Anaesthetic consideration of TURP

TURP

1. ANAESTHETIC CONSIDERATION OF TURP Dr. ZIKRULLAH

2. TURP - INTRODUCTION gold standard for BPH. most commonly performed on elderly patients. TURP carries unique complications Why? Because of the need to use large volumes of irrigating fluid .

3. ANATOMY OF PROSTATE LOCATION: in the pelvis, below neck of urinary bladder SHAPE : inverted cone Weight : 20 gm 5 LOBES: median, anterior, 2 lateral, posterior

4. ANATOMY OF PROSTATE NERVE SUPPLY BLOOD SUPPLY Sympathetic supply T11-L2 Inferior hypogastric plexus Parasympathetic supply S2,3,4 Pelvic splanchnic nerve Arterial supply Inferior vesical artery Middle rectal artery Internal pudendal artery Venous supply Vesical plexus Internal pudendal veins Vertebral venous plexus

5. WHAT IS BPH ? Non cancerous enlargement of the prostate gland Leads to symptoms of bladder outlet obstruction Disease of the old age , starts at ~ 40 ( but usually presents between 50 – 70 years )

6. Indications of TURP Prostate volume > 40-50 gm but less than 80 gm Advanced Ca prostate - to relieve BOO symptoms

7. TURP - PROCEDURE Performed in the lithotomy position using a resectoscope , through which a diathermy loop is passed. The bladder is continuously irrigated with fluid . irrigation is continued for up to 24 h. The procedure usually takes 30–90 min.

8. IRRIGATING FLUID. M/C used irrigating fluid . 1.5 glycine Cytal ( sarbitol 2.7%+ mannitol 0.54%) Others are.. Saline Ringer lactate Glucose(5.4%) Urea(1.8%) Sarbitol (3.3%) Mannitol (3%) Distilled water

9. Factors affecting amount and rate of fluid absorption Size of gland (25ml/gm of prostate) Number and size of open sinuses Hydrostatic pressure of irrigating fluid Duration of procedure (@ 20-30 ml/min) Integrity of capsule Venous pressure at irrigant -blood interface Vascularity of diseased prostate

10. PREOPERATIVE CONSIDERATIONS Elderly with coexistent diseases. Dehydrated and depleted of electrolytes d/t long-term diuretic therapy and restricted fluid intake. impaired renal function and chronic urinary infection d/t Long standing urinary obstruction

11. PREOPERATIVE EVALUATION History and datail examination of all organ systems INVESTIGATIONS Hb , TLC, DLC, platelet count Blood sugar Blood urea, S. Creatinine, S. Electrolytes Urine R/M ECG Chest X-ray Blood grouping and cross matching

12. PREOPERATIVE PREPARATION Optimization of pre-existing co-morbid conditions Consideration of ongoing drug therapy Antibiotic prophylaxis (in case of urinary tract infection or urinary obstruction) Arrangement of blood

13. CHOICE OF ANAESTHESIA Regional anaesthesia is the technique of choice for TURP. Advantages of regional over general anaesthesia Detection of early signs of TURP syndrome and bladder perforation Promotes peripheral vasodilation Reduces blood loss Good early post-operative analgesia Reduced incidence of post-operative DVT Neuroendocrine and immune response are better preserved Lower cost.

14. REGIONAL ANAESTHESIA General a naesthesia preferred when regional is contraindicated . Level of sensory block T10 dermatome level – to eliminate discomfort caused by bladder distention

15. MONITORING ECG Blood pressure Pulse oximetry Temperature Mentation Blood loss S. electrolytes (serial) EtCO 2 if GA is used

16. INTRAOPERATIVE CONSIDERATIONS Lithotomy position TURP syndrome Bladder perforation Hypothermia Transient bacterial septicemia Hemorrhage and coagulopathy

17. LITHOTOMY POSITIONING Physiologic changes with lithotomy Decreased FRC Increased venous return on elevation of legs Decreased venous return following lowering of legs Exaggeration of hypotension with SAB P roblems with lithotomy position Injury to nerves Injury to fingers Compression of major vessels at joints Lower extremity Compartment syndrome Aggravation of preexisting lower back pain

18. TURP SYNDROME Rapid absorption of a large-volume irrigation solution. Can occur 15 min after resection or upto 24 hrs postop. Incidence : < 1 % Characterized by intravascular volume shifts and plasma-solute ( osmolarity ) effects: Circulatory overload Water intoxication Hyponatremia Hypoosmolality Hyperglycinemia Hyperammonemia Hemolysis

19. TURP SYNDROME-WATER INTOXICATION Cause : cerebral edema Signs and symp : Somnolence, restlessness, seizures, coma CNS – decerebrate posture, clonus, + ve babinski’s reflex Eyes – papilloedema , dilated and non reactive pupils EEG – low voltage b/l.

20. HYPERVOLEMIA Irrigation fluid enters circulation through open prostatic venous sinuses Average rate – 20ml/min May reach upto 200 ml/min Literature suggests as much as 8 L fluid can be absorbed Average weight gain by end of surgery – 2 kg.

21. MEASUREMENT OF FLUID ABSORPTON Volume absorbed = (preoperative Na + / postoperative Na + ) ECF - ECF Volumetric fluid balance (diff. b/w amt of irrigation fluid used and volume recovered.) Gravimetry (measure rise in body weight) CVP monitoring Breath ethanol measurement Isotopes

22. TURP SYNDROME-HYPONATREMIA Cause : excessive absorption of Na free irrigation fluid During TURP, S.Na falls by 3 to 10 meq /l. SIGNS AND SYMPTOMS OF Acute Hyponatremia Nausea Vomiting Irritability Mental confusion Cardiovascular collapse Pulmonay edema Seizures

23. Manifestations of hyponatremia SERUM Na + ( mEq /l) CNS changes CVS changes ECG Changes 120 Confusion Restlessness Hypotension bradycardia wide QRS complex 115 Somnolence Nausea Cardiac depression Bradycardia Wide QRS complex Elevated ST segment 110 Seizures Coma CHF Ventricular tachycardia or fibrillation

24. TREATMENT serial sodium measurements must be done whenever unexplained changes in BP or cerebral irritation is seen. Infusion of clear fluids should be suspended. Blood loss should be replaced by slow blood transfusion. Loop diuretic – furosemide can be given. For acute hyponatremia with neurological features, rapid correction till neurological improvement is to be done.

25. Na deficit = (DESIRED [NA] - CURRENT [NA]) X 0.6 * Bd WT (KG) (*use 0.6 for men and 0.5 for women). Rate of correction should be 0.6 – 1.0 mEq / L / hr until sodium reaches 125 after that the rate is 1.5 mEq / L / hr. Hypertonic (3%) saline – Contains 514 mEq /L of NaCl . May precipitate P.Edema in presence of cardiac failure. In general, increase of 4-6 mEq /L in serum sodium level is sufficient to arrest progression of symptoms in severe hyponatremia . Further rapid increase in serum sodium level not indicated.

26. TURP SYNDROME-HYPERGLYCINEMIA Glycine is metabolized in liver by oxidative deamination to ammonia and glyoxylic and oxalic acid. Manifestations of glycine toxcity : nausea, headache, malaise, weakness, visual distubances ( transient blindness), seizures, encephalopathy.

27. TURP SYNDROME -HYPERAMMONEMIA

28. TURP SYNDROME – CLINICAL FEATURES System Signs and Symptoms Cause Neurologic Nausea, restlessness, visual disturbances, confusion, somnolence, seizures,coma,death Hyponatremia and hypoosmolality Hyperglycinemia Hyperammonemia Cardiovascular Hypertension, reflex bradycardia , pulmonary edema, CVS collapse Hypotension ECG changes(wide QRS, elevated ST segments, vent arrhythmia) Rapid fluid absorption Third spacing Hyponatremia Respiratory Tachypnea , oxygen desaturation , Pulmonary edema Hematologic Disseminated intravascular hemolysis Hyponatremia and hypoosmolality Renal Renal failure Hypotension, hemolysis , hyperoxaluria Metabolic Acidosis Deamination of glycine

29. TURP SYNDROME - PREVENTION Early diagnosis and prompt treatment Correction of fluid and electrolyte abnormalities preoperatively Cautious adminstration of IV fluids Limitation of hydrostatic pressure of irrigation fluid to 60cm Restrict duration of TURP to 1 hr Bipolar resectoscope Local vasoconstrictors

30. TURP SYNDROME - MANAGEMENT Notify surgeon and terminate surgery. Ensure oxygenation Restrict fluids Intubate and IPPV Bradycardia, hypotension: atropine, adrenergic agents Seizures : BZD, thiopentone , phenytoin, i.v.Mg 2+ Invasive monitoring of arterial and CVP Send blood sample for electrolytes, arterial blood gas analysis.

31. TURP SYNDROME - MANAGEMENT Treat mild symptoms (if S. Na + > 120 mEq /L) with fluid restriction and loop diuretic (furosemide) Treat severe symptoms (if S. Na + <120 mEq /L) with 3% NaCl IV

32. BLADDER PERFORATION Incidence – 1% Causes Trauma by surgical instrument Overdistention of bladder with irrigation fluid Manifestation Early sign : sudden decrease in return of irrigation solution from bladder TYPES- Extraperitoneal perforations Intraperitoneal perforation

33. BLOOD LOSS Difficult to quantify blood loss. Visual estimation of haemorrhage may be difficult due to dilution with irrigation fluid. Usual warning signs (tachycardia, hypotension) masked by overhydration and effects of regional anaesthesia.

34. Blood loss can be estimated on the basis of Resection time (2-5ml/min) Size of prostate (7-20ml/g) No. of open venous sinuses Intraoperative BT should be based on preop Hb , duration and difficulty of resection and clinical assessment of pt condition.

35. COAGULOPATHY Causes of excessive bleeding Dilutional thrombocytopenia DIC as a result of release of prostatic particles rich in thromboplastin into blood Local release of fibrinolytic agents (plasminogen and urokinase ) Treatment – administration of FFP , platelets, blood transfusion

36. HYPOTHERMIA Continuous fluid irrigation causes loss of temp @1 o C/hr. Elderly patients have reduced thermoregulatory capacity. Unintentional hypothermia is asso . with a significantly higher incidence of postoperative MI.

37. Postoperative shivering dislodges clots promotes postoperative bleeding. Monitor body temp maintain normothermia . measures to reduce heat loss warming blankets, heated irrigation solution and warm I/V fluids.

38. BACTEREMIA AND SEPTICEMIA INCIDENCE – 6-7% Causes Release of bacteria from prostatic tissue Preoperative indwelling urinary catheter Preoperative UTI C/F – chills, fever, tachycardia T/T – antibiotic, supportive care

39. POSTOPERATIVE COMPLICATIONS Hypothermia Hypotension Haemorrhage Septicaemia TURP syndrome Bladder spasm Clot retention Deep vein thrombosis Postoperative cognitive impairment

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