6.5 TURP

Question 1

A 75-year-old man is having a transurethral resection of the prostate (TURP) under spinal anaesthesia.

a) Which clinical features would make you suspect the patient has TURP syndrome? (6 marks)

Answer 1

Respiratory:
» Tachypnoea, hypoxia,
respiratory distress, pulmonary oedema.

Cardiovascular:
>> Hypertension (due to volume overload) 
with reflex bradycardia, then
acute congestive cardiac failure, *
hypotension, cardiovascular collapse.

> > Broadening QRS complexes,
T wave inversion due to hyponatraemia. *

Neurological:
» Burning sensation in the face and hands, *
headache, visual disturbance,
confusion, restlessness, convulsions, coma.

> > Absence of signs of high block
(as this is a differential diagnosis, although
both may happen at the same time).

Gastrointestinal:
» Nausea and vomiting.*

Question 2

b) List the intraoperative factors that may increase the risk of developing TURP syndrome. (7 marks)

Answer 2

> > Pressure of irrigation fluid:
bag height to remain less than
70 cm above the patient.

> > Large quantities of irrigation fluid used.*

> > Low venous pressure*
(hypotensive or hypovolaemic patient).

> > Prolonged surgery (more than an hour).

> > Large blood loss
(large numbers of open veins
increases rate of
absorption).

> > Capsular or bladder perforation,
allowing fluid into the peritoneum, from
where it is rapidly absorbed.*

> > Large prostate.*

Question 3

c) How would you manage suspected TURP syndrome? (7 marks)

Answer 3

Anaes emergency
cease operation asap

Taking abc approach treating

if reducing gcs <8 i+v
treat seizures with hypertonic saline / midazolam

give 100% fio2 via nrb if maintain airway
if pulomary oedema apply peep give furosemide 20-40mg iv bolus

C
Wide bore iv access
take bloods / abg - u+e

D
Fluid restrict
Treatment acute overload with furosemide
if neurological complications - give hypertonic saline

E:
Monitor labs post opeartively
may require ciritical care

urinary catheter
check fbc - dilutional hb / blood loss
__________________________________

This is an emergency situation and
I would call for help and manage and treat the patient simultaneously adopting an ABC approach.

Alert the theatre team,
stop surgery as soon as possible,
stop further
irrigation fluid.

A, B:
>> 100% oxygen.
>> Auscultate chest, check saturations.
>> Intubate if necessary.
>> Consider intravenous furosemide 
for pulmonary oedema 
(but may exacerbate hyponatraemia) 

or mannitol (100 ml 20%).*

C:

> > Atropine, inotropes and vasopressors may be required.*
Stop intravenous fluids.
Take blood for sodium, osmolality* and haemoglobin.
Site arterial line and check blood gas.

D:
» Manage seizures with lorazepam or magnesium.*

> > If serum sodium less than 120 mmol/l or severe symptoms of hyponatraemia,
give 3% sodium chloride to raise sodium by 1 mmol/h
(do not raise too rapidly or may
cause central pontine myelinolysis*).

Level 2 or 3 admission for supportive treatment,
ongoing monitoring of
osmolality, haemoglobin and sodium.

Question 4

What is TURP syndrome:

Answer 4

TURP syndrome:
» Excessive irrigation fluid
(glycine 1.5%, 220 mosmol/kg)
absorbed into circulation.

> > Occurs between 15 minutes and
24 hours after start of surgery.

> > Volume changes cause
cardiovascular complications.

> > Hyponatraemia and hyposmolality
cause neurological complications.

Free water absorption into brain parenchyma causes raised intracranial pressure, water intoxication, cerebral oedema.

Results in burning sensation in the
face and hands, headache, visual disturbance,
confusion, restlessness, convulsions, coma.

> > Glycine (an inhibitory neurotransmitter) toxicity causes nausea, headache, transient blindness, myocardial depression.

Potentiates NMDA receptor activity causing encephalopathy and seizures.

Magnesium stabilises NMDA receptors so useful in managing seizures.