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Treatment of the TUR syndrome
- Robert G Hahn (13 February 2006)
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Hypotension in TURP syndrome
- Mahindra G Chincholkar (10 February 2006)
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Prevention is better than cure
- Dr Snehal Ramnath Kumbhare (17 January 2006)
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Robert G Hahn, Professor of Anaesthesia Karolinska Institute, Stockholm
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Dear Collegaues, I appreciate your interest in my review article. I`ll try to stimulate the debate by commenting on your points. I agree with Dr. Kumbhare in that elderly people are susceptible to complications of fluid overload, and more so than younger patients. The dependence of fluid absorption on patient positioning is one of several points that had to be dropped when adjusting this article to the normal length of a BJA review - quite much of the original text needed to be deleted. During TURP, one primarily give intravenous fluid in proportion to the blood loss, while the administration should be transiently reduced when fluid absorption occurs in order to limit the acute strain of the volume overload on the cardiovascular system. For this purpose, one must monitor the both the fluid absorption and the blood loss more or less continuously. Such methods are available at low cost. With regard to Dr Chincholkar´s letter; hypertonic mannitol was successfully used in the Drinker´s study to treat the TUR syndrome in the dog (reference 21) and by Crowley´s group to treat mild symptoms and laboratory values after moderately severe fluid absorption after TURP (reference 17). It was also used by Dr. Lehman in a study with many disastrous TUR syndromes from 1966 (see the additional references on the BJA website). Apart from these studies, little is to be found in the literature about mannitol as a remedy for fluid absorption. The documentation of hypertonic saline used for this purpose is very much better, both in animals and patients, and the studies are stronger. Moreover, reports of cerebral damage has been a small issue when treating acute hyponatraemia with hypertonic saline, this issue being more critical in chronic hyponatraemia. Although several hypertonic fluids could possibly work well, my private objection to mannitol, in addition to the relatively limited documentation, is that it dilutes the serum sodium level even further, resulting in an increased risk of epileptic seizures. As hopefully being apparent from the review article, I am critical to the widespread recommendation of providing furosemide as the sole treatment of fluid absorption. This is based solely on belief and not on scientific evidence. Conflict of Interest:None declared |
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Mahindra G Chincholkar, Anaesthetist Royal Victoria Infirmary, Newcastle
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I read the review article on fluid absorption during endoscopic surgery, with great interest.1 The author has obviously made a great effort to explain the pathophysiology of this phenomenon. However the treatment of hypotension due to relative hypovolaemia is still not clear. The author states that primary indication of intravenous frusemide is to combat acute pulmonary oedema and in other situations, the best practice is to withhold this until the patient is haemodynamically stable and hypertonic saline is infused. Presumably, the continued increased flow of fluid from the plasma to the interstitial space coupled with natriuresis, promote hypovolaemia and hypotension.1, 2 Does this imply that hypertonic saline should be used for the treatment of hypotension? Certainly, the routine use of hypertonic saline is fraught with dangers, in particular, the risk of central pontine myelinolysis. Normal saline can be used for treatment of hypotension due to hypovolaemia. This will result in the administration of excess free water, but this can be ameliorated by the administration of a diuretic. The author has not made any reference to the use of mannitol for treatment of TURP syndrome. It has been shown to be an effective alternative to frusemide in inducing diuresis after prostatectomy, with a lesser sodium loss and a lesser need for postoperative volume loading.3 Hypotension, probably can be safely managed with colloids, inotropes and mannitol. 1.Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth 2006; 96: 8-20 2.Hahn RG. Fluid and electrolyte dynamics during development of TURP syndrome. Br J Urol. 1990 ; 66: 79-84 3.Crowley K, Clarkson K, Hannon V, McShane A, Kelly DG. Duretics after transurethral prostatectomy: a double-blind controlled trial comparing frusemide and mannitol. Br J Anaesth 1990 ; 65: 337-41 Conflict of Interest:None declared |
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Dr Snehal Ramnath Kumbhare, Clinical Attachment in Anaesthetics Huddersfield Royal Infirmary
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I found this article on fluid absorption in endoscopic surgery very interesting and knowledgeable covering almost all aspects associated with fluid absorption. As correctly mentioned in the article prevention is better than cure so precautions should be taken to avoid complications of excessive fluid absorption. There are certain factors which are worth considering while taking precautions. As we know patients undergoing transurethral resection of prostate(TURP), tran cervical resection of the endometrium(TCRE),or TUR of bladder tumours are usually old patients. The functional capacity of organs reduces with ageing, resulting in decreased reserve and ability to endure stress. Co- existing disease further depresses organ function and/or reserve, exacerbating risk. (1) Renal function deteriorates with age with reduction in renal plasma flow, glomerular filtration rate, and altered renal tubular function. The renal ability to balance sodium and water is impaired in elderly patients as a result of low plasma renin activity, urinary and blood aldosterone levels, and decreased response to ADH.Fluid replacement should be controlled within normal maintenance levels.(2) Therefore in the presence of cardiac or renal disease, i.v. fluids should be cautiously administered in elderly patients undergoing endoscopic surgery to prevent complications like TURP syndrome (1) As shown in various studies the absorption of irrigation fluid during TURP is determined primarily by hydrostatic pressure in the bladder and prostatic venous pressure.This hydrostatic pressure above which fluid is absorbed also depends on positioning of the patient. In the Trendelenburg (20 degrees) position it was 0.25 kPa (approximately equal to 2.5 cmH2O), increasing to 1.25 kPa in the horizontal and 1.75 kPa in the half-sitting (20 degrees) position (3) References: 1.F. Jin and F. Chung Minimizing perioperative adverse events in the elderly Br. J. Anaesth., Oct 2001; 87: 608 – 624 2.Smith HS, Lumb PD Perioperative management of fluid and blood replacement In: McLeskey CH, ed. Geriatric Anesthesiology. Williams & Wilkins, 1997; 311–24 3.Department of Anaesthesiology, Medical University, Luebeck, Germany Prevention of irrigating fluid absorption during transurethral resection of the prostate Scand J Urol Nephrol Suppl. 1984;82:1-80 PMID: 6207590 Conflict of Interest:None declared |
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