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AnAesthetic management of TURP

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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  1. 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

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

  3. 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

  4. 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.

  5. 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.

  6. 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).

  7. 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

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

  9. Premedication • Antibiotics,drugs and benzodiazepines • Anesthesia • Regional / GA

  10. 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 ??

  11. 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

  12. 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

  13. 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

  14. 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

  15. Position – lithotomy

  16. 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.

  17. Irrigation fluid

  18. 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.

  19. 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

  20. TURP syndrome

  21. 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

  22. 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%

  23. 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

  24. 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.

  25. 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

  26. 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

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

  28. In a study of 117 cases.

  29. 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.

  30. 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

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

  32. Indicators of volume gain • Ethanol 1% added to fluid and measurement of breath alcohol level. • Weight gain • Serum sodium • CVP trend etc.

  33. Hyper ammonemia • Possible CNS symptoms • 4 gm of l arginine infused in 3 minutes decreases ammonia • l arginine – 950 mosm / Kg

  34. 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.

  35. 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.

  36. 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

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

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

  39. Bladder perforation • Peri umbilical pain • Hypotension sweating restlessness • Hiccups • Rarely shoulder pain • Spinal identifies

  40. Post operative problems • Pain – not severe .- rare use opioids • Bladder spasm • Clot retention – • precipitate bradycardia • TURP syndrome • Cognition impairment

  41. 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).

  42. 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 ??

  43. Thank you all

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