ANAESTHETIC MANAGEMENT OF TURP Dr S Parthasarathy MD

ANAESTHETIC MANAGEMENT OF TURP Dr. S. Parthasarathy MD. , DA. , DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics Ph. D. (physiology) Mahatma Gandhi medical college and research institute , puducherry – India

HOW COMMON ? ? • Approximately 40 000 transurethral resections • of the prostate (TURP) are performed annually • in the UK. • In pondicherry • 60 – 70 / month

PROSTATE NERVE SUPPLY • The prostate and prostatic urethra receive sympathetic and parasympathetic supply from the prostatic plexus arising from the pelvic parasympathetic plexus, which is joined by the hypogastric plexus

NERVE AND BLOOD • Pain from prostate – sacral nerves S 2 – S 4 • But bladder distension – sympathetic – T 11 – L 2 • It has a rich blood supply and venous drainage is via the large, thin-walled sinuses adjacent to the capsule.

PROCEDURE • The operation is performed through a modified cystoscope • • Prostatic tissue is resected using an electrically energized wire loop. • • Bleeding controlled coagulation current. • • Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue.

PREOP - SYSTEMIC ILLNESS • • • Age – 69 Diabetes, musculo skeletal , Neuro, renal CVS GI , COPD , airway • Occasionly patients are dehydrated and depleted of essential electrolytes (long-term diuretic therapy and restricted fluid intake).

PREOP EVALUATION • Lab investigations , ECG , Cx. R • Urine analysis – infection • Antibiotic prophylaxis • Blood gases, echo if needed • Blood grouping – remember 6 % • Anemia large glands > 40 G

DRUGS • antihypertensive and antianginal drugs should be continued until the day of surgery. • Beta blockers • ACE inhibitors • Bronchodilators • Anti diabetic drugs • Warfarin

PREMEDICATION • Antibiotics, drugs and benzodiazepines • Anesthesia • Regional / GA

ANESTHESIA • Spinal anaesthesia is regarded as the technique of choice for TURP • 2. 5– 3. 0 ml of 0. 5% plain or hyperbaric bupivacaine may be used. • Level T 10 • Why ? ? - bladder, capsular sign !! • Why spinal ? ?

FOR SPINAL • for patients with significant respiratory disease. • good postoperative analgesia , blood loss less • may reduce the stress response to surgery. • spinal anaesthesia allows the anaesthetist to monitor the patient’s level of consciousness, which makes it easier to detect the early signs of TURP syndrome. • Early recognition of capsular tears and bladder perforation is also possible

TIPS ABOUT SPINAL • Intraoperative fluid overload less • DVT less • Use vasopressors for hypotension – add fentanyl. • Technically easy than epidural • Sacral sparing – no • USE NS than RL – more osmolar and more sodium • Warm IVF •

GENERAL ANAESTHESIA • Contraindication to spinal • Cant lie down for longer times • Cough during lying down. • ETT or proseal LMA • Dilutional hyponatremia – prolong NM blockers • Post op caudal • Rarely done under LA

LITHOTOMY • Significant amount of intravascular volume is added to the central circulation. • Perfusion pressure of lower extremities = 10 – 15 mm. Hg – compression – compartment syndrome • Nerve compressions • Respiratory changes

POSITION – LITHOTOMY

IT CAN HAPPEN !! • Under light planes of general anesthesia, penile erection may interfere with surgery. • It can usually be managed by deepening anesthesia. • Spinal anesthesia does not always prevent this complication.

Irrigation fluid

THE IDEAL IRRIGATION FLUID • is transparent (for good visibility), • electrically non-conductive (to prevent dispersion of the diathermy current), • isotonic, non-toxic • non-haemolytic when absorbed, • easy to sterilize, inexpensive. • However, no solution fulfils all of these criteria.

SOLUTIONS- OSM. ADV. AND DISADV. • Distilled water 0 visible but hemolysis • Glycine (1. 5% - 2%) 200 visual • Sorbitol (3%) diuresis • Mannitol (5%) 165 275 • Glucose( 2. 5%) 140 • Urea ( 1%) 167 hyperglycemia, diuresis, overload hyperglycemia

TURP SYNDROME

DEFINITION • Constellation of some symptoms , signs • excessive absorption of irrigating solution • Direct intravascular access • Thro perivascular spaces • Changes in volume, electrolytes, osmolarily • Asymptomatic hyponatremia has been • observed in 50% of patients undergoing TURP

HOW MUCH AND WHEN • 1– 8% • 15 minutes to after 24 hours • Direct vascular or bladder rupture and absorption • Mortality around 0. 2% - 0. 8%

CLINICAL FEATURES • Acute fluid overload --- hypertension and reflex bradycardia • Later on equilibration from ECF, hypotension and hypovolumia • Sympathetic block of spinal • Can precipitate pulmonary edema

CLINICAL FEATURES • When glycine 1. 5% is used as the irrigation fluid, early features restlessness, headache, and tachypnoea, • or a burning sensation in the face and hands. • Visual disturbance including transient blindness • increasing severity include respiratory distress, hypoxia, pulmonary oedema,

HYPOOSMOLALITY • Hypoosmolality is more important than hyponatremia • 2[Na+] + [Glucose]/18 + [ BUN ]/2. 8 • Effective pore size of BBB is 8 A – permeable to water than sodium

HOW MUCH FLUID • 8 L of irrigation solution can be absorbed by the patient during TURP. • The average rate of absorption is 20 m. L per minute may reach 200 m. L per minute; • the average weight gain by the end of surgery is 2 kg • Ethanol 1%, electrolytes (Mg). CVP etc – volume absorbed

FACTORS • Hypotensive, hypovolumic – more • Capsule perforation – more • Resection time • Fluid bag , 30 cm from operating table height • Blood loss • Large prostate (>50 G)

IN A STUDY OF 117 CASES.

GLYCINE • Nonessential amino acid • NMDA receptor activity is potentiated by glycine • Metabolized to gly oxalic acid and ammonia • Ammonia – transient blindness • Oxalate – precipitation of renal failure • Redistributed in 6 min • Half life 40 min to a few hours. • Normal plasma levels 13 - 17 mg/l.

WHAT MEANS TURP SYNDROME IN GA ? ? • in the anaesthetized patient the only clue may be tachycardia and hypertension. • • diagnosis can be confirmed by finding a low serum sodium. • An acute fall to < 120 m. Eq/L is always symptomatic. • Osmolarity more important than sodium

SERUM SODIUM • 120 - confusion – wide QRS • 115 – somnolence , nausea – st elevation + T inv. • 110 seizures , coma – V tach

INDICATORS OF VOLUME GAIN • Ethanol 1% added to fluid and measurement of breath alcohol level. • Weight gain • Serum sodium • CVP trend etc.

HYPER AMMONEMIA • Possible CNS symptoms • 4 gm of l arginine infused in 3 minutes decreases ammonia • l arginine – 950 mosm / Kg

MANAGEMENT OF TURP SYNDROME • Stop surgery • Oxygen, ventilation, inotropes anticonvulsants diuretics • Invasive monitors in selected cases. • exerts a negative control on the NMDA receptor and also having a membrane-stabilizing effect, and magnesium therapy should be considered as part of therapy for seizures in TURP syndrome.

INVESTIGATIONS • Blood , BUN, glucose , ABG , electrolytes • CXR, ECG, Hematocrit • Severe cases of symptomatic hyponatremia • 3 % hypertonic saline 2 * 0. 6 * Weight • 2 *42 = 84 ml of 3% hypertonic saline – I meq. / l • I F we correct fast – • Osmotic demyelination syndrome.

INTRAOPERATIVE • Myocardial ischaemia - can occur in up to 25% of patients during TURP, with myocardial infarction occurring in 1 -3% • Hypothermia. . Warmed irrigation fluid has NOT been shown to increase blood loss by local vasodilation. • warm i. v. fluids, active patient warming devices. • • Perforation of prostatic capsule, urethra or bladder with the resectoscope. • • Bleeding

BLOOD LOSS • blood loss should lie within the range of 7 -20 ml per gram of resected tissue. • Or • 2 - 5 ml / minute

FACTORS - 1 % • Large gland • Time , Infection • Pre op catheter • TRANEXAMIC ACID 15 MG / KG - useful • Prostate can release thromboplastin to cause fibrinolysis. -- EACA

BLADDER PERFORATION • Peri umbilical pain • Hypotension sweating restlessness • Hiccups • Rarely shoulder pain • Spinal identifies

POST OPERATIVE PROBLEMS • Pain – not severe. - rare use opioids • Bladder spasm • Clot retention – • precipitate bradycardia • TURP syndrome • Cognition impairment

DVT AND PE • compression stockings are usually adequate as prophylaxis. • Low-molecular-weight heparin should be considered in patients at higher risk • (poor mobility, malignancy, inter current illness, and obesity).

SUMMARY - TURP • High number • Preop disease , antibiotics • spinal , level, Position ( GA / LA) • TURP syndrome – irrigation fluid 20 ml/ min. , factors • Hypoosmolarity – NS , inotropes, stop surgery • Blood loss, perforation bladder • Pain ? ?

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