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Early recognition of the two cases of TURP syndrome in patients receiving spinal anaesthesia.

One of the feared complications of transurethral resection of the prostate (TURP) is the absorption of irrigation fluid causing the 'TURP syndrome'. The reported incidence of clinically detectable TURP syndrome is 2% (1). It can have a number of manifestations, affecting the cardiopulmonary system (secondary to volume overload) or central nervous system (secondary to changes in osmolality). Although it is classically associated with hyponatraemia, it can also cause hyperglycinaemia, hyperammonaemia or simply hypo-osmolality, depending on the irrigation fluid being used. One way by which absorption can be calculated is by using ethanol in the irrigation fluid and then measuring patients' expired alcohol levels'. In practice this is seldom used. A rough estimate can be obtained from measuring the balance of irrigation fluid in and out. New surgical techniques using saline as the irrigation fluid or vaporizing rather than resecting the prostate are becoming commercially available and may reduce the incidence of TURP syndrome but are not yet in common use (4,5).

At present, the most widely recommended anaesthetic technique for TURP is spinal anaesthesia, because in theory it is easier to detect signs of fluid overload and central nervous system symptoms in an awake patient. We have recently experienced two cases of clinically significant TURP syndrome, which demonstrate the advantages of this technique.

The first case was a 75-year-old man, ASA PS II, with a history of hypertension. He received a spinal anaesthetic for TURP At no time during the procedure were any sedatives given and verbal contact with the patient was maintained throughout. Forty-five minutes into the procedure the patient stated that he had a headache. It was not severe in nature and was attributed by the patient to stress. He then mentioned that his vision had become blurred. The procedure finished and he was transferred to recovery where he stated that he had some central dull chest pain. His blood test results showed haemoglobin of 121 [g.l.sup.-1] and a sodium level of 118 [mmol.l.sup.-1]. Preoperative sodium had been 143 [mmol.l.sup.-1]. A twelve lead ECG was taken to rule out acute myocardial infarct. Some minutes later he had a self-terminating 30-second tonic clonic seizure. The patient was subsequently transferred to a high dependency unit where he was treated with hypertonic saline and made an uneventful recovery.

The second case was an 83-year-old man who was classified as ASA PS III. He underwent spinal anaesthesia for TURP The patient received one single dose of propofol (30 mg) at the start of surgery, thereafter no other sedatives were administered. He remained lucid and able to verbalize throughout. After approximately 1 hour he became hypotensive. This coincided with some surgical bleeding. The patient then showed signs of confusion, discomfort and restlessness. The haemoglobin level was found to be 105 [gl.sup.-1] (preoperative 138 [gl.sup.-1]). An arterial blood gas revealed a sodium level of 122 [mmol.l.sup.-1] compared with his pre-operative sodium of 147 [mmol.l.sup.-1]. In order to allow the procedure to finish the patient was intubated and ventilated. He was then transferred to an intensive care unit, where he was extubated four hours later. He made a good recovery and returned to the ward next morning.

The above presentations are classical, but others include hypertension, bradycardia, dysrhythmias, nausea and vomiting or lethargy. The absorption of irrigation fluid is believed to be increased by several factors (pressurized irrigation fluid, hypovolaemic patient, long duration of surgery/large prostate, large blood loss (implies large number of veins open)). By paying close attention to these factors and trying to prevent them, one should be able to minimize the incidence of TURP syndrome.

We were able to diagnose the TURP syndrome early, as both patients were awake and receiving spinal anaesthesia. The earliest signs of TURP syndrome under general anaesthesia appear to be cardiorespiratory, such as desaturation and ECG changes (5).

If the serum sodium is < 120 [mmol.l.sup.-1] one can consider treatment with hypertonic saline to reverse neurological symptoms. The rate of correction should not exceed 12 [mmol.l.sup.-1] in the first 24 hours in order to avoid brain oedema.

Our two cases are a reminder that TURP syndrome still occurs and that we should always have a high index of suspicion, especially if the patients are under general anaesthesia. An awake, even lightly sedated patient under spinal anaesthesia allows early detection of TURP syndrome and prompt treatment, which may be obscured by general anaesthesia. The syndrome can cause serious morbidity and even mortality. The outcomes in our cases might have been less favourable if general anaesthesia had been used.

References

(1.) Okeke AA, Lodge R, Hinchliffe A, Walker A, Dickerson D, Gillatt DA. Ethanol-glycine irrigating fluid for transurethral resection of the prostate in practice. Br J Urol 2000; 86:43-46.

(2.) Hulthen JO. How to master absorption during transurethral resection of the prostate: basic measures guided by the ethanol method. Br J Urol 2002; 90:244-247.

(3.) Issa MM, Young MR, Bullock AR, Bouet R, Petros JA. Dilutional hyponatraemia of TURP syndrome: A historical event in the 211, century. Urology 2004; 64:298-301.

(4.) Gray RA, Moores AH, Hehir M, Worsley M. Transurethral vaporisation of the prostate and irrigating fluid absorption. Anaesthesia 2003; 58:787.

(5.) Kluger MT, Szekely SM, Singleton RJ, Helps SC. Crisis management during anaesthesia: water intoxication. Quality Safety Health Care 2005; 14:E23.

T. SHAH

P. FLISBERG

Department Anaesthesia and Pain Medicine,

Royal Perth Hospital,

Perth, Western Australia
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Title Annotation:CORRESPONDENCE
Author:Shah, T.; Flisberg, P.
Publication:Anaesthesia and Intensive Care
Date:Aug 1, 2006
Words:919
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