1. 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 ANAESTHETIC MANAGEMENT OF TURP

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

3. 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 hypogastric plexus PROSTATE NERVE SUPPLY

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. 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. PROCEDURE

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 Dilutional hyponatremia – 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

17. 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.

18. Irrigation fluid

19. 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.

20. 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

21. TURP SYNDROME

22. 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

23. 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%

24. 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

25. 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.

26. HYPOOSMOLALITY Hypoosmolality is more important than hyponatremia 2[Na+] + [Glucose]/18 + [ BUN ]/2.8 Effective pore size of BBB is 8 A – permeable to water than sodium

27. 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

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

29. IN A STUDY OF 117 CASES.

30. 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.

31. 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

32. SERUM SODIUM 120 - confusion – wide QRS 115 – somnolence, nausea – st elevation + T inv. 110 seizures, coma – V tach

33. INDICATORS OF VOLUME GAIN Ethanol 1% added to fluid and measurement of breath alcohol level. Weight gain Serum sodium CVP trend etc.

34. HYPER AMMONEMIA Possible CNS symptoms 4 gm of l arginine infused in 3 minutes decreases ammonia l arginine – 950 mosm / Kg

35. 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.

36. 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.

37. 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

38. BLOOD LOSS blood loss should lie within the range of 7-20 ml per gram of resected tissue. Or 2 - 5 ml / minute

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

40. BLADDER PERFORATION Peri umbilical pain Hypotension sweating restlessness Hiccups Rarely shoulder pain Spinal identifies

41. POST OPERATIVE PROBLEMS Pain – not severe.- rare use opioids Bladder spasm Clot retention – precipitate bradycardia TURP syndrome Cognition impairment

42. 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).

43. 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 ??

44. THANK YOU ALL