REFERENCE: Byard RW, Harrison R, Wells R, Gilbert JD. Glycine toxicity and unexpected intra-operative death. J Forensic Sci 2001;46(5):1244–1246. ABSTRACT: A rare complication of the use of glycine irrigation fluid during prostatic surgery in a 69-year-old man is described. Following cystolithopexy and transurethral resection of the prostate for benign prostatomegaly, abdominal distension developed with increasing ventilatory pressures. Despite retroperitoneal fluid evac- uation at subsequent urgent laparotomy, cardiac arrest occurred that was not amenable to resuscitation. At autopsy a traumatic defect in the posterior bladder wall filled with calculus debris was confirmed that did not communicate with the peritoneal cavity. Hyponatremia with markedly elevated levels of blood, urine, and body fluid glycine were demonstrated. Death was, therefore, attributed to glycine toxicity following tracking of glycine through a surgical de- fect in the posterior bladder wall. Careful dissection of surgical sites is required in such cases to demonstrate any additional trauma that may be associated with the fatal episode. Analysis of body fluids for glycine and electrolytes is also necessary to assist in the determina- tion of possible mechanisms of death. KEYWORDS: forensic science, forensic toxicology, glycine, hy- ponatremia, intraoperative death, transurethral resection syndrome Although the use of glycine as an irrigation solution in surgery is widespread, adverse reactions may occur. The following case is reported to demonstrate an extremely rare case of fatal glycine to- xicity occurring following perforation of the posterior bladder wall during surgery. Case Report A 68-year-old man was admitted to hospital for elective transurethral prostatic resection and endoscopic bladder stone removal (cystolithopexy). His previous medical history included ischemic heart disease with a previous infarct five years ago, non-insulin dependent diabetes mellitus, hypertension, and hyper- cholesteremia. Initially a cystoscopy with endoscopic cystolithopexy was per- formed, with crushing and fragmentation of the calculus, fol- lowed by a transurethral resection of the prostate. Standard 2% glycine (aminoacetic acid) solution was used for irrigation ac- cording to established protocols. Towards the end of the proce- dure oxygen saturations began to fall and ventilatory pressures had to be increased. The abdomen was noted to be tense and a presumptive diagnosis of bladder perforation with subsequent retroperitoneal extension of glycine was made. Laparotomy was immediately performed and retroperitoneal fluid was drained. Cardiac arrest occurred which was unresponsive to 45 min of re- suscitation. The blood sodium level taken after resuscitation was 113 mmol/L, compared with a routine preoperative level which was normal (136 mmol/L). At autopsy a recent laparotomy incision was noted with an ab- dominal drain attached to a bag containing 1500 mL of clear fluid. There were also 600 mL of free fluid within the abdominal cavity. No defect in the peritoneum was seen. Retroperitoneal tissues pos- terior to the bladder were markedly edematous and exuded clear fluid. A drainage tube inserted into the right pleural cavity was at- tached to a bag containing 500 mL of clear fluid. A similar drainage tube and bag in the left chest contained 10 mL of clear fluid. Examination of the bladder revealed a freshly cauterized bed of the prostate. An oval defect due to surgical trauma was present in the posterior bladder wall with surrounding hemorrhage, adjacent to the right ureteric orifice (Fig. 1). It measured 10  5 mm. The ureter was intact. The defect was filled with crushed bladder calcu- lus and extended transmurally into perivesicular adipose tissue. No direct communication with the peritoneal cavity was demonstrated. The surrounding soft tissues were markedly edematous. The blad- der contained 20 mL of bloody fluid. Other autopsy findings included marked coronary artery atherosclerosis with multifocal areas of myocardial fibrosis, mild bilateral nephrosclerosis, and residual benign prostatic hyperplasia. Postmortem analysis of glycine by ion exchange chromatogra- phy with lithium buffers and post-column ninhydrin detection, ac- cording to established protocols (1), revealed markedly elevated levels: left pleural fluid, 43 000 moles/L; right pleural fluid, 49 000 moles/L; peritoneal cavity, 79 000 moles/L; urine, 22 000 moles/L; and blood, 21 000 moles/L. (Normal plasma glycine=150 to 500 mole/L) (2). Death was, therefore, attributed to glycine toxicity with hypona- tremia following retroperitoneal and intraperitoneal accumulation of glycine irrigation fluid during surgery. It is possible that the presence of significant ischemic heart disease may also have miti- gated against successful resuscitation. 1244 CASE REPORT R. W. Byard, 1 M.D.; R. Harrison, 2 B.Sc.; R. Wells, 3 BMBS; and J. D. Gilbert, 1 FRCPA Glycine Toxicity and Unexpected Intra-Operative Death 1 Forensic Science Centre, Adelaide, Australia. 2 Department of Chemical Pathology, Women’s and Children’s Hospital, Adelaide, Australia. 3 Department of Surgery, Prince of Wales Hospital, Sydney, Australia. Received 31 May 2000; and in revised from 6 Oct. 2000; accepted 6 Oct. 2000. Copyright © 2001 by ASTM International