Case 36 - TURP Flashcards
What is TURP Syndrome?
TURP = Transurethral Resection of Prostate
- Water intoxication, hyponatremia, hypoosmolality 2/2 excessive amounts of irrigating fluids absorbed through the opened prostatic venous sinusoids
Hyponatremia
- serum dilution secondary to irrigating solutions
- degree of hypo Na+ related to RATE OF ABSORPTION (not to absolute amount absorbed)
What are the CNS effects of TURP syndrome?
Neurologic injury associated with rate of Na+ decrease rather than the degree of hyponatremia
- CNS effects secondary to cerebral edema with concomitant increase in ICP
CNS effects:
- h/a
- agitation / restlessness
- confusion
- seziures
- coma
- clonus
- papilledema
What are the cardiovascular effects of TURP syndrome?
- CV effects are due to fluid overload and hyponatremia
Na+ < 120 meq/L
- negative inotropic effects
- hypotension
- pulm edema
- CHF
Na+ < 115 meq/L
- widened QRS
- ventric ectopy
- t-wave inversion
Na + < 110 meq/l
- cardiac and resp arrest
How would you tx TURP syndrome?
- surgery should conclude ASAP
- ABC
- consider tracheal intubation and mech ventilation
- Tx - increase Na+ levels
- fluid restrection
- loop diuretics
- severe cases/symptomatic hyponatremia may require hyper tonic saline solution (3% NaCl)
- rapid correction of hyponatremia –> cerebral edema and cerebral pontine myelinolysis
- tx patient symptoms
What are other complications of TURP?
Bladder Perforation
- extraperitoneal or intraperitoneal
- decrease return of irrigating fluids
- regional anes –> complain of abd pain, n/v
Bleeding
- related to size of gland and resection time
- prostate is vascular organ
Coagulopathy
- dilution of coag factors
- DIC
Transient bacteremia/septicemia
- prostate is rich in pathogens, can enter prostatic venous sinuoids into systemic circulation
Irrigating fluids toxicity
- hyponatremia
- fluid overload
- sorbitol and mannitol solutions –> lactic acidosis and hypergycemia
Hypothermia
- room temp irrigating fluids can cause this
- use warm fluids to decrease heat loss/shivering
Anything you can do to minimize incidence of TURP Syndrome?
Main Goal: limit amount of irrigating fluids absorbed
- restrict height of irrigating fluid
- will help decrease hydrostatic pressure driving fluid into sinuses
- limit resection to < 90 min
- restricting TURP to prostate glands < 45 g
-
injeting intraprostatic vasopressin
- vasoconstricts vessels and limits absorption of irrigant fluid
What type of irrrigating solutions exist today?
- solutions include glycine and a mixture of sorbitol and mannitol
What toxicities are associated with glycine?
Glycine toxicity
1) blindness
- inhibitor effect of glycine on CNS
2) Hyperammonemia - glycine is metabolized to ammonia
- symptoms: n/v, coma
3) myocardial depression
Why may regional anesthesia be beneficial in a TURP patient?
1) early detection of TURP Syndrome
* allows to monitor mental status changes, irritability & h/a, early signs of hyponatremia
2) detection of bladder perf
- awake patient will complain of abdominal or shoulder pain despite sensory blockade
3) decrease blood loss
- decrease in BP in central and peripheral circulations
4) decrease incidence of DVT
- possibly due to decrease in stress response (promotes hypercoaguable state)
5) post op analgesia
*GENA will hide s/sx of hyponatremia, bladder perf. bucking on tube will increase venous pressure leading to increase risk of bleeding*
If regional anesthesia is selected, what level of anesthesia is required?
- level of anesthesia depends on anatomy and sensory of involved structures
T11 - L2
- bladder dome
- prostate
S2 - S4
- bladder neck
- prostate
- penis
- scrotum
Blockade to T10 level is sufficient.
epidural blockade may result in incomplete block of sacral nerve roots
what is the sodium deficit equation?
Na+ deficit (mEq) = Total body water x (Na desired - Na observed)
Total body water = 0.6 x lean body weight (male)
total body water = 0.5 x lean body weight (female)
What rate should you correct Na+ deficiency using hypertonic saline?
Na+ deficient:
- fluid restrict
- Lasix
- hypertonic saline (3% NaCl)
Hypertonic saline (3% NaCl)
- contains 513 mEq/L of Na+
- symptomatic hyponatremia: 3 mEq/L per hour to avoid cerebral pontine myelinolysis (CPM)
CPM
- sevre damage of myelin sheath of nerve cells in the Pons portion of brainstem
- can lead to acute paralysis, dysphagia, dysarthria
