Makindo Medical Notes.com

Related Subjects: |Sodium Physiology |Hyponatraemia |TURP Hyponatraemia syndrome |Hypernatraemia |Diabetes Insipidus |Benign Prostatic Hyperplasia |Prostate Cancer

Transurethral resection (TUR) syndrome is an iatrogenic form of water intoxication, a combination of fluid overload and hyponatremia due to absorption of Large volumes of hypotonic irrigation fluid (e.g., glycine, sorbitol, mannitol) are used during TURP to maintain a clear surgical field. A sudden drop in Na leads to progressive cerebral oedema with cell swelling and dysfunction.

About

• A cause of acute hyponatraemia post TURP
• A medical emergency in a surgical patient
• Absorption of the irrigation fluid (2000 ml or more)

Aetiology

• Transurethral resection of the prostate involves removal of prostatic tissue by means of electrocautery.
• Irrigation solution is used to distend the bladder, clear the surgical site, and remove blood and resected tissue.
• Normal saline cannot be used as it conducts electric current and would be dangerous to both, surgeon and patient.
• Distilled water does not conduct but causes hyponatraemia, intravascular haemolysis, and hyperkalaemia
• Subsequent haemoglobin precipitation in the renal tubules causes acute renal failure.
• In practice glycine is used which has a osmolarity of 200 mOsml/L Normal is 275-285. The result is a sudden water overload resulting in dilutional hyponatraemia

Prevention

• Use isotonic irrigation fluids instead of hypotonic solutions whenever possible.
• Limit the duration of the TURP procedure to reduce the risk of significant fluid absorption.
• Monitor fluid balance and electrolyte levels closely during and after the procedure.
• Train surgical and anaesthesia teams to recognize and manage early signs of TURP syndrome.

Clinical

• Transient prickling and burning sensations in the face and the neck together with lethargy and apprehension
• Patient may become restless and complain of a headache
• Confusion, Seizure, Coma, Bradycardia and arterial hypotension
• These come on during or in the hours post-surgery
• Progressive coma and seizures

Investigations

• U&E shows low sodium = 120 mmol/L
• Plasma osmolality reduced

Management

• ABC. Oxygen. Central pontine myelinolysis is a potential complication.
• Stop the fluids and the surgery if perioperative. Monitor sodium.
• Consider 3% N-saline with Furosemide to cause diuresis often about 500 ml to 1 L of 3% in 24 hrs
• Correct the hyponatremia slowly but sufficiently to avoid hyponatraemic symptoms
• Intensive care unit (ICU) admission for severe cases.

Review

• Transurethral Resection of the Prostate Syndrome: Almost Gone but Not Forgotten