I_am_sharing_Transurethral_r-WPS_Office-1-1-1_(1)-1_with_you.pptx

Details turp

1. Anaesthesia in transurethral resection of Prostate (TURP)... Prepared by, Dr.Mohammed Moin Uddin Mozomder DA student (2022-24]

2. Guided by Prof.Dr.Satyajit Dhar FCPS, MD Dept.of anesthesiology & ICU Chittagong Medical College & Hosp ital

3. Introduction.... TURP is the 2nd most common procedure in men over 65 years of age. surgical procedure of choice in men with symptomatic bladder outlet obstruction secondary to benign prostatic hyperplasia,cancer or bladder neck contracture. BPH affects 50%of males of 60 years & 90% of 85 year old, so TURP is most commonly performed on elderly patients, a population group with a high incidence of cardiac,respiratory & renal disease. TURP caries unique complications because of the need to use large volume of irrigating fluid for the endoscopic resection.

4. TURP -Procedure ... performed in the lithotomy position using a resectoscope, through which a diathermy loop is passed. The prostatic tissue is resected in small strips under direct vision using diathermy loop. The bladder is continuously irrigated with fluid. Irrigation is continued for upto 24 hours after operation. The procedure usually takes 30-90min.

5. TURP-irrigating solution ... Most commonly used irrigants are hypotonic so that significant absorption of water nevertheless can occur. Irrigation fluid has to be non- haemolytic so that hemolysis does not occur if it enters the circulation. During TURP procedure 20 ml/min irrigant solution is normally absorbed. This is a total of 1- 1.5 liters for the average case. Absorption upto 5 liters has been recorded,In clinical practice it is almost impossible to accurately asses the volume absorbed.

6. Irrigation fluids... Uses.... Distend bladder & prostatic urethra Flushes out blood & tissue debris Improve visibility Characteristic of Ideal irrigation fluid.... Transparent Isotonic Electrically inert Non hemolytic Inexpensive Non metabolizable Rapidly excretable Non toxic,Easy to Sterilise

7. Properties of commonly used irrigating solution

8. Preoperative consideration.... Patients for TURP are frequently elderly with coexistent diseases -Cardiac disease 67%, Abnormal Electrocardiogram (ECG)77%,Chronic Obstructive Pulmonary disease 29%, DM 8%. Long standing urinary obstruction can lead to impaired renal function & chronic urinary infection. About 30% of TURP patients have infected urine preoperatively.

9. Preoperative consideration... Antibiotic prophylaxis is required for patients with a proven urinary tract infection or a potential risk for infection(indwelling catheter). Antihypertensive & Anti anginal drugs should be continued until the day of surgery to prevent rebound HTN & tachycardia. Drugs for Pulmonary disease treatment shuold be continued- routine ECG & chest x-ray should be obtained before surgery,check FBC, electrolytes,creatinine.

10. Preoperative evaluation.... History & examination of all organ system Investigation... Hb%,TLC,platelet count Blood Sugar, blood urea, s.creatinine, S.electrolyte Ecg,chest x-ray Urine R/M Blood grouping & Cross matching

11. Choice of Anaesthesia... Regional or general anesthesia is the technique of choice for TURP. spinal anaesthesia is the anaesthetic technique of choice for patient undergoing TURP. Sensory supply to the bladder is from T10- T12, for a satisfactory anaesthesia, a block to T10 is required. For spinal anaesthesia an appropriate dose of heavy bupivacaine 0.5 % is 3ml, if isobaric bupivacaine 0.5% is used 3-4 ml are suitable. Patients with chronic chest disease tend to cough on lying flat,sedation can help to reduce coughing. In elderly people 1-2 mg midazolam(+Fentanyl 50mcg) is usually adequate. Higher dose may result in loss of airway control, restlessness, confusion.

12. Choice of Anaesthesia.... Advantage of regional over general Anesthesia... Allow monitoring of mentation & early sign of TURP & bladder perforation. Promote peripheral vasodilation & reducing circulatory overload. Reduces blood loss,Requiring fewer transmission. Good early postoperative Analgesia. Reduce incidence of postoperative DVT. lower cost. ★★★ General anesthesia preferred when regional is contraindicate.

13. Regional Anaesthesia.... Techniques.... subarachnoid block Epidural block Caudal block Saddle block Level of sensory block... T10 dermatome level - To eliminate discomfort caused by bladder distention. T9 dermatome level -Enable to elicit capsular sign(pain on perforation of prostatic capsule).

14. Advantage of SAB over epidural anaesthesia... Technically easier to perform Dense motor block No sacral sparing Low incidence of PDFH

15. Pacemaker & anaesthesia for TURP... Pacemaker are devices implanted subcutaneously which provide permanent cardiac pacing. Common indications of pacemaker are... Arrhythmias associated with syncope & heart failure sick sinus syndrome Heart block post MI

16. Anaesthetic considerations during TURP in a patient with pacemakers Preoperatively.... Assessment of cardiovascular function. Presence of a qualified pacemaker consultant during surgery is advisable with backup batteries. ECG (to ensure heart rate is totally pacemaker dependent or not). Chest x-ray (to identify pulse generation & lead position)

17. Intraoperatively... Regional anaesthesia can be safely used in the proposed surgery. Electromagnetic interference (EMI) from surgical electrocautery can suppress pacemaker generator or even change its mode of function. This EMI can be minimized by.. Limiting use of electrocautery using bipolar cautery Use of the lowest Effective power output Placement of patient plate as far away from the pacemaker as possible. Continuous monitoring of arterial pulse wave Anaesthetic considerations during TURP in a patient with pacemakers...

18. Monitoring... ECG Blood pressure Pulse oximetry Temperature Blood loss Mentation ETCO2 if g/a is used

19. TURP intra-operative consideration . Because of the characteristics of the Prostate &the large amount of irrigation fluid often necessary, TURP can be associated with number of complications... TURP syndrome Hemorrhage Bladder perforation Hypothermia Septicemia DIC

20. TURP syndrome... TURP often open the extensive network of venous sinuses in the Prostate, potentially allowing systemic absorption of irrigating fluid. Absorption of large amount of fluid (2 liter or more)result in a constellation of symptoms & sign commonly referred to As the TURP syndrome. Can occur 15 min after resection or upto 24 hours post op. The incidence of TURP syndrome less than 1%.

21. TURP syndrome... Normally about 20 ml/min of irrigation fluid is absorbed (1-1.5 L for the normal case - resection time about 45-60 min).In clinical practice almost impossible to assess accurately the volume absorbed. The amount of absorbed depends upon the following factors... Hydrostatic pressure Venous pressure... more fluid is absorbed if the patient is hypovolemic or hypotensive. Duration of surgery or large Prostate .. If surgery lasting more than an hour or with Prostate weight >50gm.

22. TURP syndrome... Blood loss.... large blood loss implies a large number of veins open. Surgical skills.... most important is preservation of the Prostatic capsule during surgery because violation of the prostatic capsule promote entry of irrigation fluid into the periprostatic & retroperitoneal space. The TURP syndrome consist of pulmonary oedema,cerebral oedema,hyponatremia due to absorption of large amounts of hypotonic irrigation fluid.

23. TURP Syndrome... Cerebral oedema caused by acute Hypo-osmolality can increase intracranial pressure with bradycardia,hypertension & neurological symptoms. when serum sodium level falls to less then 120 mEq/L sign of cardiovascular depression can occur, less then 115 Meq/L causes bradycardia,widening of the QRS complex, ST segment elevation, Ventricular ectopic beats & T wave inversion. A serum sodium level less then 110 Meq/L can cause respiratory & cardiac arrest.

24. Manifestation of TURP syndrome.... Hypoosmolality Hyponatremia Fluid overload Congestive cardiac failure Pulmonary Edema Hypotension Solute toxicity Hyperglycinemia Hyperglycemia(sorbitol) Hyperammonemia Intravascular volume expansion (mannitol)

25. Clinical sign-symptoms of TURP syndrome.... Symptoms in the awake patient... Vertigo,Headache, Nausea or Vomiting Abdominals pain visual disturbance or blurred vision Chest tightness Dyspnoea

26. Clinical sign.... signs will be detected earlier in the awake patient. Confusion /Agitation /Restlessness Altered level of consciousness seizure pupillary dilatation. papilloedema. Cyanosis,oliguria. Widened QRS /ST change on ECG Cardiac arrest In the anaesthetized patient the only clue may be tachycardia & Hypotension. Diagnosis can be confirmed by finding of low serum sodium, An acute fall to <120 meq/L is always symptomatic.

27. Classical triad of TURP syndrome... Hypertension Bradycardia Altered mental status Absorption of TURP irrigation fluid depends on.... Duration of resection The pressure of irrigation fluid

28. TURP syndrome water intoxication.... Cause :cerebral edema Sign-symptome : Somnolence, restlessness, seizure, comma CNS: decrease posture,Clonus,+ve babinski's reflex EYES : papilloedema, dilated & non-reactive pupils EEG : Low voltage

29. TURP syndrome Hyponatremia.... Cause Excessive absorption of Na free irrigation fluid. During TURP S.Na fall by 3 to 10 meq/L Sign & symptoms of Acute Hyponatremia ... Nausea vomiting Irritability Mental confusion Cardiovascular collapse pulmonary edema seizures

30. TURP syndrome Hyperglycemia... Toxicity may also arise from absorption of the glycine in the irrigation fluid. Glycine non essential amino acid, is an inhibitory neurotransmitter in Spinal cord & Retina. Metabolized in liver by oxidative deamination to ammonia & Oxalic acid. When absorbed in large amounts, has direct toxic effects on heart & retina. Manifestation of glycine toxicity... Nausea, headache, Weakness, visual disturbances (Transient blindnesses) Seizures, Encephalopathy.

31. TURP syndrome management... Treatment of TURP syndrome depends on early recognition & should be based on the severity of symptom. If detected intra-operatively bleeding points should be coagulated, surgery terminated as soon as possible & i/v fluid should be stopped. The absorbed water must be eliminated : furosemide 40 mg i/v. Check Arterial blood gas, S.Sodium, HB%

32. .....

33. TURP bladder perforation... The incidence of bladder perforation during TURP is about 1% Perforation mostly occurs in trauma by surgical instrument, overdistension of bladder with irrigation fluid. Manifestation… Early sign: sudden decrease in return of irrigation solution from bladder. Extra-peritoneal perforations :pain in periumbilical, inguinal & suprapubic region. Intraperitoneal : generalized abdominal pain,shoulder tip pain,abdominal rigidity.

34. TURP syndrome prevention.... Early diagnosis & start treatment. Correction of fluid & electrolyte abnormality preoperatively. Cautious administration of IV fluids. Limitation of hydrostatic pressure Of irrigation fluid to 60cm. Restrict duration of TURP to 1 hour. Bipolar resectoscope. Vaporization methods. Local vasoconstrictors.

35. Postoperative complications Hypothermia Hypotension Hemorrhage Septicemia TURP syndrome Bladder spasm Clot retention DVT Postoperative cognitive impairment

36. TURP summary.... TURP is common operation performed in an elderly population with many comorbidities. The main challenges are blood loss & TURP syndrome due to excessive absorption of irrigation solution. Spinal anaesthesia is the anaesthetic technique of choice, it allows to recognise early signs of TURP & bladder perforation. Treat Hypotension associated with spinal anaesthesia with vasopressors rather than large amounts of iv crystalloid solution.