aesthetic management of turp
TRANSCRIPT
Aesthetic management of TURP
MULTIPLE CHOICE QUESTIONS
1. Concerning TURP (transurethral resection of the prostate):a. A spinal block to T5 is required to prevent discomfort from
peritoneal irritation during surgeryb. Spinal anaesthesia is the method of choicec. Ethanol can be added to the irrigating fluid and the patient’s
breath can be analysed every few minutesd. TURP syndrome only occurs following TURPe. Occurs immediately postoperatively
MULTIPLE CHOICE QUESTIONS
2. Glycine:a. is used as 2.0% irrigation fluidb. is an essential amino acidc. is metabolised to NH3d. can cause seizures and visual disturbance in high plasma levelse. is an excitatory neurotransmitter
MULTIPLE CHOICE QUESTIONS
3. Features of TURP syndrome include:a. Tachycardiab. Hypotensionc. Hypertensiond. Nauseae. Seizures
MULTIPLE CHOICE QUESTIONS
4. Management of TURP syndrome can include:a. Intubation and ventilationb. Large volumes of IV 0.9% salinec. IV frusemided. 8.4% NaHCO3e. Diazepam
How common ??
TURP is the 2nd most common surgical procedure in men over 65.
Approximately 40 000 (TURP) are performed annually in the UK.
Symptomatic benign prostatic hypertrophy is the most common indication for TURP.
Procedure
• The operation is performed through a modified cystoscope (resectoscope)
• Prostatic tissue is resected using an electrically energized wire loop.
• Bleeding controlled by coagulation current.
• Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue.
Anesthetic problems
Type of patients# Elderly males usually > 60 yrs# Coexisting diseases
cardiac disease 67%cardiovascular disease 50%COPD 29%DM 8%
# Occasionally patients are dehydrated and depleted of essential electrolytes (long-term diuretic therapy and restricted fluid intake).
# Mortality rate 0.2-0.8 %
Anesthetic problems
Lithotomy position•↓ Functional residual capacity → atelectasis & hypoxia especially with trendelenburg position•CVS
• Leg elevation ↑ venous return (600ml) → HF• Rapid lowering of leg → hypotension
•Iatrogenic nerve injury• Peroneal N. compreesion → loss of dorsiflexion• Saphenous N. →numbness along the medial cuff• Obturator or femoral N.
Preop. evaluation
• Lab investigations , ECG ,CxR• Urine analysis – infection • Antibiotic prophylaxis • Blood gases, echo if needed • Blood grouping and matching in anemic patient with large prostate >
40 G • antihypertensive and antianginal drugs should be continued until the
day of surgery.
Intraop. Managements
Monitoring•Standard monitoring
• ECG• Pulse oximetry• NIBP
•Temperature monitoring•Mental status (awake)
Intraop. Managements
Anesthetic techniqueRegional anesthesia is the anesthetic technique of choice because of:
• Promote VD & peripheral pooling of blood → ↓ circulatory overload• Allow early detection of TURP syndrome & bladder perforation• ↓ blood loss by ↓ blood pressure• Postop. Analgesia• ↓ incidence of DVT But there is NO EVIDENCE of difference in mortality & morbidity
between regional & general anesthesia
Intraop. Managements
Spinal anesthesia
Level??Why??
T10Bladder distension
Intraop. Managements
Fluids• Fluid restriction• Normal saline• Use vasopressors for hypotension
TURP Syndrome• A clinical diagnosis based on symptoms and signs caused by an excess
absorption of irrigation fluid into the circulation. It occurs due to acute changes in:
• Intravascular volume• Plasma Na+ concentration• Osmolality• Manifestation are primarily of circulatory overload, water intoxication and
occasionally, toxicity from solute in irrigating fluid.• Between 1% and 8% of TURP procedures are complicated by TURP syndrome
• The syndrome has also been reported after endometrial ablation and ureteroscopic procedures.
• TURP syndrome can occur within 15 minutes after resection starts or up to 24 hours postoperatively
IRRIGATION FLUID
The properties of an ideal irrigation fluid are:• Transparent (allows visualization)• Isotonic• Electrically non- conductive (to allow MONOPOLAR diathermy to work)• Non-haemolytic• Not metabolized• Non- toxic• Inexpensive• Sterile.
IRRIGATION FLUID
• The effects are proportional to the volume of irrigating solution absorbed.
• Normally about 20 ml/min of irrigating fluid are absorbed into circulation. It is usually 1-1.5 L, but may be increased to 5-8 L.
• Average weight gain by the end of surgery is 2 kg.
IRRIGATION FLUID
Factors which influence absorption of irrigation fluid are:-• Hydrostatic pressure of irrigation fluid- the height of the fluid should be kept as low
as possible to achieve adequate flow of fluid (usually 70 cm) without excessive ∼pressure causing fluid entering the patient circulation.
• Low peripheral venous pressure (e.g. if patient is hypovolemic, or hypotensive)• Duration of surgery- should be no more than 1 hour. Irrigating fluid absorption may
occur throughout TURP, but the risk is greatest 30 minutes after surgery commences.• Large blood loss i.e. open prostatic vessels through which irrigation fluid is absorbed• Capsular or bladder perforation which allows large volumes of irrigation fluid into
the peritoneal cavity, where it is then absorbed.• Prostate size patients with gland sizes larger than 45 g were at a greater risk of TURP
syndrome development (1.5% compared with 0.8%)
IRRIGATION FLUID
Clinical picture
• Early symptoms• Awake patient: restlessness, headache, dyspnea, tachypnea. It may progress to
respiratory distress, hypoxia, pulmonary edema, nausea, vomiting• Anesthetized patient: hypertension then hypotension, bradycardia, ↑ airway
pressure, delayed recovery• Late symptoms
• Cerebral edema caused by acute hypo-osmolality leads to ↑ ICP, bradycardia, HTN and neurologic manifestation.
• ECG changes:• < 120 mEq/L: widening to QRS complex• < 115 mEq/L: widening to QRS complex, ↑ ST segment, inverted T wave• < 110 mEq/L: PVCs, VT, VF, cardiac arrest
• Hyperglycemia: with sorbitol & dextrose
Glycine
• Glycine is an inhibitory neurotransmitter in the CNS and retina.• NMDA receptor activity is potentiated by glycine, which can cause
encephalopathy and seizures.• Magnesium has a negative effect on NMDA receptors, and membrane
stabilising effect. Hence, Mg2+ should be considered for seizure control in TURP syndrome.
• Visual disturbances have been reported with glycine. Symptoms range from a deterioration in vision to light perception only. Vision usually returns to normal 2-12 hours later. Fundoscopy is normal, with a normal pupil response to light.
• Glycine is metabolised by oxidative deamination, by the liver and kidneys, to glyoxylic acid and NH3. NH3 (hyperammonemia) has a cerebral depressant effect.
Management of TURP syndrome
If TURP syndrome is suspected:• Surgery must be stopped.• IV fluids should be stopped.• Airway and breathing - support respiration, if necessary (intubation & ventilation)• Circulation- bradycardia and hypotension should be treated with
glycopyrrolate and vasopressors.• Seizures should be treated with anticonvulsants (eg diazepam,
lorazepam, thiopentone), i.v. magnesium.• Investigations - check Na+, osmolality, and Hb.
Management of TURP syndrome
• Diuretics (e.g. frusemide 40mg) is only recommended if there is acute pulmonary oedema (due to transient hypervolaemia). Frusemide may further decrease Na+, but it is effective at removing free water. Mannitol (eg 100ml of 20%) causes less Na+ loss than loop diuretics.
• Severe hyponatraemia (ie Na+ < 120mMol/L, or severe symptoms such as transient blindness, persistent nausea and vomiting, severe headaches, hypotension (drop in systolic of >50mmHg)) should be treated by increasing extracellular fluid tonicity in order to shift water from ICF to ECF, thus ameliorating cerebral oedema. This can be achieved using:o Hypertonic saline (3%) in those with normal renal function,o Haemofiltration - if the patient has chronic renal failureo 8.4% NaHCO3 can be used if hypertonic saline is unavailable.
Management of severe TURP syndrome.
Aidan M. O'Donnell, and Irwin T.H. Foo Contin Educ Anaesth Crit Care Pain 2009;9:92-96
©The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email:
Future developments
• Bipolar electrosurgery devices, laser, ultrasound or microwave have been introduced, and these devices are compatible with electrolyte-containing irrigation solutions. However, histology specimens cannot be obtained.
• Use of these solutions reduces the risk for development of hyponatremia. However, absorption of a large volume of saline solution will expand the extracellular fluid volume and may generate volume overload, pulmonary edema, and hypertension.
Prevention
• To reduce the incidence of TURP syndrome:-• Limit resection time to <60 mins• Hydrostatic pressure of irrigation fluid 70 cm∼• Spinal anaesthesia- allows earlier detection of TURP syndrome• Do NOT administer hypotonic i.v. fluid• Hypotension due to spinal anaesthesia should be treated with vasopressors, rather than large boluses of i.v. crystalloid
MULTIPLE CHOICE QUESTIONS
1. Concerning TURP (transurethral resection of the prostate):a. A spinal block to T5 is required to prevent discomfort from
peritoneal irritation during surgeryb. Spinal anaesthesia is the method of choicec. Ethanol can be added to the irrigating fluid and the patient’s
breath can be analysed every few minutesd. TURP syndrome only occurs following TURPe. Occurs immediately postoperatively
F
TT
FF
MULTIPLE CHOICE QUESTIONS
2. Glycine:a. is used as 2.0% irrigation fluidb. is an essential amino acidc. is metabolised to NH3d. can cause seizures and visual disturbance in high plasma levelse. is an excitatory neurotransmitter
FFTTF
MULTIPLE CHOICE QUESTIONS
3. Features of TURP syndrome include:a. Tachycardiab. Hypotensionc. Hypertensiond. Nauseae. Seizures
FTTTT
MULTIPLE CHOICE QUESTIONS
4. Management of TURP syndrome can include:a. Intubation and ventilationb. Large volumes of IV 0.9% salinec. IV frusemided. 8.4% NaHCO3e. Diazepam
TFTTT
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