices have multiple cannisters and the equipment involves cumbersome set up. This can result in an OR running behind schedule, or worse, an incorrect setup. There is also the issue that some nurses may be filling in or generally participate in few gynecological procedures, which can lead to challenges when working with an unfamiliar and unintuitive system, further delaying the OR. In our discussions, some nurses relied upon having system guidelines listed in the OR, while others suggested that training sessions and a clearly marked device would better ensure the ability to manage fluid deficits with consistency, accuracy and confidence.
The good news? Fluid management systems have come a long way since the dawn of hysteroscopic procedures. Automated systems do take much of the physicality out of the role, and visibility into clear fluid bags ensures we’re tracking the deficit as closely as possible. Of course, future innovations are anticipated, and will continue to move us forward in how we care for patients during hysteroscopic procedures.
During the AORN roundtable discussion, we discussed a “wish list” of features that would make fluid management easier in the OR. For instance, imagine if setup didn’t involve working around complicated tubing, or simplified collection systems made reading fluid deficits more straightforward. Furthermore, an automated user interface that clearly displays deficit and pressure settings could assist nurses and surgeons in the quick, reactive decision-making that keeps procedures on track. It’s exciting to think about the patients could we serve with these seemingly modest but impactful advancements in the technology we use.
The fast-paced diversity of my role as an OR nurse is part of what makes it challenging, as well as stimulating and meaningful. In an environment where several procedures may be happening at once and over the course of a day, it’s vital that the equipment we rely on is able to perform in a manner that enhances the procedure at hand. As we continue to treat the millions of women with hysteroscopic procedures, I look forward to seeing where the future takes this critical piece of technology.
Disclosure: Mary reports being a paid consultant for Hologic, Inc. for the MyoSure procedure.
References:
1. AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media. The Journal of Minimally Invasive Gynecology. Accessed on January 29, 2018. http://www.aquilex.co.uk/resources/2013-US-AAGL-FM-Guidelines.pdf.