A brief discussion about anesthetic considerations in TURP

1. Ashish Dhandare
Anesthesia in TURP

2. Preanaesthetic considerations :-
• Elderly men – multiple comorbidities.
- medications.
• Investigations – CBC,
Renal function tests,
Liver function tests,
Electrolytes,
Coagulation profile.

3. Geriatric pts :-
• CNS :- 1) Reduced functional CNS tissue
↓
Decreased requirement of anesthetics.
2) Reduced temp control ability
↓
Prone to develop hypothermia
• PNS :- Increased sensitivity to NMB
↓
Prolonged action of NMB

4. CVS :- 1) Baroreceptor Fn impaired (esp CCF pts)
↓
Reduced CVS ability to compensate for h’rrhage
& vasodilatory action of anesthetics
↓
Severe Hypotension
2) a) Cardiac d/s common
↓
Thus impaired CVS Fn common.
b) Anesthetic agents – cardiac suppressants
↓
Optimized before surgery.

5. RS :- 1) Reduced alveolar surface area,
Reduced diffusion capacity,
Pulmonary fibrosis.
CC>FRC – earlier closure of airways,
↓
Reduced pulmonary reserve
2) Resp d/ss are common.
Renal :- 1)Impaired renal Fn
↓
Prolonged action of drugs.
2) Advancing age & GA – risk of ARF.

6. Irrigating fluid :-
• Ideal irrigant fluid –
1) Iso-osmolar & non-hemolytic,
2) Non-electrolytic,
3) Non-toxic,
4) Non-metabolizable & rapidly ecretable,
5) Transparent,
6) Sterile & Inexpensive.

7. A)Saline & RL :- electrolytic
↓
Conducts current
B) Water :- Hypotonic
Hemolysis with prolonged use
↓
Hb - binds with plasma proteins -nephrotoxic
K+ - hyperkalaemia.
C) 5.4% Glucose :- Tissue charring
Surgical site & instruments sticky
Elevated sr. glucose levels.

8. D) 1.8% Urea :-a) Urea crystallizes on instruments
b) highly permeable – elevated sr. urea
↓
N, V, headache, Tachycardia, high BP,
blurred vision, convulsions, coma.
c) Has osmotic diuretic effect
↓
dehydration
E) 3.3% Sorbitol :- metabolized into CO2, Glucose, &
H2O.
Water intoxication
elevated sr. glucose levels.

9. F) 3% Mannitol :- Osmotic diuretic
Dehydration, hyperosmolarity,
acidosis.
G) Cytal :- 2.7% Sorbitol + 0.54% Mannitol

10. H) 1.5% Glycine :- a) M.C.ly used.
b) Osmolality – 200mosm
c) metabolized in liver
↓
NH3, H2O & oxalic acid
(glycolic acid)
1) Hyperammonemia,
2) H2O intoxication
↓
cerebral oedema, seizures.
3) Oxalic acid – Ca oxalate
↓
deposited in kidneys - ARF
& Hyper-oxaluria.↓

11. Complications a/w TURP :-
A) TURP syndrome,
B) Glycine toxicity,
C) Hemolysis,
D) Hypothermia,
E) Bleeding,
F) Perforation,
G) Bacteremia.

12. A) TURP syndrome :-
• Cluster of signs & symptoms caused d/to absorption
of irrigating fluid.
• Incidence – 0.7-1.4%
• Mortality – 0.5-0.8%
• 1st described in 1973 when 1.2% glycine was used.
as “Syndrome of overhydration.”
↓
Triad of ;- Bradycardia,
Increased SBP, DBP & PP,
Cerebral signs.

13. • TURP syndrome consists of:-
1) CNS manifestations,
2) CVS manifesstations,
3) Hemolysis, &
4) Hypothermia.
• CNS :- Restlessness, agitation, confusion –
classic 1st signs.
N, V, disorientation, sizures,
cerebral oedema, coma.
Blurred vision, papillary oedema
↓
D/to water intoxication, dilutional
hyponatremia & hypotonicity.

14. Blindness, delayed recovery, drowsiness
↓
d/to glycine toxicity.

15. CVS :- Bradycardia, HTN, sometimes hypotension,
arrhythmias,
cyanosis,
dysnoea, pulm congestion, pulm oedema,
Left heart failure, cardiac arrest.
↓
d/to fluid overload,
hemodilution &
negative inotropic effect of hyponatremia.

16. • Faster the fall of Na+, more the toxic symptoms.
• sr. Na+ drop to 120 meq/L or drop by 20-30 meq/L
•
Sr. Na+
(meq/L)
CNS effects ECG effects
120 Confusion &
restlessness
Wide QRS
115 Nausea,
Somnolence
Wide QRS, ST
elevation
110 Seizures, Coma V. Tachycardia/
fibrillation

17. • Time of occurrence of TURP syndrome:-
1)Intra-op depends on;-
experience of the surgeon,
aggressiveness of surgeon in resection,
pathology & size of the gland,
amount of irrigating fluid used.
usually after 60 mins of irrigation.
2)can occur post-op;-
if the integrity of prostatic capsule/ wall of the
bladder is damaged
↓
Irrigating fluid into intra/extra-peritoneal space
↓
Absorbed into the intravascular space.

18. Treatment of TURP syndrome :-
1) Immediately terminate Sx with 1st sign/ symptom,
2) Warm NS for irrigation,
3) Assist ventilation if required,
4) Immediately send blood for lab tests – CBC,
Electrolytes,
Coag. profile.
5) IV diuretics – a) Furosemide 20mg.
b) those on chronic diuretics – 40mg
c) more based on the response obtained
from initial 20mg dose.

19. 6) Hypertonic saline :- Use restricted to those who
develop seizures &
cardiac dysfunction.
7) Central venous cath :- CVP – Guide to fluid therapy.
8) Arterial BP & PAC :- if haemodynamic instability.
9) Monitor K+ :- Hypokalemia with diuresis.
10) Reassurance :- esp visual changes - temporary &
will resolve as conditon improves.

20. B)Glycine toxicity :-
A) Manifestations :-
1) Neurotoxicity – Inhibitory neurotransmitter.
Direct neurotoxic
↓
N, V, Headache, malaise, weakness,
visual – blurring to complete blindness.
NMDA receptor activity – seizures.
2) Renal toxicity :- Glycine → NH3 & Oxalate.
Ca oxalate - renal failure

21. B) Treatment of glycine toxicity :-
1) Arginine – ↑ses NH3 metabolism via urea
cycle.
2) Mg – Negative control on NMDA receptors.
3) Vision – returns to normal
when glycine levels return to normal.
usually within 24 hrs.

22. C) Hemolysis :-
• when hypotonic fluids are used.
• leads to haemoglobinemia, haemoglobinuria,
anemia &
hyperkalemia.
• may cause ARF.
• chills, clamminess, chest tightness, BP, HR.
• Treatment :- Diuresis,
electrolyte correction.

23. D) Bleeding :-
• Difficult to quatify d/to dilution.
• tachycardia & hypotension masked by bradycardia &
HTN of overhydration syndrome.
• roughly – 15ml/gm of resected prostatic tissue or
2.6-4.6 ml/min.
• True bld loss calculation :-
collect all the irrigant-bld mixture &
measure its hematocrit.
Bld loss = Hb of bld-rrigant mixture/Pt’s Hb * Total amt
of irrigating
fluid used.

24. • Causes of increased bld loss during TURP :-
1) Circulatory overload – hypervolemia
↓
↑sed venous pressure
2) Vasodilatation :-
SAB – pooling of blood in LLs.
Lithotomy – stasis of bld in pelvic region
↓
↑sed Venous pressure in prostaticc sinuses.

25. 3)Urokinase (plasm protein frm resected prostate tissue)
↓
Activates plasminogen
Plasminogen → plasmin → fibrinolysis
↓
Delayed post-op bleeding,
Oozing from prostatic fossa,
Bleeding from puncture sites.
• Treatment of bleeding :-
Tranexemic acid,
fibrinogen & blood transfusion.

26. E) Perforation :-
• D/to instrumentation/ overdistension of bladder.
• Urethral/
Intraperitoneal ( rupture of bladder dome)/
Extraperitoneal ( rupture of bladder neck)/
Capsular or peri-prostatic extravasation.
• Symptoms :- pain, N, V.
• Signs :- Abd distension, rigidity, diaphoresis,
bradycardia, HTN, nonreturn of irrigating fluid.
• Treatment :-
1) ectraperitoneal/ periprostatic /urethral tears –
a) localised – catheterisation & antibiotics.
b) extensive tears – surgical exploration
2) Intraperitoneal – surgical repair.

27. F) Hypothermia :-
• d/to use of cold IVF/ irrigating fluid.
• d/to cold OT table.
• d/to cold, dry operating room.
• Irrigating fluid @ room temp – body temp drops by
>2 °C.
G) Bacteremia :-
• bacteria may enter bld stream from infected urinary
tract,
• rigors, hypotension.

28. Factors affecting intravascular absorption :-
• Number & size of venous sinuses opened.
• Duration of exposure :-
reduction of resection time to <1hr reduces the
incidence of TURP & morbidity & mortality a/w it.
Avg rate of absorption of fluid – 10-30 ml/min
• Venous pressure at irrigant bld interface.
Irrigant fluid bag - max at 60cms height (2 Ft) above
pubic symphysis
↓
Hydrostatic pressure of 60cms
Maximum allowable pressure.

29. How to minimize to risk of TURP syndrome :-
1) Preparation before surgery :- adequate hydration,
electrolytes analysis,
coagulation profile.
2) Limit the duration of surgery – 1 hr/less.
3) Bag @ max 60cms height.
4) Limit the extent of bladder distension.
Frequent drainage of bladder.
5) Careful surgical resection – reduces the exposure of
venous sinuses & preserves capsule of prostate.

30. 6) Maintaining stable BP.
Prevent fall in BP.
7) Intraprostatic vasopressin.
8) Use of Laser excision or bipolar electrode excision.
Above factors reduce the risk of bleeding &
absorption of irrigating fluid.
↓
minimizing the risk of developing TURP syndrome.

31. SAB – anaesthetic method of choice :-
• Little anesthetic required.
• Pt awake & mentation can be assessed.
• Early recognition of complications.
• Minimal respiratory & physiological disturbance.
• Peripheral vasodilation – prevents circulatory overload
• More venous pressure at sinuses d/to pooling of bld.
• Low morbidity & mortality.
•Good surgical access & m/s relaxation.

32. Thank you.