TURP Flashcards
TURP: what’s your anesthetic plan? What exactly is TURP syndrome?
General anesthetic. Although i realize that NA can provide the benefit of assessing the pt for signs of TURP syndrome (confusion, restlessness, headache, dyspnea, arrhythmias, ab/shoulder pain), Newer laser techniques have reduced the incidence of TURP, and patients may not be agreeable to staying awake during surgery. This also guarantees an airway in a patient who has (blah, blah, blah)
TURP syndrome is the signs/symptoms that can occur during TURP due to absorption of the irrigating fluids into the prostatic veins
What monitors you placing for TURP?
Standard ASA and you can argue an arterial line for access for frequent serum sodium blood draws.
What level of anesthesia do you need for TURP? Will abdoinal pain or shoulder pain be masked with T10 sensory level?
I would choose to use either hyperbaric bupivacaine or tetracaine due
to their duration of action, which ranges from 90-120 minutes without added
epinephrine. My goal would be to achieve a T10 sensory level of anesthesia, which
would provide adequate analgesia for the procedure while, at the same time, allowing
monitoring for the signs and symptoms of bladder perforation. The abdominal pain
and/or diaphragmatic irritation (shoulder pain) often associated with bladder
perforation would not be masked by a neuraxial anesthetic providing T 10 sensory
analgesia
Which irrigation solns are available for TURP? What is the ideal irrigation solution?
glycine, sorbitol, mannitol
Ideal: electricall inertbecause balanced electrolyte solutions (i.e. LR) can ·
interfere with electrocautery and disperse electrical current, placing the surgeon and
patient at risk of burn injury.
Isotonic: because hypotonic solutions result in hemolysis
inexpenxive-due to large volume used.
Can you use distilled water for irrigation in TURP?
In the past, distilled water has been used for irrigation during TURP
because it is electrically inert and completely transparent. However, it is no longer
used for this procedure because its hypotonicity places the patient at risk for
intravascular hemolysis, hyponatremia,
The surgeon decides to use a glycine irrigation solution. Twenty minutes into
the surgery the patient becomes agitated and his blood pressure increases to
198/100 mmHg. What do you think is going on? Wyd?
Inadequate anesthesia
TURP syndrome
myocardial ischemia
bladder perforation (decreased return of irrigating fluid) In response, I would ensure adequate ventilation
with 100% oxygen; obtain a 12-lead ECG to look for signs of myocardial ischemia;
ask the surgeon to stop operating and evaluate the patient for bladder perforation;
hypoxia
ensure adequate analgesia; and check the patient’s temperature (hypothermia from irrigating fluids), hemoglobin (can have bleeding, also consider checking coats as they can have DIC or dilution of coagulation factors), serum
sodium, serum glucose, and arterial blood gases (pt can go into respiratory failure).
Signs of bladder perforation:
abdominal pain, htn, bradycardic, diaphoresis, nausea, left shoulder pain
would still need to rule out myocardial ischemia,
which could present similarly or concurrently. Therefore, I would obtain a 12-lead
EKG to look for signs of myocardial ischemia, ensure adequate ventilation and
oxygenation (100% oxygen, adequate hemoglobin), ensure adequate analgesia, and
treat any hemodynamic instability. At the same time, I would ask the surgeon to
assess whether there has been decreased return of irrigation solution from the bladder
(another sign of bladder perforation), discontinue or finish the procedure quickly,
identify and assess any bladder perforation, and consider performing a suprapubic
cystostomy (if bladder perforation is identified).
If pt becomes uncooperative during spinal anesthetic for TURP and triesto stop getting off the table-wyd?
GA
And make sure you always let them know that although you are doing NA, you may have to convert to GA.
After a TURP in which the pt got sux, pt isn’t waking-DDx:
pseudocholinestease deficiency
TURP syndrome: irrigation solution, I would also
consider the following causes and/or contributing factors: (1) TURP syndrome
(hyperglycinemia and hyperammonemia secondary to glycine metabolism can lead to
CNS toxicity; hyponatremia secondary to volume overload can lead to cerebral
edema); (2) cerebral ischemia/hypoperfusion (secondary to cardiac arrhythmia,
hypoxia, cerebral edema, hypotension, anemia, and/or an altered cerebral
autoregulation curve with chronic HTN); (3) hypoglycemia (increased risk with tight
perioperative glucose control of an insulin dependent diabetic patient), ( 4)
hypothermia secondary to autonomic neuropathy (increased susceptibility to
hypothermia) and/or inadequate warming of irrigation solution or the operating room
(decreases MAC and limits drug metabolism); (5) hypoxia and/or hypercarbia
secondary to the ventilation/perfusion mismatching that may occur with COPD,
pulmonary edema, and/or aspiration; (6) hypocarbia (secondary to overaggressive
ventilation); (7) medication error;
You use a peripheral nerve stimulator and notice fade with train-of-four. What
do you think? When does it happen?
Fade with a train of four is consistent with residual nondepolarizing
blockade or Phase II blockade from a depolarizing muscle relaxant (succinylcholine).Phase II blockade can occur with excessive doses (7-10 mg/kg), prolonged infusions,
or abnormal metabolism of succinylcholine.
What is a dibucaine number? If a pt has a dibucaine number of 32, then what?
The dibucaine number used to assess how pts respond to plasma cholinesterase. A low dibucaine number represents a defect in pseudocholinesterase genotype.
Low number 20-30: homozygous atypical genotype for pseudocholinesterase. Basically, if you’re not inhibited by dibucaine-something else is inhibiting you-oh your alleles.
.Dibucaine inhibits the pseudocholinesterase activity of
patients who are homozygous normal (two normal alleles -7 NIN) by 80%,
homozygous atypical (two atypical alleles -7 A/A) by 20%, and heterozygous (one
normal and one atypical allele -7 A/N) by 40-60%. A dibucaine number of32,
therefore, is consistent with a patient with the extremely rare (112500-3000)
homozygous atypical genotype for pseudocholinesterase. This patient is likely to
require continued mechanical ventilation with adequate sedation for 4-8 hours
following succinylcholine administration.
What would you do with a pt with pseudocholinesterase deficiency?
I would ensure adequate sedation and mechanical ventilation until
passive diffusion of succinylcholine away from the neuromuscular junction results in
the full return of the patient’s strength, and until the patient meets all other extubation
criteria.
After TURP, pt can’t see-now what?
There are a number of potential causes of this patient’s visual
disturbance following TURP, including: (1) anterior or posterior ischemic optic
neuropathy, (2) glycine toxicity, (3) cortical blindness, (4) acute glaucoma,
Corneal abrasion physical exam:
eye pain that is exacerbated by blinking and ocular
movement; the sensation of a foreign body in the eye; tearing; conjunctivitis;
photophobia
Break down two types of ischemic optic neuropathy
Ischemic Optic Neuropathy: painless visual loss; afferent pupil defect
(absent/impaired light reflex); visual field deficits or complete vision loss
a. Anterior Ischemic Optic Neuropathy: optic disc edema and/or
hemorrhage
b. Posterior Ischemic Optic Neuropathy: the optic disc appears
normal initially
