Sei sulla pagina 1di 4

Indian J. Anaesth.

KRISHNA MOORTHY, 2002; 46 (6)


PHILIP : 441-444
: SERUM POTASSIUM IN TURP SYNDROME 441

SERUM ELECTROLYTES IN TURP SYNDROME –


IS THE ROLE OF POTASSIUM UNDER-ESTIMATED?
Dr. H. Krishna Moorthy1 Dr. Shoba Philip2

SUMMARY
In this study, we have analysed the various changes in plasma sodium and potassium levels during endourological procedures using
either of the two commonly used fluids for irrigation (1.5% glycine or sterile water) and their correlation with various other
parameters namely duration of procedure, weight of gland resected, volume of irrigating fluid used and height of irrigating fluid
column. Significant changes were found to occur in the potassium levels concomitant with the alterations in sodium levels. This could
precipitate/aggravate the cardiotoxic effects during TURP syndrome. The study thus emphasised the need to assess the levels of both
plasma sodium and potassium pre and post operatively for endourological procedures. The various other parameters studied had
different influence on the levels of these electrolytes. The inability of 1.5% glycine to maintain isotonicity was proved.
Keywords : TURP Syndrome, 1.5% Glycine, Hyponatremia, Hyperkalemia.

Introduction endourological procedures using different irrigating fluids.


The various clinical manifestations produced due The variation in the electrolytes has been correlated with
to the absorption of large quantities of irrigating fluid other determinants like duration of procedure, height of
during endourological procedures are together called as irrigating fluid column, volume of irrigating fluid used
TURP Syndrome.1 Though the syndrome is characteristically and weight of the gland resected.
described during Trans Urethral Resection of Prostate
Materials and methods
(TURP) in upto 20% of patients, it can occur during any
other endourological procedures using irrigating fluid, 90 patients with Benign Prostatic Hyperplasia (BPH)
particularly during Per Cutaneous Nephro Lithotomy undergoing TURP (with ASA grades II and III) and 42
(PCNL). Established TURP syndrome occurs only in small other patients undergoing PCNL (ASA grade II) were
number of patients and is characterised by dyspnoea, included in the study. TURP patients belonged to the age
nausea, hypertension, increased central venous pressure, group of 50–80 years and PCNL patients belonged to the
cerebral edema, cardiogenic shock and renal failure. age group of 30–50 years. TURP was routinely performed
Improved surgical/anaesthetic techniques as well as under regional anaesthesia (sub arachnoid block) and
incomplete and atypical forms of the syndrome could be PCNL was performed under general anaesthesia. All the
the reason for its low incidence. Dilutional hyponatremia, patients were carefully observed for the onset of TURP
water intoxication and glycine and ammonia toxicities syndrome during the procedure. The procedure was
have been postulated as the causes for TURP syndrome. terminated when there were early manifestations of TURP
Acute hyponatremia with blood sodium concentration syndrome namely restlessness, bradycardia, yawning etc
below 115–120 meqL-1 could be potentially serious to (under regional anaesthesia) and changes in cardiac rate
the patient. Although significant hyponatremia has or rhythm (under general anaesthesia).
been reported following TURP in 11–41% of patients,2 Patients undergoing TURP were assessed for
potassium changes in the plasma have not been extensively the preoperative plasma sodium and potassium levels
studied properly or reported so far. (in meqL-1) using autoanalyser, on the day of surgery.
In this paper, we have analysed the changes in Two different and commonly used irrigating fluids namely
sodium and potassium levels in the plasma during various 1.5% glycine and sterile water were used for irrigation.
The duration of procedure, weight of prostate gland
1. MS., DNB (Surg), M Ch, DNB (Uro), MNAMS; resected and the volume of irrigating fluid used during
Consultant Urologist the procedure were recorded. The irrigating fluid was
2. MD., DA., DNB (Anaes); Consultant Anaesthesiologist
kept at 50, 60 and 70 cm height, measured from the level
Lourdes Hospital, Cochin - 682 012, India.
Correspond to :
of pubic symphysis of the patient on the operating table.
Dr. H. Krishna Moorthy The plasma levels of sodium and potassium were measured
Consultant Urologist, Lourdesh Hospital, at the end of the procedure also.
Cochin - 682 012 India.
442 INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2002

Patients undergoing PCNL were also assessed for Table No.1 : Changes in sodium levels during
the preoperative sodium and potassium levels in plasma endourological procedures
using the same method as above. The irrigating fluid
used was either sterile water or 0.9% saline (normal Proce- Irrig. Fluid Sodium in meqL-1 ± SD % change P value
dure
saline). The duration of procedure, volume of fluid used Pre operative Post operative
and height of fluid column, measured from the level of
TURP 1.5% glycine 145.7±0.7 140.5±1.1 - 3.6 0.015
posterior axillary level, were noted in each case. The
height of fluid column was kept at 60 and 70 cm from TURP Sterile water 136.7±0.9 133.4±0.8 - 3.8 0.012
the level of posterior axillary line of the patient on the PCNL Sterile water 138.4±1.2 131.0±0.8 - 5.3 0.024
top of operating table. The post operative plasma levels
of electrolytes were also measured. PCNL Normal saline 139.0±0.9 138.5±0.5 - 0.4 N.S

The mean values of pre and post operative sodium


Table No. 2 depicts the changes in mean levels of
and potassium levels were compared to each other and
plasma potassium during TURP and PCNL. There was
statistical significance of the difference in values was
statistically significant increase in the mean levels of
assessed using student’s paired t test. The changes in the
potassium when 1.5% glycine or sterile water was used
plasma electrolyte levels were also correlated with the
as irrigating fluid during both surgical procedures. The
type of irrigating fluid, mean height of fluid column,
percentage rise in potassium levels was much higher
duration of procedure and the weight of gland resected.
compared to the percentage change in sodium levels during
Pearson’s Correlation Coefficient was used to assess
these endourological procedures. The potassium level was
statistical significance of correlated parameters.
not significantly altered when normal saline was used as
Observations irrigating fluid during PCNL.
Out of the 90 patients undergoing TURP, 54 patients Table No. 2 : Changes in potassium levels during
had 1.5% glycine as irrigating fluid and the rest 36 patients endourological procedures
had sterile water for irrigation. The weight of the gland
resected varied from 10 gm to 60 gm and the maximum Procedure Irrig. Fluid Potassium in meqL-1±SD % change P value
duration of procedure was 60 minutes. The volume of Pre operative Post operative
fluid used for irrigation varied from 3–25 litres.
TURP 1.5% glycine 4.28±0.13 4.87±0.11 +13.7 < 0.001
Of the 42 patients undergoing PCNL, 20 patients
TURP Sterile water 4.16±0.20 4.84±0.15 +16.3 < 0.001
had normal saline as irrigating fluid and the rest had
sterile water for irrigation. The duration of procedure PCNL Sterile water 3.69±0.20 4.27±0.32 + 15.7 < 0.001
varied from 20 – 60 minutes. The volume of fluid used
PCNL Normal saline 4.31±0.16 4.27±0.19 - 0.9 N.S
for irrigation ranged from 2–20 litres.
None of the patients in our study group showed Table No. 3 shows correlation between the changes
full blown clinical manifestations of TURP syndrome. in sodium levels and the various determinants. Though it
Under regional anaesthesia, early manifestations like was observed that there was no statistically significant
restlessness and bradycardia were observed in a small correlation between the various parameters, the height of
number of patients (10 out of 90) especially when weight fluid column and the volume of irrigating fluid used had
of the gland exceeded 50 grams and the duration of better correlation with the changes in sodium levels
procedure exceeded 45 minutes. Under general anaesthesia, compared to the duration of procedures and the weight of
bradycardia was the early sign and was observed in 3 patients, gland resected.
who had surgical procedures lasting for 60 minutes.
Table No. 3 : Sodium levels – correlation values
The mean levels of sodium pre and post operatively
in patients undergoing TURP and PCNL are given in Correlation Correlation Coefficient T P
Table No. 1. There was statistically significant reduction Duration Vs sodium 0.122 0.71 0.480
in the mean sodium levels post operatively when 1.5%
glycine or sterile water was used as irrigating fluid during Wt. of gland Vs sodium 0.149 0.88 0.387

both surgical procedures. However, sodium levels did not Volume of fluid Vs sodium 0.178 1.06 0.298
show significant alteration when normal saline was used
Height of fluid Vs sodium 0.166 0.97 0.312
as irrigating fluid during PCNL.
KRISHNA MOORTHY, PHILIP : SERUM POTASSIUM IN TURP SYNDROME 443

When the correlation between changes in potassium Our study showed that significant hyperkalemia occurred
levels and the determinants was studied (Table No. 4), it in patients undergoing TURP and PCNL and the variation
was observed that the duration of procedure had better in potassium levels was dependent more on the duration
correlation than the weight of gland resected, volume of of procedure than the other determinants. Clinical
irrigating fluid used and the height of fluid column. manifestations of hyperkalemia occur when the plasma
However none of the determinants had statistically levels of potassium rise above 6 meqL-1. The ECG will
significant correlation with the changes in potassium levels. show tall, peaked T waves, PR prolongation, decrease in
amplitude of P wave, QRS widening and arrhythmias.
Table No. 4 : Potassium levels – correlation values Flaccid paralysis and respiratory arrest occur when
potassium level rises above 7 meqL-1. Hyperkalemic
Correlation Correlation Coefficient T P cardiotoxicity is increased by hyponatremia and acidosis.
Duration Vs potassium 0.129 0.76 0.453 Therefore it is possible that the cardiovascular changes
occuring in TURP syndrome can be due to a combination
Wt. of gland Vs potassium - 0.002 0.01 0.990
of both hyponatemia and hyperkalemia. Hahn et al14 also
Vol. of fluid Vs potassium 0.044 0.025 0.800 found out significant elevation of serum potassium during
absorption of irrigating fluid intraoperatively. However
Ht. of fluid Vs potassium 0.038 0.019 0.891
these authors reported inconsistency in the serum
electrolyte values when measured postoperatively. We
Discussion observed that both 1.5% glycine and sterile water produced
Water intoxication with hyponatremia has been significant plasma potassium changes during endourological
postulated as the primary cause for the genesis of TURP procedures. The exact cause of this change in potassium
syndrome. Different methods for assessing the fluid and levels is not known. It is probably due to haemolysis
electrolyte imbalance during TURP have been suggested. during absorption of fluid into circulation. This was
These include the use of load cell transducers,3 emphasised by the fact that there was no significant
measurement of serum acid phosphatase,4,5 assessment of alteration in potassium levels when normal saline was
breath ethanol6 and monitoring of plasma concentration used as irrigating fluid. The inability of 1.5% glycine to
of fluorescein.7 Absorption of large quantities of irrigating maintain isotonicity was found out in other studies also.15
fluid during TURP leads to dilutional hyponatremia8 and This signifies the importance of monitoring potassium
severe metabolic acidosis called TURP acidosis.9 levels also during endourological procedures when 1.5%
Significant change in sodium levels was noted in our glycine or sterile water was used as irrigating fluid,
studies also, which was independent of the type of especially when the duration of procedure was longer.
irrigating fluid (1.5% glycine or sterile water) used for Adequate measures like administration of calcium,
the procedure. On the contrary, studies by Moskovitz alkalinisation and even hemodialysis in severe cases can
et al10 demonstrated no significant changes in serum counter this potassium toxicity.
sodium, potassium, albumin and other parameters when
distilled water was used as irrigating fluid. The safety of Conclusions
distilled water has been confirmed by Shih et al,11 when Though it is very difficult to avoid occurrence of
these authors used suprapubic cystostomy drainage during TURP sydrome, the best prevention could be obtained by
TURP. However we found that the variation in sodium adopting a correct surgical technique. Procedures lasting
levels correlated with the volume of fluid used and height for more than 60 minutes and prostate glands weighing
of irrigating fluid column and to a lesser extent to the more than 60 grams could be associated with more
duration of procedure and the weight of gland resected. complications. Staged TURP is ideal for larger glands.
Norlen et al12 also have confirmed that more the height Early identification of TURP syndrome, administration of
of fluid column, larger is the variation of sodium levels. frusemide and hypertonic saline could prevent and treat
Normal saline was found not to alter the serum sodium the basic pathophysiology of TURP syndrome. Limitation
levels in our study. of the height of irrigating fluid column to 60 cm could
provide optimum vision to the surgeon and reduce the
The change in potassium levels during TURP has
complications of fluid absorption. 1.5% glycine was seen
not been properly studied. Norlen et al13 have reported
not to be isohaemolytic and produced significant changes
significant changes in potassium levels (mainly in the
in both sodium and potassium levels when absorbed into
form of dilutional hypokalemia) in the skeletal muscles
circulation during TURP and PCNL. There was no added
post operatively when distilled water was used as irrigant.
advantage of using 1.5% glycine over sterile water as far
444 INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2002

as the changes in sodium and potassium levels were 6. Oku S, Kadowaki T, Uemura T, Nishioka H : Early detection
concerned. Though 2.2% glycine is isohaemolytic, the of absorption of irrigating fluid during transurethral resection
toxic effects of glycine prevent its routine use as irrigating of the prostate with alcohol gas detector tube. Nippon
fluid during endourological procedures. Our study Hinyokika Gakkai Zasshi. 1993; 84(2): 374-81.
emphasised the need to assess both sodium and potassium 7. Bender DA, Coppinger SW : Estimation of irrigant absorption
levels in plasma during endourological procedures during transurethral resection of the prostate – assessment of
fluorescein as a marker. Urol. Res. 1992; 20(1): 67-9.
and adoption of corrective steps to prevent serious and
fatal complications. Preoperative levels of sodium and 8. Agarwal R, Emmett M : The post transurethral resection of
prostate syndrome – therapeutic proposals. Am. J. Kid. Dis.
potassium should be estimated and necessary corrections
1994; 24(1): 108-11.
made before taking up the patient for surgery. Normally
the fall in serum sodium during TURP has been identified 9. Scheingraber S, Heitmann L, Weber W, Finsterer U : Are
there acid-base changes during transurethral resection of the
to be in the range of 5–8 meqL-1. However the cardiotoxic
prostate? Anesthesia and Analgesia. 2000; 90(4): 946-50.
effects of hyponatremia will be dependent on the
10. MoskovitzB, Ross M, Bolkier M, Rosenberg B, Levin DR :
concomitant variation in plasma potassium levels during
The use of distilled water as an irrigating fluid in patients
the procedure. Normal saline should be used as irrigating undergoing transurethral resection of the prostate. Eur. Urol.
fluid whenever possisble. However due to electrical 1989; 16(4): 267-70.
conductivity, its use is currently restricted to PCNL
11. Shih HC, Kang HM, Yang CR, Ho WM : Safety of distilled
alone. Laser TURP can also help to minimise fluid water as an irrigating fluid for transurethral resection of the
absorption and its complications especially in cardiac prostate. Chung Hua i Hsueh Tsa Chih – Chinese Medical
and critically ill patients. Journal. 1999; 62(8): 503-8.
12. Norlen H, Allegen LG : A comparison between intermittent
References
and continuous transurethral resection of the prostate. Scand.
1. Tausin FP, Sans L : Prostate transurethral resection syndrome. J. Urol. Nephrol. 1993; 27(1): 21-5.
Ann. Fr. Anaesth. Reanim. 1992; 11(2): 168-9.
13. Norlen H, Dimberg M, Vinnars E, Aligen LG, Brandt LG :
2. Goel CM, Badenoch DF, Fowler CG, Blandy JP, Tiptaft RC : Water and electrolytes in muscle tissue and free amino acids
Transurethral resection syndrome – a prospective study. Eur. in muscle and plasma in connection with transurethral resection
Urol. 1992; 21(1): 15-7. of the prostate using distilled water as an irrigating fluid.
3. Coppinger SW, Lewis CA, Milroy EJ : A method of measuring Scand. J. Urol. Nephrol. 1990; 24(1), 21-6.
fluid balance during transurethral resection of the prostate. 14. Hahn RG, Berlin T, Lewenhaupt A : Factors influencing the
Br. J. Urol. 1995; 76(1): 66-72. osmolality and the concentration of blood haemoglobin and
4. Permi J : Serum acid phosphatase in TUR syndrome. Ann. electrolytes during transurethral resection of the prostate. Acta
Chir. Gynecol. Suppl. 1993; 206: 24-30. Anaesth. Scand. 1987; 31(7): 601-7.
5. Hahn RG : Acid phosphatase levels in serum during 15. Hahn RG : Fluid and electrolyte dynamics during development
transurethral prostatectomy. Br. J. Urol. 1989; 64(5): 500-3. of the TURP syndrome. Br. J. Urol. 1990; 66(1): 79-84.

NOTIFICATION
‘Indian Journal of Anaesthesia’ is the most widely read journal in the country amongst the
anaesthesia community. As a mark of service to our community, the journal proposes to publish
the advertisements related to ‘Vacancy positions’ in the Department of Anaesthesia, Critical Care
& Pain Services in teaching institutions and hospitals at the following discounted rates, per insertion,
per issue.

Inside full page (B/W) Rs. 6000/-


Inside half page (B/W) Rs. 3000/-
Inside Quarter (B/W) Rs. 2000/-

Interested institutions may please contact the ‘Editorial Office’.


— Editor

Potrebbero piacerti anche