anest turp
DESCRIPTION
anesthesia for TURP transurethral resection of prostateTRANSCRIPT
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Anesthesia for TURP
Claudio Melloni
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Anesthesia for Turp is not always routine
Major KO: 2.5 - 20% of patients perioperative mortality rate :0.5 - 6%, Holtgrewe HL, Valk VVL. Factors influencing the mortalityand morbidity
of transurethral prostatectomy: a study of 2,015 cases.J.Urol 1962; 87: 450‑9.
Roos, N. P., Wennberg, J. E., Malenka, D. J. et al: Mortality and,.re‑operation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med, 320: 1120,1989
Malenka, D. J., Roos, N., Fisher, E. S. et al: Further study of the increased risk of mortality following transurethral resection of the prostate: a chart‑based analysis. J Urol, 144: 224, 19
Seagroatt, V.: Mortality after prostatectomy: selection and surgical approach. Lancet, 346: 1521, 1995
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Risk factors in anesthesia for TURP
Patients,their intrinsic risk factors and anesthesia related risks
Surgical Procedure;its complication,some peculiar to the technique used;
Utilization of irrigating fluids.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Turp Syndrome
Cardiovascular;hypotension,hypertension,dysrythmias,shock,pulmonary edema,cardiac arrest….
Respiratory;tight feeeling in the chest or throat ,shortness of breath,hyperventilation,dyspnea,pulmonary edema….
Cerebral;dizziness,mental confusion, and lethargy lapsing into coma,headaches,nausea, ,restlessness ,retching,blindness,twitches and seizures.;
bacteremia…...
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Late Turp syndrome
4 - 24 hours later Some of these cases could be ascribed to instrumental perforation of the
prostatic capsule ( and more rarely of the bladder) fluid deposited in a pool in the retroperitoneal space the fluid may comprime the caval veins and diffuse through the peritoneal
membrane again creating flows according the Starling laws;electrolytes entering the pool of fluid and solutes contributing to plasma volume decrease as the solute travel in the opposite direction,i.e.toward the cell,where they are metabolized or accumulate
In these case moderate hyponatremia and hypoosmolality develop with a time delay ,some hours following the operation.Clinically there is a tendency toward an
increased incidence of abdominal pain,bradycardia and hypotension
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
TURP symptoms associated with 2000 or + ml glycine absorption(Hahn et al.J.Ethanol monitoring of the
TURS.Clin.Anesth.1996;8:652-655)
Intraop symptoms freq(20-
60%):BP ,HR,BP common(10-
20%):prickling skin,nausea,tiredness.uneasiness
rare (<10%):blurred vision,chest pain,confusion
Postop symptoms confusion,BP,nausea,tr
ansient anuria bradyc,diarrhea,freezin
g,vomiting
blurred vision,depressed consciousness,abdominal pain
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Ideal requirements of an Irrigating solution
Purpose:give the surgeon a clear view of the operating field by removing blood and pieces of resected tissues.
Electrolyte free to allow cutting with a resectoscope Isotonicelectrically inertnon toxic,clear transparenteasy to sterilize and handlenot too expensive….
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Irrigating fluids
H2O distilled glycine 1.2-1.5% mannitol 3% mannitol –sorbitol(2.7-0.54 %
respectively)mixtures.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Toxicity of irrigating fluidsglycine :
significant cardiac and retinal toxicity may cause hyperammonemia because its
metabolites overload the urea synthesis cycle
glucose may cause severe hyperglycemia
mannitol and sorbitol may cause lactic acidosis and hyerglycemia due to shifts in the glycolysis pathways
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Volume absorption
the intravesical pressure (governed by the height of the irrigation bag above the prostatic sinuses)
the number of prostatic sinuses opened retroperitoneal and paravescical spaces,even in
absence of surgical perforation– length of the procedure,– experience of the surgeon(or inexperience)– difficult resections
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
entrainment of the solution
Circulatory overload haemodilution hypotonia and hypoosmolality …………. haemolysis,shock ,renal failure…….. acidosis hypoperfusion shock circulatory
failure hypoxemia
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Vol.absorbed= ((preop serum Na/postop serum NA)*ECF in KG))-ECF in KG.
P es,if a preop sodium was 140 and postop is 110,the calculation yelds for an estimate of EC as 30% of body weight for a 70 kg man=21 kg:
1)140/110=1,2 2)1,2*21=26,6 3)26,6-21=5.6,volume gain in KG(or lt).
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Hypotension-hypertension...
Perioperative hypotension during TURP is sometimes preceded by hypertension . Profound hyponatremia by itself does not explain the hypotension;however, hyponatremia with hypertension may lead to net water flux along osmotic and hydrostatic pressure gradients out of the intravascular space and into the lungs, which triggers pulmonary edema and hypovolemic shock . This concept is consistent with the findings of Hahn(17) who hypothesized that the absorption of fluids derives from two sources;one from direct absorption into the circulation(early phase?)and the second form interstitial accumulation ,both from periprostatic and retoperitoneal spaces and from fluid shifts along physiological gradients,according to Starling equation?????..................The excretion of urine is rapidly increased by all irrigating fluids ,especially mannitol (18) resulting in a osmotic diuresis and hence a net loss of circulating volume,but the situation changes according to the volume administered ,since exretion of glycine is less thant that of mannitol or sorbitol,with a greater intracellular accumulation of glycine (19)(20).
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Atallah et al.Does spinal anesthesia affect cerebral oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8.
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basal after spi chri 30 chirend post30 post60 post120
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jug.bulb O2 sat
art-jug O2 diff
CPP
jug bulb O2 content
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Atallah et al.Does spinal anesthesia affect cerebral oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8.
CPP decrease and SjbO2 decrease,a-jbO2 increase:CBF decrease,CMRO2 unaffected:impaired cerebral oxygenation
patients with symptoms more affected by decrease in SjbO2
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Biphasic absorption of fluids
H yp oosm ola lity
A P O ed em a H yp ovo lem ic sh ock
H 2 O in te rs t
B P
N A d iu res is
H 2 0 en tra in m en t
Atrial natriuretic factor
glycine
Ca++
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Hypoosmolality > hyonatremia
In a series of 72 patients undergoing TURP, serum sodium concentration decreased by 10 to 54 mmol/L in 19 (26%), while osmolality changed in only two (3%): the 2 patients who had both hyponatremia (serum sodium concentration decreases of 27 and 30 mmol/L) and hypoosmolality (serum osmolality of 260 and 256 mmol/L) developed pulmonary edema and encephalopathy. The five patients in this series with the largest decreases in serum sodium concentration (by 34 to 54 mmol/L) had no changes in serum osmolality and no signs of TURP syndrome. (Desmond J. Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatremia during transurethral resection. Can J Surg 1970; 13:116-21).
A review of a series of 2000 consecutive patients( Henderson DJ,Middleton RG.Coma from hyponatremia following transurethral resection of prostate.Urology 15;267-71,1980) revealed 14 coma cases potoperatively,with sodium levels 15-20 meq/lt below normal level:the coma was ,at that time , correctly,ascribed to water intoxication and associated surgical risk factors were identified,because in 9 of these cases the prostatic capsule was surgically violated or large venous sinuses were opened;all 14 patients eventually awoke without sequelae.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Blood loss Total blood loss after TURP is significantly correlated
with the prostatic tissue weight but when the tissue weight resected exceeds 35
gr,blood loss was in excess of the linear correlation(Smyth R, Cheng D, Asokumar B et al. Coagulopathies in patients after transurethral resection of the prostate: spinal versus general anaesthesia. Anesth Analg 1995; 81: 680‑5)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Smyth R, Cheng D, Asokumar B et al. Coagulopathies in patients after transurethral
resection of the prostate: spinal versus general anaesthesia. Anesth Analg 1995; 81: 680‑5
. There was no significant difference in measured coagulation variables (fibrinogen, factor V, plasminogen, antithrombin III, and FDP) between the spinal and GA groups, but there were significant decreases in postoperative fibrinogen and Factor V levels compared to preoperative values in both spinal and general anesthesia groups.
3 pts (6%) had increased FDP levels 1 h postop. The prostatic tissue weight and the surgical duration was significantly higher in these patients.
The authors concluded that perioperative blood loss in TURP patients is not affected by the anesthetic technique,but 6% of TURP patients developed subclinical intravascular coagulopathies which correlated with mass of resected prostate tissue.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Therapy of Turp syndrome
diuretics? Saline hypertonic saline? Inotropes/vasopressors(?) The most feared complication of correcting
hyponatremia is central pontine myelinolysis (CPM
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Treatment of symptomatic hyponatremia
Safest treatment;symptomatic slow therapy ( <=0.7 mmolLt/h) , has been associated with a higher
morbidity and mortality than has rapid correction (=>1.0 mmol/lt/hr) Many reports suggesting that a 1.5- to 2.0-mmol /Lt/hr correction
rate is safe have failed to consider changes in osmolality. Several investigators have suggested that osmotic stress is probably greater when correcting chronic compared with acute hyponatremia
a prompt treatment with increases in the serum Na concentration not > 2 mmol/lt/hr;in general the correction dose not require doses > 100 ml/hr .
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Hyperglycinemia
Incidence and severity of circulatory and nervous symptoms(nausea, vomiting, headache, malaise weakness,seizures, from blurred vision to complete blindness…) proportional to the amount of glycine absorbed:» serum glycine concentration threshold for symptomatic
visual impairment (>4000 mmol/L) and blindness (>13,734 mmol/L)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Glycine toxicity
Retina cardiomyocites kidney(Hyperoxaluria from metabolism into oxalate and glycolate)
hyperammoniemia
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Treatment of hyperglycinemia
Mg? NMDA antagonists L-arginine
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection syndrome using glycine as the
irrigant. J Urol 1995; 154: 123‑8
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%
glycine absorption
0-3001-2 lt>3 lt
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Nilsson A,Olsson J,Hahn RG.Symptoms of the TURP syndrome using glycine as the irrigant.J
Urol 1995;154:123-128
glycine
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Fluid absorption during TURP;influence of
operating time(Hahn RG, Ekengren J. Patterns of irrigating fluid absorption during transurethral resection of the prostate as indicated by
ethanol. I Urol 1993: 149: 502‑6
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op-time <= 60 min op time > 60 min
>2000
1001-2000
501-1000
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Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Urine composition 90 min after i.v infusion of 15 ml/kg of irrigating fluids(10 healthy male
volunteers) Nilsson A, Randmaa 1, Hahn RG. Haemodynamic effects of
irrigating fluids studied by Doppler ultrasonography in volunteers. Br I Urol 1996; 77: 541‑6
Osmotic gap represents negatively
charged ions not measured
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Urinary excretion of sodium during and after iv
infusion of glycine solution in sheep and humans. (Hahn RG Trapping of electrolytes during fluid absorptionin transurethral resection of the
prostate. Scand j Urol Nephrol, in press)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Trepanier,CA,Lessard,MR,Brochu,J,Turcotte,G.Another feature of TURP syndrome:hyperglycemia
and lactic acidosis caused by massive absorption of sorbitol.Brit. J. Anaesth. 87;316-9:2001
hyperglycaemia and lactic acidosis
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Gehring et al.Irrigation fluid absorption during TURP;spinal vs general anesthesia.AAS
1999;43:458-63. Blood ethanol
absorption rate Blood ethanol maximum levels
Blood ethanol area
under the curve Estimated volume of absorption(Hahn
nomogram)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Gehring et al.Irrigation fluid absorption during TURP;spinal vs general
anesthesia.AAS 1999;43:458-63.
Extent of irrigating fluid absorption significantly higher in absorption afflicted patients undergoing spinal anesthesia….;lower CVP may be the cause
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Why regional anesth.is to be preferred
It allows the appearance of the full clinical manifestation of symptoms » (under GA only rise and fall in blood pressure ,respiratory
arrest and severe bradycardia,with a variety of ECG modifications)
possibility of early detection of TUR syndrome
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
significant fluid absorption has taken place when ethanol concentration in plasma exceeeds 0.1/1000.Plasma and exhaled ethanol demonstrated a linear correlation ,while plasma ethanol correlated inversely with plasma sodium .The measurements were consistent both in patients under spinal and ga ,undergoing mechanical ventilation;but ethanol levels were not predictive of sodium concentrations so that the authors recommended additional separate electrolytes determinations whenever exhaled ethanol exceeds 0.2/1000.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Recommendations for anesth.
continuous warming of i.v. fluids (warming of the patient) lab monit :Hb,Na ,glyc ;coag in susp.cases PVC? NIBP,SaO2,etcO2,ethanol EGA,lactate consciousness be vigilant
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Recommendations for surgery
Minimize absorption» Limiting the height of the irrigation bag to 40 cm above the prostate» use continuous irrigating resectoscopes» use suprapubic trocar drainage
keep intravesical pressure < 15 cm H2O continuous warming of irrigating fluid Resection time < 1 hour leave a rim of tissue on the capsule until near the end of the
procedure New techniques….
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Difficulties for the anesthesiologist who wants to introduce a method for monitoring of fluid
absorption in their hospital
Urologist often regard fluid absorption as a complication indicating poor operative skills» address this point cautiously because this determines the
success of the project... many clinicians believe TUR syndrome is too rare to
warrant routine monitoring:» prepare by reading some prospective studies where the incidence
of the mild form of the syndrome have actually been studied….–Hahn,RG,Editorial.The transurethral resection syndrome-not yet a
finished story.Reg.Anesth.Pain Med.1998;23:115-118.Professor of Anesthesiology,Karolinska Institute Stockholm,Sweden