British Journal of Anaesthesia 106 (1): 51–6 (2011)

Advance Access publication 4 November 2010 . doi:10.1093/bja/aeq303

Effect of temperature on fluidity of irrigation fluids

M. de Freitas Fonseca 1*, C. M. Andrade Jr 1, M. J. E. de Mello 2 and C. P. Crispi 1
1
Serviço de Anestesiologia, Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Av. Rui Barbosa, 716, Flamengo, Rio de Janeiro—RJ CEP
22250-020, Brazil
2
Departamento de Fı́sico-Quı́mica, Instituto de Quı́mica, Bloco A, sala 408, CT, Universidade Federal do Rio de Janeiro, Cidade Universitária.
Ilha do Fundão, Rio de Janeiro—RJ CEP 21941-590, Brazil
* Corresponding author. E-mail: marlon@biof.ufrj.br or marlon@iff.fiocruz.br

Background. Fluid overload is a major complication during surgical hysteroscopy and

Key points transurethral resection of the prostate. We evaluated the role of temperature on

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† The rate of intravasation
of irrigating fluids during
endoscopic prostatic or
gynaecological depends
partly on the physical
properties of the
irrigating fluids: these
vary with temperature.
† In this laboratory study,
the effect of temperature
on intravasation rates of
commonly used irrigation
fluids was estimated.
† Estimated intravasation
rate varied inversely with
the temperature of the
irrigating solutions.
† If confirmed in clinical
practice, the use of
warmed irrigating
solutions (to prevent
patient hypothermia) may
potentiate intravasation
and so reduce the safe
duration of surgery.
absorption of the irrigation solution (IRRSOL) in endoscopic surgery when warm fluids are
used to minimize hypothermia.
Methods. We measured the density and dynamic fluidity of five IRRSOLs (0.9% saline,
Ringer’s lactate, 1.5% glycine, 5% dextrose, and 2.5/0.54% sorbitol/mannitol) at three
different temperatures (178C, 278C, and 378C). Next, a hypothetical typical endoscopic
resection surgery was defined as the reference: total IRRSOL absorption (750 ml),
resection time (30 min), and IRRSOL temperature (178C). On the basis of Poiseuille’s law,
we calculated new values for intravasation using the predetermined dynamic fluidity
values at 278C and 378C to assess the influence of the IRRSOL temperature on
intravascular absorption (under identical conditions) and then estimated the time to
reach fluid overload at each temperature with both electrolyte and non-electrolyte
IRRSOLs.
Results. Density and fluidity varied with temperature. In these specific conditions, when
the temperature of the IRRSOL was increased from 178C to 378C, the mean absorption
rate was predicted to increase about 54% and the theoretical ‘safe’ duration of surgery
decreased by 65%, for both electrolyte and non-electrolyte IRRSOLs. The reduction in
the ‘safe’ duration of surgery averaged 21.1 min for non-electrolyte IRRSOL (reduced
from 60.0 to 38.9 min) and 35.2 min when electrolyte IRRSOLs were used (reduced from
100.0 to 64.8 min).
Conclusions. Compared with cold fluids, isothermic IRRSOL may increase the risk of fluid
overload because dynamic viscosity decreases at higher temperatures.
Keywords: fluids, irrigating; hysteroscopy; surgery, endoscopic; temperature; transurethral
prostate resection; viscosity
Accepted for publication: 25 August 2010

The systemic absorption of irrigation solutions (IRRSOLs) is a
major risk factor for complications during hysteroscopy1 and
transurethral resection of the prostate2 (TURP).3 – 5 During
surgical resection, hydrostatic pressure is usually higher
than intravascular pressures, mainly in the venous bed,6
allowing intravasation of IRRSOL from the surgical field to
the intravascular space. The greater the difference between
these hydrostatic pressures, the higher the flow rate into
the blood and the higher the risk of fluid overload.7 Moreover,
although it is important to control surgical time and to keep
distension pressure as low as possible, fluid overload may
occur before the predicted period.5 8
Currently, either bipolar or monopolar diathermy surgical
technique is used to minimize bleeding during hysteroscopy
and TURP. Although surgery can be performed with
electrolyte IRRSOL when using bipolar cautery, a monopolar
probe requires non-electrolyte fluids.9 10 Severe compli-
cations may occur with electrolyte IRRSOL,8 11 but fluid over-
load becomes particularly dangerous when non-electrolyte
solutions are used because there is the additional risk of dilu-
tional hyponatraemia and cerebral oedema.12 13
Hypothermia has been shown to increase surgical compli-
cations.14 – 16 Initially, attention was paid towards the theor-
etical haemostatic effects of locally applied cold IRRSOL used
to avoid blood loss during TURP; the results of this were
equivocal.17 18 More recently, the benefits of warm IRRSOL
for maintaining the core body temperature and homeostasis
without increasing blood loss or resection time (especially in
older men undergoing TURP) have been realized.19 – 22
Although it has been shown that less IRRSOL may be used

& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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BJA
in patients receiving cold solutions,17 there have been no
reports describing the influence of fluid temperature on the
intravasation rate itself or on the risk of fluid overload. There-
fore, we investigated the potential use of warm IRRSOL
during endoscopic surgery, as a means to prevent hypother-
mia. If warmed IRRSOLs are used, one would expect an
increase in the intravasation rate (flow) from physical prin-
ciples. Our objective was to assess the influence of changes
in IRRSOL temperature on dynamic fluidity and, conse-
quently, on the potential absorption rate and risk of fluid
overload.
Methods
We estimated intravasation rates during hypothetical endo-
scopic resection surgeries by measuring the physical proper-
ties of five common IRRSOLs at three temperatures.
Theoretical intravasation rates were calculated according to
Hagen –Poiseuille’s law (‘Poiseuille’s law’),23 which describes
the laminar flow of an incompressible uniform viscous
liquid (Newtonian fluid) through a cylindrical tube with a con-
stant cross-section.
Determination of density and dynamic fluidity
The density, dynamic viscosity, and fluidity of five IRRSOLs at
three temperatures were measured, according to Faria and
colleagues;24 we chose typical solutions that are used
during hysteroscopy and TURP.
Previous measurements of the temperature of saline in
our operating theatres were 17–198C (IFF-FIOCRUZ, Rio de
Janeiro, Brazil), so we chose 178C (290 K) as the minimum
temperature, 378C (310 K) to represent the typical tempera-
ture when at equilibrium with the body, and 278C (300 K)
being midway between these two. In fact, 278C may approxi-
mate the actual environmental conditions in tropical
countries such as Brazil, without air conditioning (e.g. if the
solution bags are stored outside the operating theatre). The
three non-electrolyte IRRSOLs were 1.5% glycine (200
mOsm kg21), a solution of 2.7/0.54% sorbitol/mannitol (178
mOsm kg21), and 5% dextrose in water (277 mOsm kg21).
The two electrolyte solutions were Ringer’s lactate (273
mOsm kg21) and 0.9% normal saline (308 mOsm kg21).
We determined the dynamic viscosity of each fluid by
measuring its respective efflux time24 with measurements
repeated five times at each temperature (178C, 278C, and
378C) and the mean values used to calculate the respective
dynamic fluid viscosity. The efflux times were measured
with Cannon –Fenske viscosimeters (Schott-Geräte) (internal
diameter 0.54 mm, calibrated and certified by the manufac-
turer). The viscosimeters were coupled to an automatic
module (Schott-Geräte, model AVS 350) and then immersed
in a thermostatic bath (Schott-Geräte, model CT 1450/2),
controlled to within +0.01 K. The uncertainty in the efflux
time was 0.01 s. For the conversion of efflux time to viscosity,
the following equation was used:
h = k(t − v)r
52
de Freitas Fonseca et al.
where k is the viscosimeter constant, t the efflux time, v the
Hagenbach correction (taken from the viscosimeter manual,
Schott-Geräte), and r the density. Solution densities were
previously measured with a digital oscillating U-tube
density meter (Anton Paar, model DMA 4500) with an uncer-
tainty of 5×1025 g cm23. For all samples, and for each temp-
erature, density was measured at least twice; a third
measurement was made only if the difference between the
two measurements was .3×1025 g cm23 (according to
routine laboratory procedures). The cell temperature of the
density meter was controlled to within +0.01 K. Tridistilled
water and dry air were used to calibrate the instrument.
The uncertainty in the dynamic viscosity was ,2×1023
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mPa s; respective dynamic fluidities were calculated as the
reciprocal of viscosity.
Intravasation rate: estimations based on fluidity
values
Theoretically, dynamic fluid viscosity (and fluidity) remains
nearly constant if the vessels are not very small and the
temperature remains constant. We also assumed that
IRRSOLs show Newtonian behaviour, because the
Fahraeus –Lindqvist effect does not occur (viscosity does
not change with the diameter of the tube). Hence, theoretical
intravasation rates (flow) could be expressed as a linear func-
tion of dynamic fluidity according to Hagen –Poiseuille’s law:
dV pR4 |DP|
Intravasation rate (flow) = = ,
dt 8hL
where R is the internal radius of the tube, |DP| the pressure
decrease between the two ends (surgical field and intravas-
cular compartment), h the dynamic fluid viscosity
(fluidity21), and L the total length of the tube system (i.e.
opened cut vessels).
Because, in theory, the hypothetical controlled system
parameters (R, |DP|, and L) were kept constant, estimations
of the new intravasation rate should reflect only changes in
the fluid composition and temperature (i.e. fluidity). Using
hypothetical values at 178C for mean absorption (Table 1)
and actual values of fluidity (Fig. 1), we found the constant
pR 4|DP|/8L for each case. Then, we estimated intravasation
rates for each fluid at each temperature as follows:
Intravasation rate (flow) = F · C,
where F is the dynamic fluidity and C the constant pR 4|DP|/8L.
Assuming that the duration of each endoscopic resection
surgery is the same, no matter the magnitude of fluid temp-
erature,20 we calculated (for each case) new values for the
total absorbed fluid volume at 278C and 378C by multiplying
the surgical time of each surgery by the respective new mean
absorption rate value (Table 1).
We assumed that the distension pressure remained con-
stant. We also assumed that oscillations in both distension
and intravascular pressures were identical in all cases.
Other theoretically controlled variables included: depth of
Temperature of irrigation solution and fluid overload BJA

Table 1 Calculated changes in absorption rate of distension media during endoscopic resection surgery as a response to variation in dynamic
fluidity, applying a linear intravasation model based on Poiseuille’s law. Temp, distension fluid temperature. Maximum absorption reference
according to American College of Obstetricians and Gynecologists Committee on Gynecologic Pratice (2005);25 Time limits for Ringer’s lactate and
normal saline may be longer because both contain sodium (values were calculated to demonstrate that ionic and non ionic solutions exhibit
similar behaviour). Reference values (in grey) were as follows: total intravasation of 750 ml after 30 min of surgery with IRRSOL at typical
temperature (290 K) and intrauterine hydrostatic pressure kept below 100 mm Hg (hypothetical endoscopic surgery with all variables being
controlled). Calculations according to Poiseuille’s law were made considering respective dynamic fluidities for each solution at 278C and 378C
(see text for details)

Hypothetical values with basis on a customary non-complicated endoscopic resection surgery with distension fluid at usual room conditions (Temp:
290 K¼178C)
Irrigation solutions Intravasation (ml) Mean absorption (ml min21) Limit to stop (min) Electrolytic solution (yes/no)
Glycine 1.5% 750 25.00 60.0 No

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Sorb/mannit 2.7/0.54% 750 25.00 60.0 No
Dextrose 5% 750 25.00 60.0 No
Ringer’s lactate 750 25.00 100.0 Yes
Saline 0.9% 750 25.00 100.0 Yes
Estimations with basis on actual values of fluidity if distension fluid were slightly warmed (Temp: 300 K¼278C)
Intravasation (ml) Mean absorption (ml min21) Limit to stop (min) Decrease in safe time (%)
Glycine 1.5% 945 31.50 47.6 220.7
Sorb/mannit 2.7/0.54% 963 32.10 46.7 222.2
Dextrose 5% 952 31.73 47.3 221.2
Ringer’s lactate 955 31.83 78.5 221.5
Saline 0.9% 954 31.80 78.6 221.4
Estimations with basis on actual values of fluidity if distension fluid were isothermic (Temp: 310 K¼378C)
Intravasation (ml) Mean absorption (ml min21) Limit to stop (min) Decrease in safe time (%)
Glycine 1.5% 1136 37.87 39.6 234.0
Sorb/mannit 2.7/0.54% 1174 39.13 38.3 236.2
Dextrose 5% 1157 38.57 38.9 235.2
Ringer’s lactate 1160 38.67 64.7 235.3
Saline 0.9% 1156 38.53 64.9 235.1

cuts (with resectoscope), internal radius (cross-section) of
the cut vessels, duration of surgery, uterine cavity size (i.e.
hysterometry), endometrial status and permeability of the
Fallopian tubes (if hysteroscopy), prostate weight (if TURP),
equipment, body area or BMI, external fluid circuits, and
the ability and strategy of the physicians (surgeons and
anaesthetists).
For the primary endoscopic surgery, which was theoreti-
cally performed with IRRSOL at an ambient fluid temperature
of 178C (comparable with the actual fluid temperature that
we use in our operating theatre), we chose hypothetical
baseline values as follows: total intravasation 750 ml after
30 min of resection (mean absorption rate 25 ml min21).
Then, new values for intravasation rate and total intravasa-
tion were calculated according to Poiseuille’s law for each
solution at 278C (the midpoint between 178C and 378C) and
at 378C (isothermic solutions), using the respective predeter-
mined values of dynamic fluidity.
Finally, for healthy adult patients, we predetermined the
maximum volume that (in theory) could be absorbed to
avoid fluid overload, using the 2005 Technology Assessment
of the American College of Obstetricians and Gynecologists
Committee on Gynecologic Practice.25 The theoretical limits
for the amount of intravasation in a normal adult were
1500 ml of free water for monopolar electrode (fluids
without ions) and 2500 ml of an electrolyte solution (when
bipolar energy is used for endoscopic resection). The respect-
ive time limits to stop surgery (when maximum intravasation
is reached) were then calculated and compared based on the
estimated values of the intravasation rate at 278C and 378C.
Results
Density and dynamic fluidity variation from 1788C to
3788C
As expected, the dynamic fluidity increases and the fluid
density (although more slowly) decreases with temperature.
Actually, variations in density were almost imperceptible in
this temperature range (Fig. 1).
Intravasation rate: estimations based on fluidity
values
With respect to specific baseline values (Table 1; in grey),
when the temperature of the IRRSOL increased from 178C
to 378C, the mean absorption rate was predicted to increase
by 54% (changing from 25.0 to 38.6 ml min21). Because
mainly the dynamic fluidities changed, the predicted time
limits for fluid overload were inversely proportional to the

53
BJA de Freitas Fonseca et al.

1.3 1.3

Visco (o)

Dens (x)
1.1 1.5% glycine 1.1
0.9 0.9
0.7 0.7
1.3 1.3
Visco (o)

Dens (x)
2.7/0.54% sorbitol/mannitol
1.1 1.1
0.9 0.9
0.7 0.7
1.3 1.3
Visco (o)

Dens (x)
5% dextrose in water
1.1 1.1

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0.9 0.9
0.7 0.7
1.3 1.3
Visco (o)

Dens (x)
1.1 Ringer’s lactate 1.1
0.9 0.9
0.7 0.7
1.3 1.3
Visco (o)

Dens (x)
0.9% NaCl
1.1 1.1
0.9 0.9
0.7 0.7
15 20 25 30 35 40
Temperature of irrigation solution (ºC)

Fig 1 Fluid density at 101 kPa (kg litre21) and dynamic viscosity (mPa s) as a function of temperature. Measurements were made in the
laboratory according to Faria and colleagues;24 1 Pa¼1 N m22; 101 kPah 1 atm.

temperature for all solutions. As a consequence, the theoreti-
cal safe duration of surgery decreased by 65% for both
non-electrolyte and electrolyte solutions from 178C to 378C.
Absolute values averaged 21.1 min (decreasing from 60.0
to 38.9 min) for surgeries using non-electrolyte solutions
and 35.2 min (decreasing from 100.0 to 64.8 min) when elec-
trolyte solutions were chosen (Table 1).
Discussion
In this study, the physical properties of five different IRRSOLs
were determined at three different temperatures (178C, 278C,
and 378C). We used actual values of density and dynamic
fluidity (determined in the laboratory) and a simplified theor-
etical model (Hagen – Poiseuille’s law). The density of the
fluids changed as a function of temperature; however, the
observed differences between 178C, 278C, and 378C were irre-
levant for practical purposes (,1%). In contrast, the changes
in dynamic fluidity were greater, which should be of concern
to surgeons and anaesthetists. Furthermore, under otherwise
identical conditions, the fluid absorption rate during endo-
scopic resection surgery was predicted to be directly pro-
portional to fluid temperature. It appears that the main
consequence of fluidity changes is to affect the time to over-
load, which decreases when warmer solutions are being
used, because temperature can change dynamic fluidity
and, consequently, the flow through a hypothetical tube
system (here compared with cut vessels).
Kulatilake and colleagues17 found no significant differences
in blood loss or in mean operating time, when TURP was
carried out with cold IRRSOL (88C) rather than with IRRSOL
at room temperature (not specified). Curiously, they did not
test the influence of temperature on intravasation itself and
they found statistically significant differences in the consump-
tion of IRRSOL. When their surgeries were performed with an
IRRSOL at a temperature of 88C, the IRRSOL consumption was
reduced by 39.0%. Walton and Rawstron18 reported a small
reduction in blood loss when TURP surgeries were carried
out with very cold distension media (28C). Unfortunately,
data concerning intracavitary pressure, fluid temperature in
the ambient group, and, in particular, fluid balance with
respective estimates of intravasation were not reported. In
addition to the intrinsic temperature-dependent fluidity
changes, the flow is directly proportional to the fourth
power of the internal radius of tubes (i.e. vessels). This
suggests that cold irrigation fluids may decrease absorption,
since the vasoconstriction reflex of cut vessels to lower temp-
erature decreases their cross-section significantly. Therefore,
this hypothesis should be tested in real patients, in order to
evaluate the complex interactions that likely occur among a

54
Temperature of irrigation solution and fluid overload
mechanically distended cavity, the fluid kinetics driven by
hydrostatic and osmotic pressure differences, and the physio-
logical system response during endoscopic resection surgery
(not considered in this study).
Despite the current controversies about platelet functions
during hypothermia,26 a nearly constant core body tempera-
ture should be maintained in order to retain biological
homeostasis, normal oxygen balance, and coagulation
status.16 27 In practice, hypothermia often occurs during
endoscopic resection surgery even if isothermic IRRSOLs
are used. This may be explained by a decrease in fluid temp-
erature while bags are being emptied, body exposure to cold
air and solutions in the operating theatre, and physiological
alterations secondary to anaesthesia.
Alterations in the redistribution of body heat are the major
initial cause of hypothermia in patients administered general
or regional anaesthesia. Although epidural or spinal anaes-
thesia may be helpful because redistribution during neuraxial
anaesthesia is typically restricted to the legs,28 the use of
general anaesthesia may be advantageous because it may
permit earlier hospital discharge. However, when compared
with general anaesthesia, regional techniques ( per se)
improve neither irrigation fluid absorption nor safety,5 and
intraoperative shivering may be a problem during surgery
under regional blockade because of movements during
endoscopic resection especially with cold IRRSOL.
Fluid absorption through Fallopian tubes may also vary
according to temperature as the dynamic fluidities of fluids
will increase as their temperature increases. Thus, when
warmed, fluids tend to flow more easily from the higher to
the lower pressure compartments. Also, our experience per-
forming laparoscopic surgery immediately after complex oper-
ative hysteroscopy supports data from Molnar and
colleagues,29 who found no major effect of tubal patency on
fluid balance. Especially when we are assuming (distension
pressure below 100 mm Hg), we believe that no significant
amount of distension medium could flow through tubal ostia.8
During hypothermia, shivering increases oxygen con-
sumption and surgical bleeding. Older patients are more sus-
ceptible to shivering and to other hypothermia-related
complications, including myocardial morbidity and a higher
relative risk for transfusion.16 With respect to intravasation
and risk of fluid overload, the resection time limit should be
shorter in the elderly. Elderly patients undergoing TURP
usually do not tolerate rapid increases in preload, and hypo-
natraemia occurs with lower fluid absorption volumes
because the total body water is decreased. Fortunately,
patients undergoing hysteroscopy for complex multiple myo-
mectomy are mostly young and often otherwise healthy.
Thus, cold IRRSOL may benefit the younger patient popu-
lation without major negative consequences, whereas the
elderly undergoing TURP are at higher risk for both hypother-
mia and fluid overload.
The present study suggests that intravasation flow may
increase significantly at higher temperature. On the basis
of actual fluid measurements combined with the specifics
of human physiology, our data predict a lower risk of fluid
BJA
overload in endoscopic resection procedures when a colder
IRRSOL is used. It is uncertain as to whether these benefits
will translate into clinical practice in the absence of data
from randomized clinical trials. Although some flow is often
necessary for irrigating and cleaning the surgical field
during resection, the bladder and uterus may warm fluids
(at least slightly) by direct contact. Therefore, we suggest
that future trials should consider the effects of using
IRRSOL temperatures as low as possible.
In conclusion, we believe that isothermic IRRSOL may
increase the risk of fluid overload when compared with
cold or ambient fluids because dynamic viscosity decreases
at higher temperatures (subject to controlled evaluation in
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clinical trials). Warm IRRSOL may worsen the benefit/risk
profile.
Acknowledgements
The authors acknowledge the invaluable assistance of Prof.
Dr Oswaldo E. Barcia and Luı́za V.P. Mendes (Department of
de Fı́sico-Quı́mica, Instituto de Quı́mica/UFRJ, Rio de
Janeiro, Brazil) with the performance of this study.
Conflict of interest
None declared.
Funding
This study was funded from institutional funds.
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