TURP

Question 1

A 74-year-old man underwent TURP under SA. His pre-op assessment was unremarkable & bloods were normal.
During surgery , prostate was huge & surgeon took about 75 minutes to resect 35 gm of it, there was significant bloodloss even they have reasonable haemostasis. You have been asked to review him in recovery room because of hypotension, restlessness & agitation. You confirmed that then noted that BP was 80/50, HR 125/min & SpO2 87%. No new drugs or IVF given since surgery. The recovery staff are struggling to proceed him to keep his O2 mask on. When you spoke to him, he was severely confused. Urine in catheter bag is dark, but not blood stained. His labs shows Hb 9, haematocrit 34.6%, Na 114 mmol/L & Plasma osmolarity 240 mOsm/kg .

Q1. What’re the possible deferential diagnosis?

Answer 1

1. Post TURP syndrome, cerebrovascular accident, MI, Sepsis, Hypovolemia and hypervolumeia

Question 2

Q2. Why is he agitated & confused?

Answer 2

2. Hepatic encephalopathy due increased ammonia as a metabolite of glycein./ Cerebral Edema due to low Na./ Pulmonary Edema secondary to hyponatremia

Question 3

Q4. Look at the labs given. What do they show? Why?

Answer 3

4. Dilutional hyponatremia. Due to use of glycein which is hypotonic solution absorped in liver and cause water intoxication

Question 3

Q5. What’s the most likely diagnosis? Define it please.

Answer 3

5. Post TURP syndrome; dilutional hypotonic hypovolemia due to use of glycein rich hypotonic irregation solution with direct absorption into circulation leading to sever dilutional hyponatremia.

Question 4

Q3. What’s the cause of hypoxia?

Answer 4

3. Pulmonary Edema secondary to hyponatremia.

Question 5

Q6. What’re the clinical features of post-TURP syndrome?

Answer 5

6. Restlessness, confusion, agitation, features of heart failure and hypoxia.

Question 6

Q7. In general, What’re the mechanisms by which hyponatraemia could be developed ?

Answer 6

7. Depletional , dilutional, endocrine

Question 7

Q8. What causes hyponatraemia in post-TURP syndrome?

Answer 7

8. Dilutional as glycein which hypotonic solution and cause water intoxication.

Question 7

Q9. How to treat this patient with hyponatraemia & BP 80/50?

Answer 7

9. Use of diuretics like mannitol and frusamide. And also giving NaCl

Question 7

Q10. Which diuretics to be used?

Answer 7

10. Osmotic like mannitol and loop like frusamide.

Question 8

Q11. How these diuretics work?

Answer 8

11. Increased osmotic pressure and increase water excretion.

Question 9

Q12. Where should he be kept overnight? Why?

Answer 9

12. ITU, as pt has physiological deranged functions like confusion

Question 10

Q13. What other systemic problems are anticipated in post-TURP syndrome? Why?

Answer 10

13. CVS – > arrhythmia CNS– > seizures and agitation

Question 11

Q14. How to manage post-TURP syndrome if developed intra-op?

Answer 11

14. Stop the operation and stop irregation and start supporting the pt shifting him to ITU

Question 12

Q15. Why he is oliguric?

Answer 12

15. low perfusion which will cause AKI

Question 13

Q16. How to manage fluid overload?

Answer 13

16. stop irregation and CCRISP – > start IV fluids and diuretics and start pt on O2 and

Question 14

Q17 How much is the daily requirement of sodium & potassium?

Answer 14

17. Na 1-2 mequv/l/kg// k–> 0.5-1 meq/l/kg

Question 15

Q18. What to be done to prevent fluid overload recurrence for this patient

Answer 15

18. Admission pt to ITU stop IV fluids and use diuretics. Monitor and report about the case