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PATIENT SAFETY

Transurethral Resection Syndrome Detected and Managed Using Transesophageal Doppler

Patrick Schober, MD^*, Eric J.H. Meuleman, PhD, Christa Boer, PhD^*, Stephan A. Loer, PhD^*, and Lothar A. Schwarte, PhD, DESA, EDIC^*

From the Departments of *Anesthesiology, and Urology, VU University Medical Center, Amsterdam, The Netherlands.

Address correspondence to and reprint requests to Lothar A. Schwarte, MD, PhD, DESA, EDIC, Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands. Address e-mail to L.Schwarte{at}vumc.nl.

Abstract

Transurethral resection syndrome during transurethral resection of the prostate (TURP) results from excessive absorption of electrolyte-free irrigation fluids causing acute hypervolemia and hyponatremia. Neuraxial anesthesia is often recommended for TURP procedures because early signs of neurological deterioration can be detected. However, in patients requiring general anesthesia, other continuous and noninvasive measures are needed. Acute intravascular hypervolemia should be reflected by changes in hemodynamic values. Transesophageal Doppler ultrasonography of the aorta allows determination of stroke volume and other advanced hemodynamic variables related to intravascular volume status. We describe the first case of intraoperative detection of a TURP syndrome by noninvasive Doppler monitoring of hemodynamic variables during TURP.

Transurethral resection syndrome during transurethral resection of the prostate (TURP) is a systemic complication1,2 caused by excessive absorption of electrolyte-free irrigation fluids.3 This syndrome is characterized by hypervolemia and hyponatremia,4 the latter reported to occur in up to 41% of TURP procedures.5 Such a complication may potentially cause cerebral and pulmonary edema, cardiovascular compromise, and death.6 Spinal anesthesia is frequently recommended for TURP procedures, allowing early detection of neurological deterioration. However, in patients requiring general anesthesia, this clinical evaluation is impossible and therefore other measures are needed for an early recognition of TURP syndrome. In clinical practice, serial determinations of serum sodium concentration [Na⁺] are performed to detect and estimate fluid absorption. However, this method is invasive, not continuous, and must be applied both early and frequently. Thus, a continuous and noninvasive method is desirable.

Acute intravascular hypervolemia should be reflected by changes in hemodynamic values. Central venous4,7 and pulmonary artery catheters are invasive and may even be rather insensitive.3 Therefore, a continuous and noninvasive hemodynamic monitoring technique would be beneficial. In the case presented here, transesophageal Doppler (TED) ultrasonography of the descending aorta allowed us to determine stroke volume, cardiac output,8 and other advanced hemodynamic variables related to intravascular volume status.9 This is the first report of intraoperative detection of a TURP syndrome by noninvasive TED-monitoring of hemodynamic variables during TURP under general anesthesia.

CASE REPORT

A 75-year-old, ASA class 1 patient (60 kg bodyweight, 165 cm height, no medication or coexisting diseases) was scheduled for combined repeat-TURP and cystolithotripsy. Previously, the patient had undergone TURP procedures uneventfully. The current procedure was performed under general anesthesia upon the patient's request, because an earlier TURP operation under spinal anesthesia had been an unpleasant experience. Anesthesia was induced and maintained with propofol (200 mg bolus, followed by 8–10 mg · kg^–1 · h^–1) and sufentanil (20 µg initially, supplemented as required). Endotracheal intubation was facilitated with rocuronium (40 mg), and subsequent mechanical ventilation was adjusted to maintain normoxemia (Spo₂ >96%) and normocapnia (ETco₂ 35–45 mm Hg).

In addition to standard monitoring, a TED probe (diameter 6 mm, Fig. 1) was inserted via the right nostril (CardioQ, Deltex Medical). This was done because we are currently introducing the TED system in our institution and started to define indication guidelines for its use in several surgical specialties. We routinely inserted the TED probe in several groups of patients undergoing general anesthesia, mainly patients in whom we expected larger intravascular volume shifts due to blood loss, third space loss, or due to fluid absorption, as in the case presented. Correct insertion depth and orientation of the TED probe towards the descending aorta were confirmed by optical and acoustical online analysis of TED-signal quality. The data were stored electronically for later analysis.

View larger version (111K): [in this window] [in a new window]   Figure 1. Photography of the transesophageal Doppler (TED) probe used in the presented case. Note the high flexibility and the diameter of the probe (6 mm).

Calculated preoperative fluid deficits (approximately 1000 mL) were replaced with isotonic crystalloids (lactated Ringer's solution; 500 mL) and colloids (hydroxyethyl starch 6%, Voluven; 500 mL). This fluid load was associated with both an increased stroke volume (from 57 to 82 mL) and cardiac output (from 3.2 to 4.7 L/min). Furthermore, the TED-derived flow time (FTc, flow time corrected for heart rate), a variable of intravascular volume status,9 showed an adequate volume responsiveness (+10%, from 328 to 361 ms).

Surgery, using a sorbitol-containing irrigation fluid (Sorbitol 5%, Baxter; bag placed 60 cm above the patient), initially proceeded uneventfully with stable hemodynamics both in standard and TED-derived variables. After 60 min of surgery, an increase in stroke volume (over 20 minutes to 114 mL) and cardiac output (to 7.2 L/min) alerted us to inform the surgeons of suspected TURP syndrome (Fig. 2). Compatible with acute, intravascular hypervolemia, a rapid increase in the TED-derived flow time (FTc) from 328 to 399 ms was measured (Fig. 2). The suspected TURP syndrome was subsequently confirmed by an immediately sampled venous blood analysis, revealing a marked decrease in serum [Na⁺] from 142 to 118 mmol/L (Table 1).

View larger version (39K): [in this window] [in a new window]   Figure 2. Representative transesophageal Doppler (TED) traces of the descending aorta during baseline conditions before (A) and during transurethral resection of the prostate syndrome (B). The x-axis represents the time axis, the y-axis the Doppler velocity in cm/s. The horizontal solid white line represents the zero flow mark. The area under the solid gray curve (AUC) represents aortic blood flow per cardiac beat. Note that both peak velocity (i.e., curve amplitude) and aortic blood flow per cardiac beat (AUC) are markedly increased during transurethral resection of the prostate syndrome (B).

This hyperdynamic circulation was associated with decreased arterial blood pressure (approximately 90/60 mmHg, heart rate 62/min) and calculated systemic vascular resistance. Consistent with decreased systemic vascular resistance, a marked increase in TED-derived mean systolic blood flow acceleration (from 4.8 to 6.6 cm/s²) and peak velocity (from 43 to 64 cm/s, Fig. 2) was measured.9 To restore systemic vascular resistance and arterial blood pressure, phenylephrine (2 x 100 µg) and ephedrine (2 x 5 mg) were administered.

Simultaneously, to treat the hypotonic hypervolemia, diuresis was stimulated (furosemide, 20 mg) and hypertonic saline solution (500 mL NaCl 1.5% over 30 min) was administered to replace urinary volume loss. This treatment prevented further deterioration of serum electrolytes, confirmed by a [Na⁺] of 118 mmol/L 20 min after initiation of therapy. After termination of surgery (total operation time 67 min) and the propofol infusion, the patient did not regain consciousness, protective airway reflexes, or spontaneous ventilation. Moreover, administration of anesthesia reversal drugs, flumazenil (0.5 mg) and physostigmine (2.0 mg), was unsuccessful. Twenty-five minutes after discontinuation of the propofol infusion, the patient was transferred sedated and ventilated to the postanesthesia care unit (PACU) for further therapy. His neurologic impairment was attributed to TURP syndrome. The TED probe was left in place for hemodynamic monitoring. Conventional calculation of fluid balance was difficult because of large volume shifts caused by furosemide-induced diuresis, bladder flushing, and hypertonic saline infusion. In this specific situation, TED aided volume management, resulting in a total infusion of 1000 mL NaCl 1.5%, 500 mL NaCl 0.9%, and 1000 mL hydroxyethyl starch 6% in 0.9% NaCl. During the first 3 postoperative hours, his cardiac output gradually normalized from 7.2 to 4.0 L/min and stroke volume from 114 to 81 mL. Additionally, restoration of TED-derived flow time from 399 to 377 ms was achieved. At the same time, the TED-derived systolic peak velocity also returned to near baseline values.

The patient gradually regained consciousness, and was tracheally extubated uneventfully 4 h after surgery. With the TED probe in place, the fully awake patient was monitored for hemodynamic stability until discharge from the PACU (Table 1 contains the course of venous blood values during PACU therapy and after PACU discharge).

The patient remained hemodynamically and neurologically stable for the remainder of his hospital stay and was discharged on the second postoperative day.

DISCUSSION

This is the first case of a human TURP syndrome in which continuous cardiac output measurement by TED is reported. Cardiac output measurement, combined with the other presented TED-derived variables, allowed both early detection and facilitated subsequent therapy. TURP syndromes are initiated by excessive absorption of irrigation fluid, causing intravascular hypervolemia and hyponatremia.3 Thus, early detection of hypervolemia (and associated hemodynamic changes) appears promising to rapidly identify developing TURP syndrome. Continuous and noninvasive methods are desirable, with TED meeting both demands.

The TED technique provides high validity, demonstrating good clinical agreement with cardiac output changes as measured by pulmonary artery catheter thermodilution.10 TED has already been widely used intraoperatively, especially to optimize perioperative fluid management.11–13 Modern TED probes, as used in the presented case, are small and highly flexible,9 allowing the probes to remain in place even during patient transfer (Fig. 1). Insertion of TED probes is simple and no complications from these probes have been reported. Contraindications derive from the route of insertion, i.e., esophageal diseases, such as varices or severe coagulopathy9 or, for instance, a nasal route is contraindicated with basal skull fractures. Measurements may be disturbed by turbulent descending aortic blood flow, e.g., caused by severe aortic coarctation or an intraaortic balloon pump.9

TURP remains the "gold standard" in surgical treatment of symptomatic benign prostate hyperplasia.14 The typical and potentially fatal complication of TURP procedures is TURP syndrome, which requires immediate action by the anesthesiologist and surgeon. In awake patients, a TURP syndrome usually presents with neurological symptoms, e.g., confusion and nausea.3,15 Thus, TURP procedures were at first performed under spinal anesthesia, i.e., with the patient awake. However, since not all TURP procedures can be performed under neuraxial anesthesia, alternative measures are required for rapid detection of TURP syndrome during general anesthesia. Numerous surrogate markers (surgery time, surgeon experience, resected tissue weight,16 or the height of the irrigating solution bag17) have failed to accurately predict the amount of irrigation fluid absorbed, and thus the risk of developing TURP syndrome. Adding alcohol as a tracer to the irrigation fluid allows expiratory alcohol detection if sufficient amounts of irrigation fluids are absorbed.18–21 However, this technique is limited because ethanol levels are not predictive of the sodium concentration21 and it cannot be used in patients with a history of alcohol abuse.20 Thus, frequent blood sampling for electrolyte analysis remains the "best practice" to detect developing hyponatremia, because the degree of hyponatremia poorly correlates with the clinical severity of TURP syndrome.22,23 Multiple factors may contribute, e.g., individual volume status, cardiovascular function or perioperative medication, including anesthetics. Moreover, certain hemodynamic and neurologic effects are relatively specific for certain irrigating fluids3 and therefore independent from plasma sodium concentration.

In the presented case, the onset of acute, intravascular hypervolemia was detected with TED monitoring by a marked increase in stroke volume and cardiac output. Along with these volumetric variables, time-related (i.e., FTc) and accelerometric variables (i.e., peak velocity and mean acceleration)9 were measured and indicated a decreased systemic vascular resistance. These are composite variables (e.g., stroke volume depends on preload and ventricular contractility whereas peak velocity and mean acceleration depend both on ventricular contractility and afterload9), which have theoretical limitations. Unfortunately, there is no single independent variable to determine preload, afterload or contractility. However, these TED-derived variables in combination can be used to clarify the hemodynamic situation.

To our knowledge, this is the first case report of the use of TED to identify hemodynamic changes during TURP syndrome. A limited number of studies report noninvasive cardiac output measurements in uncomplicated TURP procedures.24,25 In the presented case, the increase in cardiac output may be supported by hypervolemia (Frank-Starling relationship26), hemodilution, and a reduction in peripheral vascular tone. Animal models of TURP syndrome confirm this initial hypervolemia with hemodilution and an increase in cardiac output and aortic blood flow.27 Although increased intravascular volume may increase arterial blood pressure,28 the patient presented developed arterial hypotension, which is in agreement with other reports on sorbitol-containing irrigation fluids. Although glycine solutions may increase systemic resistance29 and arterial blood pressure,27–29 sorbitol-containing fluids (as used in the presented case) tend to decrease both systemic vascular resistance and arterial blood pressure.29 Thus, current literature supports the hemodynamic changes observed in the presented case. In contrast to other reports of bradycardia during TURP syndrome,30 our patient had a relatively stable heart rate of approximately 60 bpm, possibly because the early, repetitive administration of ephedrine counteracted the development of severe bradycardia.

Along with hemodynamic stabilization, correction of hyponatremia is crucial in TURP syndrome management. Although an asymptomatic, moderate hyponatremia usually resolves with intravascular volume regulation (diuretic therapy and fluid restriction),31 treatment with hypertonic saline appears indicated when symptoms occur3,31 or serum sodium decreases below 120 mmol/L.3 Therapy aims at a sodium concentration of approximately 130 mmol/L but with avoiding over-correction.32 The optimal rate of sodium repletion remains controversial. Traditionally, correction in chronic hyponatremia is restricted to 0.5 mmol · L^–1 · h^–1, because rapid (over-)correction may promote central pontine myelinolysis.33 This recommendation has been adopted by some for the treatment of TURP syndrome.31 However, since acute hyponatremia might be corrected more rapidly,33 repletion rates of sodium in TURP syndrome of 1 mmol · L^–1 · h^–1 are regarded as safe.3 Therefore, we estimate that infusion of 2 mL/kg of NaCl 1.5% will increase serum sodium level by approximately 1 mmol/L.34 Although there are various formulas for calculating free water excess and sodium deficit, each may fail to accurately guide therapy in the individual patient.35 Thus, frequent determination of serum sodium concentration is mandatory. In our patient, sodium concentration was corrected at an average rate of approximately 3 mmol · L^–1 · h^–1 resulting in no adverse sequelae.

In conclusion, the presented case demonstrates that TED may facilitate early detection and successful management of patients with TURP syndrome; however, it does not make TED a standard of care for that procedure. Endoscopic surgery is a rapidly expanding area, and complications similar to TURP syndrome are increasingly reported from other specialties,3 e.g., during hysteroscopic surgery.36 Thus, the increasing requirement to detect and manage TURP (-like) syndromes may promote applications of TED, as described in the present case.

Footnotes

Accepted for publication March 25, 2008.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schober, P. Articles by Schwarte, L. A. Search for Related Content PubMed PubMed Citation Articles by Schober, P. Articles by Schwarte, L. A. Related Collections Cardiovascular Complications Patient Safety Technology