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TURP for PG EXCEL detailed slides 2018.pptx
1. “ 89 YEAR OLD MALE PATIEN WITH
I.H.D & HYPERTENSION & HAS PACEMAKER IN SITU
FOR SINUS BRADYCARDIA.
HE HAS POSTED FOR T.U.R.P FOR B.P.H.
HOW WILL YOU EVALUATE AND MANAGE THE PATIENT.”
Dr. S. B. Gangadhar
Prof and Head, Department of Anaesthesiology
Sri Siddhartha Medical College & Research Institute
Tumakuru, Karnataka
Dr. Kemapachary
Prof and Head, Department of Anaesthesiology
Aadi Chunchunagiri Institute of Medical Science
Mandya, Karnataka
3. Chief Complaints-
Pain abdomen since 3 hours
Inability to Pass Urine Since 6 hours
History of Presenting illness
Known case of hypertension & Pacemaker in situ for
sinus bradycardia now presented with Pain
abdomen & inability to pass urine,
History of difficulty in passing and weak streaming
of urine since 1 year.
No history of fever, burning of micturition,
haematuria
Past History –
History of pacemaker inserted 6 years ago for
sinus bradycardia.
History of hypertension since 5 years on Tab.
Amlodipine 5mg OD
History of chest pain 3 years ago for which he
was given medications and no interventions
was done.
Drug History –
Patient is on:
Tab. Amlodipine 5mg OD
Tab. Aspirin 150mg OD
Tab. Clopidogrel – 150mg OD
Tab. Atorvastatin 10mg OD
Per Abdomen – Supra pubic tenderness present.
No guarding
Airway – MPC – class III, TMD>6.5cm, Head
Extension & Mouth Opening – Adequate
USG Abdomen- 90g Prostate
Complete Haemogram – Hb- 10g/dl
Patient is conscious and oriented
Pulse 60 beats per min, regular, good volume
BP – 140/90 mm of Hg in right arm, supine position
RR – 16 bpm, regular
Moderately built and nourished , BMI - 26
PICCLE –
4. Summarize the Clinical findings. Give the
provisional diagnosis. What are your differential
diagnosis
5. 89y/male patient presented with inability to pass urine since 12 hours. Patient is in pacemaker for
sinus bradycardia since 6 years. Patient is also a known case of hypertension on T.AMLODIPINE
5mg OD since 5 years. Patient also gives a history of IHD for which he is on Tab. ASPIRIN 150 mg
OD , Tab. CLOPIDOGREL 150 mg OD and Tab. ATORVASTATIN 10mg OD. Per abdomen examination,
there is supra-pubic tenderness present.
Provisional Diagnosis
89 year hypertensive male patient with Benign prostatic hypertrophy with acute retention of urine
with pace maker in situ with IHD
7. What is a pacemaker?
What are the types and indications?
8. An artificial pacemaker small electronic medical that is placed in the
chest wall or abdomen to help control abnormal heart rhythm.
Types of pacemaker: two types
1. Temporary Pacemaker: To correct the heart rate in situation where
the problem is not permanent.
Eg: During cardiac surgery, drug overdosage, Myocardial infarction
2. Permanent Pacemaker: Implanted permanently under the chest
wall for discharge of conduction system of the heart
10. What history would you like to obtain
regarding a pacemaker preoperatively?
11. History obtain during preoperatively-
1. Date of last device interrogation
2. Type of device
3. Manufacturer and model
4. Indication for device for eg. Sick-sinus syndrome, AV block, syncope
5. Battery longevity are documented more than 3 months
6. Pacing mode and programmed lower rate
7. Is the patient pacemaker dependent
8. What is the underlying rhythm and heart rate.
9. What is the response of this device to magnet placement.
12. What are the anaesthetic implications of
patient present with pacemaker?
13. The major anaesthetic concern in a patient with pacemaker in this patient in this
patient is EMI with the pacemaker with use of cautery. Electromagnetic
interference can lead to-
1. Inhibition of pacemaker with Electromagnetic interfence.
2. Transient or permanent loss of capture
3. Pacemaker failure after direct contact with Electro-cautery/ Cardioversion
4. Myocardial burns with increased pacing threshold if electorcautery travels
through the myocardium.
14. How will you evaluate the patient
preoperatively?
15. Here mainly we have to evaluate this patient in 3 aspects,
,i.e..1.pacemaker.2.geriatric.3.Ischemic Heart Disease with Hypertension
Pacemaker: A patient with the preexisting pacemaker coming for surgery will be having
atleast one of the three underlying cardiac problems
• Sustained or intermittent bradydysarrythmia
• Tachydysarrythmia
• Heart failure
So, how we are going to confirm the cardiac pathology in this patient i.e. by
• Patient history
• Physical examination
• Medical records
• Chest X- Ray
• ECG/Rhythm strip
• Clinical indication for the pacemaker
• The best way to determine pacemaker function preoperatively is interrogation by
concerned cardiologist.
16. Geriatric: Preoperative evaluation for a geriatric patient is important
because most of the elderly patients are ASA ≥III and with low function
status so we are going to ask
• history of any previous illness, medication history
• current functional status
• Assessment of Cardiovascular, Respiratory and also bone and joint diseases
and LFT
• Mental status is also important
Ischemic heart disease with Hypertension - We have to consider
preoperative evaluation in this patient because
• Hypotension and ischemia on ECG are more common in poorly controlled
Hypertension patients
• Anti hypertensive drugs to be continued peri-operatively.
17. This patient is on multiple medications, which drug
will you continue and which drug will you stop
before the surgery??
18. This patient is on 3 medicines
1. Tab. Amlodpine 5mg Once Daily for Hypertension
2. Tab. Aspirin 150mg Once Daily for IHD
3. Tab. Clopidogrel 150 mg Once Daily for IHD
4. Tab. Atorvastatin 10mg Once Daily for IHD
• Patient should continue Tab. Amlodipine 5mg on the day of the
surgery
• Tab. Aspirin 150mg should be stopped 3 days prior to surgery
• Tab. Clopidogrel150mg should be stopped 5 days for surgery
• Tab. Atorvastatin 10mg should be continued on the day of the surgery
20. 1. Compete haemogram: To rule out anaemia and infection
2. B.Urea and S.Creatinine: for renal functioning
3. Urine routine: to rule out UTI
4. Serum Electrolytes: for baseline electrolyte values
5. Chest Xray: look for placement of pacemaker and lung fields
6. ECG: look for LVH and pacing spikes followed by normal QRS complex
7. 2D Echo: to assess Ejection fraction, any wall motion abnormalities, any
valvular changes, look for clots, vegetations, etc
8. USG abdomen: to assess pre and post void residual urine test and prostate size
and weight
9. PSA
10. Pressure flow studies(urodynamics): cystometrogram, cystoscopy,
uroflowmetry
11. Cystometrogram: measures bladder pressure, compliance and capacity during
urine storage.
22. 1. NIBP
2. ECG
3. Pulse oximetry
4. Temperature
5. Intra-arterial line
6. Central Venous line
23. What is your choice of technique of
anaesthesia?? and why??
24. PLAN A-
General Anaesthesia with endotracheal intubation with Controlled
Ventilation
PLAN B-
Spinal Anaesthesia with 10mg 0.5% Hyperbaric Bupivacaine with a
Dermatome level of T10
25. How will you ensure the Intraoperatively safety
with respect to pacemaker in situ?
26. I will ensure that at the time of surgery:
1. Anaesthetist should be ready with CPR,TEMPORARY/CONTINOUS
PACING & EXTERNAL DEFEBRILLATOR is available before starting the
surgery
2. Pacemaker is set to Asynchronous mode
3. Placing grounding electrode 15cms away from the pacemaker
4. Use of bipolar rather than monopolar cautery
5. Use of short bursts of cautery
6. Coagulation mode is better than cutting
7. Availability of appropriate cardiac consultant
30. The TURP syndrome is essentially a clinical diagnosis based on
constellation of symptoms with signs associated with excessive
absorption of irrigating fluid into the circulation.
The irrigation fluid either gains direct intravascular occurs (through
prostatic venous plexus) or is more slowly absorbed from the
retroperitoneal and perivesical space.
• CVS – Hypertension, Bradycardia, Dysarrhythmia, Respiratory Distress,
Cyanosis, Hypotension, Shock and death
• Hematologic- Hyperglycemia, Hyperammonemia,
Hyponatremia,Hyposmolality, hemolysis, anaemia
• CNS- Nausea, Vomiting, Confusion, restlessness, blindness, twitches,
seizures, lethargy
31. How will you recognize TURP SYNDROME
intraoperatively?
32. As this patient is in General Anaesthesia with controlled Ventillation-
• Typically a rise and then a fall in blood pressure,
• Severe refractory bradycardia
• Respiratory arrest.
The electrocardiogram (ECG) will show
• ST-segment changes,
• U waves, and
• widening of the QRS complex
35. 1. Ask the surgeon to stop the surgery
2. Access haemodynamics,as Reflex bradycardiais present we have to use
vasopressors & inotropes
3. Access respiratory system:RR,100%O2 at 8-10L/MIN.
4. Intubate the patient if he is not maintaining spontaneous
ventilation&maintained with IPPV
5. Auscultate the chest for pulmonary edema:use of inj.Frusemide can be used
both for pulmonary edema&Renal failure.
6. If any episode of seizures--treat with anti-epileptics like
diazepam,midazolam,magnesium is the drug of choice if irrigation fluid used is
Glycine.
7. Blood to be collected and send for ABG
8. Serum Sodium concentration and Serum Creatinine should be assesed
9. Correction of hyponatremia—with hypertonic saline 3%-5% at 1-2ml/kg/hr.
10. Transfuse packed RBCS if necessary
11. If bleeding still continues---look for DIC/primary fibrinolysis.
37. Irrigation fluid is used in TURP for 3 reasons
1. Facilitate the clear vision of the surgical field,
2. Wash away blood and dissected tissue debris.
3. To distend the operative site and increase the visibility to the
surgeon
39. RULE OF 60
• Surgery should be less than 60mins
• Irrigation fluid should be at a maximum height of 60cm from the operating
table
• Not remove more than 60g of prostate
• Capsular/bladder perforation allows large volume of fluids into peritoneal
cavity
• Large blood loss implies a large number of open veins
• Low venous pressure: if the pt is hypovolemic/hypotensive
40. What are the properties of ideal irrigation
fluid?
41. A ideal irrigation fluid does not exist in reality.
It has to be:
• Transparent
• Electrically non conductive
• Isotonic
• Non toxic and anaphylactogenic
• Non haemolytic
• Non metabolised when rapidly absorbed and rapidly excreted
• Easy to sterilize
• Inexpensive
43. SOLUTION OSMOLALI
TY
(mOsm/l)
ADVANTAGES DISADVANTAGE
Distilled water 0 Improved visibility Hemolysis
Hemoglobinemia
Hemoglobinuria
hyponatremia
Glycine (1.5%)
Glycine (1.2%)
200
175
Less likely to TURP
syndrome
Transient postoperative visual loss
syndrome,hyperammonemia
hyperoxaluria
Sorbitol (3.3%) 165 Same as glycine Hyperglycemia,lacticacidosis,osmo
tic diuresis
Mannitol (5%) 275 Isosmolar solution not
metabolized
Osmotic dieresis,possible of acute
intravascular volume expansion
Cytal 178 Same as sorbitol and
mannitol
Same as sorbitol and mannitol
Glucose (2.5%) 139 Less likelihood of
TURP syndrome
hyperglycemia
Urea (1%) 167 Same as glucose -
52. 2. Electromagnetic Interference is not seen with:
a) Nerve Stimulator
b) Radio frequency ablation
c) Transcutaneous Nerve Stimulation
d) Laser TURP
54. 3. Use of Electro-cautery with pacemaker. Choose the incorrect
statement-
a) Device Interrogation by Cardiac implantable electronics device consultant
within 12 months of elective surgery is needed
b) The pacemaker is set to Asynchronous mode before anaesthesia
c) Use of monopolar cautery is better than bipolar cautery.
d) None of the above
55. Answer is :
C----use of monopolar cautery
is better than bipolar cautery is the
wrong statement.
56. 4. Normal level of Glycine in the blood
a) 13-17 mg/L
b) 20-25mg/L
c) 5-10 mg/L
d) 8-12 mg/L
58. 5. Which of the statements is correct regarding absorption of
irrigation fluid during TURP?
a) Increased bleeding is associated with increased absorption
b) Prostate weight of more than 60 g is associated with increased absorption
c) Capsular perforation is associated with increased absorption
d) All of the above
