Is Fluid Type and Not the Procedure the Culprit in Fluid Extravasation?

Abstract

It was with some interest that I read the article “Fluid Extravasation in Hip Arthroscopy: A Systematic Review,” by Ekhtiari et al.1Ekhtiari S. Haldane C.E. de Sa D. Simunovic N. Ayeni O.R. Fluid extravasation in hip arthroscopy: a systematic review.Arthroscopy. 2017; 33: 873-880Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar This consisted of a retrospective review of 14 studies involving 22 occurrences of symptomatic hip fluid extravasation. The authors conclude, in a rather alarming manner, “fluid extravasation is a rare but potentially life-threatening complication.” There is also a recommendation to consider surgical intervention. The problem of fluid extravasation has been reviewed and discussed multiple times for previous procedures. Indeed, I had previously commented on an article by Fowler and Owens in Arthroscopy.2Fowler J. Owens B.D. Abdominal compartment syndrome after hip arthroscopy.Arthroscopy. 2010; 26: 128-130Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar In that article, the authors reviewed a serious complication of fluid extravasation following the procedure. However, as I commented in an editorial review,3Siegel M.G. Irrigation fluid complications.Arthroscopy. 2010; 26: 576Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar the authors failed to consider that the fluid used was saline. The known problems with high saline infusion have been described and reported. Indeed, the failure to use Ringer's lactate in a procedure with the risk of high-volume fluid extravasation is well-known. The use of high-volume saline with fluid extravasation can and may cause dilutional hyperchloremic acidosis. This complication is eliminated with the use of lactated Ringer's solution.4Ladner B. Nester K. Cascio B. Abdominal fluid extravasation during hip arthroscopy.Arthroscopy. 2010; 26: 131-135Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The infusion of saline solution in a bolus administration has been associated with decreased gastric motility and decreased ability to produce urine. This complication is not found with a bolus infusion of lactated Ringer's solution.5Stewart P.A. Modern quantitative acid-base chemistry.Can J Physiol Pharmacol. 1983; 61: 1444-1461Crossref PubMed Scopus (1029) Google Scholar, 6Williams E.L. Hildebrand K.L. McCormick S.A. Bedel M.J. The effect of intravenous lactated Ringer's solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers.Anesth Analg. 1999; 88: 999-1003PubMed Google Scholar The authors of this paper give a fluid analysis, reporting that 2 studies used Ringer's lactate and 2 studies did not specify the fluid used. Management of the cases also finds that 2 cases were treated by simple observation and discharge. What the authors do not describe, and which is critical to this paper, is which patients had the most serious complications and which fluid was used. Table 2 and the data provided do not give the specific reference to the author or the paper that would allow for an analysis of the fluid and complication. If the patients treated with Ringer's lactate had lesser complications and morbidity, this would be a significant finding. My concern is that the authors and Arthroscopy have published a paper that has implications for treatments following fluid extravasation. In a sweeping statement, it clearly implies that such a complication is life-threatening and surgical intervention should be considered in the treatment algorithm. However, this belies the basic facts of the paper and data presented. That is, fluid extravasation complications may be related to the type of fluid and not the mere presence of the fluid. I am shocked that the conclusions stated in this paper are so sweeping and all encompassing. One could have stated a similar conclusion in 1900 about blood fluid transfusions, which were banned due to the risks of reactions. Only after blood types were discovered was it considered a safe procedure. So, consider the facts and data. The problems of fluid extravasation may be due not to the fluid, but to the type used. The use of Ringer's lactate is not a standard in arthroscopy. One could ascribe many of the reported issues to the failure to have a standardized and accepted fluid for all arthroscopic procedures where fluid extravasation is a risk. Download .pdf (.15 MB) Help with pdf files ICMJE Author Disclosure Forms Authors' ReplyArthroscopyVol. 33Issue 8PreviewThank you for your interest in our article. We appreciate your response and have considered and discussed it among ourselves, the authors. While we acknowledge that fluid type may certainly alter the frequency and/or severity of fluid extravasation during hip arthroscopy, we did not feel that the data included in our review were sufficient to draw such a conclusion. Only 56% of the included studies reported using normal saline, and some case reports did include the use of Ringer's lactate. Thus, while there is no doubt that the 2 fluids are physiologically different, it would not have been accurate to comment on fluid type beyond providing descriptive statistics. Full-Text PDF