Anaesthetic management of turp
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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

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AnAesthetic management of TURP

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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 hypogastricplexus


Nerve and blood

  • Pain from prostate – sacral nerves S2 –S4

  • But bladder distension – sympathetic – T11 – 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 ,CxR

  • 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

  • Dilutionalhyponatremia – 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 mmHg – 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%) 165 hyperglycemia, diuresis

  • Mannitol (5%) 275 diuresis, overload

  • Glucose( 2.5%) 140 hyperglycemia

  • Urea ( 1%) 167


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, nausea, vomiting, confusion, convulsions, and coma.


Hypoosmolality

  • Hypoosmolalityis 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 mL per minute may reach 200 mL 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 mEq/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 the 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 ??


Thank you all


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