FLUID & ELECTROLYTE PROTOCOL IN BENIGN

PROSTATIC HYPERPLASIA (BPH)

PREETI

ANATOMY OF THE PROSTATE

• normal prostate weighs around 18 gm.• contains 70% glandular and 30% fibromuscular

stroma• urethra runs through the length of the prostate• Divided into 5 lobes or 2 zones- transitional and

peripheral

WHAT IS BPH ? Non cancerous enlargement of the prostate gland Mainly of the middle lobe or the transitional zone Leads to symptoms of bladder outlet obstruction Disease of the old age, starts at ~ 40 but usually

presents between 50 – 70 years estimated 50% of men have histologic evidence of

BPH by age 50 years and 75% by age 80 years In 40-50% of these patients, BPH becomes clinically

significant

PROSTATIC HYPERTROPHY

EFFECTS OF PROSTATIC ENLARGEMENT

URETHRAL CHANGESEnlongation of the prostatic urethraExaggeration of the posterior curveLateral urethral compression (if unilateral)

DIFFICULTY IN MICTURITION AND FOLEYS INSERTION

BLADDER CHANGES :Compensatory detrusor hypertrophy (increase atonicity)Post prostatic pouch (retention)

CYSTITIS

VESICLES PILES

URETER AND KIDNEYHydroureter and hydronephrosis (Due to obstruction)Vesiculo-uretric refluxAcute pylonephritis Uremia

CLINICAL PRESENTATIONS FREQUENCY

Initially nocturnal Gradually increases to both at day and night –

cystitis & irritation.

HESITENCY – (waiting for urination) d/t median lobe pressing the orifice.

URGENCY – deranged internal sphincter mechanism.

DYSURIA

DRIBBLING URINE – poor stream

HEMATURIA – rupture of dilated veinscystitisprostatic erosionCalculi formation

PAIN – lower abdomen

ACUTE RETENTION

GRADING

ON P/R

I Enlarged, felt easily and finger can be reached above it.

II Enlarged, felt easily but the finger is reached with difficulty.

III Enlarged, felt easily but finger cannot reach above it.

On USG :Normal 10-15 gm (weight of prostate)I 15-20 gmII 20-50 gmIII 50-150 gmIV > 150 gm

On URETHROSCOPY

Normal – 2-2.5 cm (length - prostatic urethra)I 2.5-3.0 cmII 3.0-3.5 cmIII > 3.5 cm

ADVERSE EFFECTS OF BPH Erodes Quality of Life Complications:

Urinary retentionRecurrent hematuriaBladder stonesCompromised renal function

COEXISTING PROBLEMS

Patients with symptomatic BPH are frequently elderly with coexistent diseases

abnormal electrocardiogram (ECG) 77%cardiac disease 67%chronic obstructive pulmonary disease 29% diabetes mellitus 8%

COEXISTING PROBLEMS Occasionally patients are dehydrated and

depleted of essential electrolytes ex.long-term diuretic therapyrestricted fluid intakeCHF

Long standing urinary obstruction can lead toimpaired renal functionchronic urinary infection.

Patients need to be fully evaluated for the co-morbidities and optimized with the help of all investigations and special advices from cardiologist, nephrologist, endocrinologist and physician, if required.

INVESTIGATIONSINVESTIGATIONS AIM

1 Hemoglobin -O2 carrying capacity-Max allowable blood loss

2 Blood group & Rh type -Arrange for compatible blood

3 Total Count -Any Infections/Inflamation

4 Diff count -Acute/chronic inf, allergies

5 ESR -normal/↑/↓

6 RBS -Screening for DM

7 Blood Urea -Renal Function

8 Serum Creatinine -Renal Function

9 Urine -Renal Function

10 ECG -Evaluate for IHD, MI, Dysrhythmias, heart Blocks.

11 CXR -Pulmonary evaluation and Cardiac evaluation- Cardiomeg, Pul Edema, PH.

INVESTIGATIONS

Total serum proteins – more chance of fluid overload if hypoproteinemia seen.

PFTs USG Abdomen :

- Obstruction / calculi / Cysts/ Organomegaly

- Hydroureter with Hydronephrosis

- Prostate size Electrolytes : Na, K, Cl, Mg, Ca ABG

SURGICAL THERAPIES

The options available are:TURPSuprapubic (transvesicular) prostatectomyPerineal / retropubic prostatectomyTrans urethral electro vapourizationTrans urethral laser ( under LA)Trans urethral incision

TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) –

considered gold standard by most

TURP is considered as one of the most difficult procedures that a surgeon can learn and master.

It involves removal of the gland upto the level of the capsule.

Excision and coagulation of the hypertrophied tissue (adenoma) are performed under direct vision through a resectoscope.

Wire loop

Continuous irrigation is necessary to provide

Good visibility by dilating the bladder and the prostate

Maintaining an operative field free of dissected prostatic tissue debris and blood

IRRIGATING SOLUTIONS

Common solutions areGlycine 1.2% and 1.5%Mannitol 3% & 5%Glucose 2.5% & 4%Sorbitol 3.5 %CYTAL (sorbitol 2.7%+mannitol 0.54%)Urea 1%

The ideal duration of resection is – 60 min estimated that 10-30 ml of irrigating fluid is

absorbed per minute of resection time. Absorption of small amount

spontaneous diuresis Absorption of large amount

over hydrationIncreased intravascular pressureDecreased plasma oncotic pressureGeneralized edema

Absorption of irrigation fluid

Takes place via the large prostatic venous sinuses.

Also, the type of irrigation fluid is important.

NORMALLY….

Water constitutes over 50% of an individual’s weightInfant- 70-80%Adult 50-60%

Geriatric 45-55%Water requirement= 2500cc/day; minimum of 1500 cc/day

ELECTROLYTES

salts or minerals in extracellular or intracellular body fluids

○ Sodium – major cation of ECF

○ Potassium – major cation of ICF

○ Chloride - major anion of ICF

Electrolyte Plasma (mEq/L)

ISF ICF

Sodium 142 141 10

Potassium 5 4.1 150

Calcium 5 4.1 -

Magnesium 3 3 40

chloride 103 115 15

ELETROLYTES…

SolutionSolution VolumeVolume NaNa++ KK++ CaCa2+2+ ClCl-- HCOHCO33-- DextrosDextros

eemOsm/LmOsm/L

ECFECF 142 4 5 103 27 280-310

Lactated Lactated Ringer’sRinger’s 130 4 3 109 28 273

0.9% NaCl0.9% NaCl 154 154 308

0.45% NaCl0.45% NaCl 77 77 154

D5/0.45% D5/0.45% NaClNaCl 77 77 50 406

3% NaCl3% NaCl 513 513 1026

6% 6% HetastarchHetastarch 500 154 154 310

5% Albumin5% Albumin 250,500130-160

<2.5

130-160 330

25% 25% AlbuminAlbumin

20,50,100

130-160

<2.5

130-160 330

PARENTERAL FLUID THERAPYPARENTERAL FLUID THERAPY

DISTURBANCES ENCOUNTERED…In case of BPH commonly seen are:Circulatory overloadHypo osmolarityWater intoxicationHyponatremiaHypomagnesemia

Circulatory overload Hypervolumia – in acute cases, leads to

Hypo osmolarity – (increased intravascular volume and hemodilution)

Hypertension – leading to hypertension anginal pain fluid shift leading to pulmonary edema esp. where

cardiac reserve is limited.cerebral edema can be precipitatedHyponatremia – dilutionalRenal derangements – amount of irrigation fluid

inversely proportional to post op urine output

HYPERVOLEMIA

Irrigation fluid enters circulation through open prostatic venous sinuses

Average rate – 20ml/min May reach upto 200 ml/min Literature suggests as many as 8 L can

be absorbed Average weight gain by end of surgery –

2 kg.

CALCULATION OF FLUID ABSORBED… Determine serum Na at beginning of the

surgery Again at the time of estimation of vol absorbed Volume absorbed =

(preop Na / postop Na) Χ ECF – ECFECF = 20% - 30% of total body water

Example :

In a pt. with body wt = 50 kg, preop Na 140, postop Na 100

Then, volume absorption=

140/100 Χ ECF- ECF =1.4 ECF- ECF

= 0.4 ECF

= 0.4 Χ 50 Χ 20%

= 4 litres

HYPONATREMIA The absorption of large amounts of electrolyte-free

irrigating fluid leads to Dilutional hyponatremia. sodium: (N 135-145 meq/L)

Major extracellular cationEssential for proper functioning of excitatory cells esp.

heart and brainLevels may typically fall by 3-10 meq/L

The fall in serum sodium inconsistent with amount of total fluid absorbed but dependent on the rate of absorption of fluid

HYPONATREMIA Acute severe hyponatremia associated with

Abnormal neurological symptomsCan lead to irreversible brain damageOn EEG- may lead to loss of α wave activity

The CNS derangement is not due to hyponatremia per se but acute hypo osmolarity

A slow rate in fall of osmolarity apparently allows the CNS to adapt to the hyponatremia.

less than 120 mmol / L indicates a severe hyponatremia. A decrease in serum (Na) of 20 to 30 mmol / L implies absorption of 3 to 4 L.

At levels < 110 meq/L pt can develop respiratory and cardiac arrest

PREVENTION Pt should be adequately prepared pre op Pts with CHF – treat vigourosly

diuretics and fluid restriction

Conservative surgical approach in critically ill pts- ex. simple canalization or balloon dialatation

Most imp factor – preservation of prostatic capsule (surgeon’s skills)

Limit hydrostatic pressure of irrigating solution to <60 cm of H2O

Prevent bladder overdistension

Hyponatremia also accentuated by pre op deficiency or excessive intra op bleeding.

Below 120 meq cellular activity is deranged. Surgery should be terminated at levels below this.

Administer intravenous fluids cautiously:Use a microdrip set, esp. in pts with cardiac or

renal derangementsUse vasopressors instead of large boluses of

fluid in case of hypotension during regional anesthesia.

TREATMENT Administration of hypertonic saline to treat - not

always necessary. Not recommended unless pt develops clinical

signs of hyponatremia. Spontaneous or induced diuresis with 20 mg

furosemide – corrects hyponatremia in few hrs Saline administration itself can provoke

pulmonary edema – due to fluid overload Hypertonic saline- should be given with serum

osmolarity monitoring

TREATMENT CONTD…

Rapid administration of hypertonic saline – associated with central pontine myelinolysisAlso c/a osmotic demyelination syndrome.

Sodium should not be corrected at a rate faster than 1.5 meq/ L/ hour

3. Water intoxication

WATER INTOXICATION:

Some patients exhibit neurological signs like:Decerebrate postureClonusbabinski reflex presentConvulsions and eventually coma

Eye exam: papilledema, dilated and sluggishly reacting pupil

EEG- low voltage b/l

BBB essentially impermeable to sodium but freely permeable to water

Cerbral oedema → raise ICT → bradycardia and hypertension → other neurological symptoms.

WATER INTOXICATION:

Cell in a hypotonic solution

•Hemolysis can occur

TURP SYNDROME The TURP syndrome is an iatrogenic surgical

complication but the responsibility for its diagnosis and treatment falls upon the anaesthetist, hence the importance.

During TURP, there is opening up of an extensive network of venous sinuses allowing excessive systemic absorption of irrigation fluid.

This extensive absorption of fluid( > 2L) results in a combination of S/S referred to as TURP syndrome.

Seen in approx 2% of Pt.

What is to be done…..

Preop Correct any fluid / electrolyte imbalanceCorrect anemiaT/t cardiac failure

Intra op Blood loss should be carefully replacedHydrostatic pressure of the irrigating fluid should

not exceed 60 cm of H2O. – avoid excessive elevation of the irrigating bag

Intra op (cont..)Care that bladder outflow remains unobstructed

(watch the Uro-bag volume)If Ht is changed from 60 to 70 cm ~ 2 fold

increase in fluid absorption is seen.Resection time should not exceed 60 minHowever, at least 300 ml of fluid / min is needed

for good visual field. This cannot be achieved at below 60 cm. DONOT LOWER excessively as this will prolong resection time.

TREATMENT Depends on the detection of hyponatremia – serial

sodium measurements must be done whenever unexplained changes in BP or cerebral irritation is seen.

Infusion of clear fluids should be suspended. Blood loss should be replaced by slow blood

transfusion. Loop diuretic – furosamide is t/b given Sodium correction is controversial.

For established cases In case of acute hyponatremia with neurological

features, rapid correction till neurological improvement is to be done.

Na deficit =

(DESIRED [NA] - CURRENT [NA]) X 0.6 * Bd WT (KG) (*use 0.6 for men and 0.5 for women).

Rate of correction should be 0.6 – 1.0 mEq / L / hr until sodium reaches 125 after that the rate is 1.5 mEq / L / hr.

½ correction is done in initial 8 hr then the rest over 1-3 days.

Hypertonic saline may be used to rapidly increase serum sodium level in patients with severe acute or chronic hyponatremia, as manifested by severe confusion, coma, seizures, or evidence of brainstem herniation.

Hypertonic (3%) saline – Contains 514 mEq/L of NaCl. May precipitate P.Edema in presence of cardiac failure.

osmolarity Sh/b acertained before hand and CVP monitored thereby

In general, increase of 4-6 mEq/L in serum sodium level is sufficient to arrest progression of symptoms in severe hyponatremia. Further rapid increase in serum sodium level not indicated.

BLEEDING

Normally the blood loss during TURP2-5 ml / min of resection time20-50 ml / gm of tissue resected

Extent of blood loss is determined byResection timeSize of glandSurgical expertise

Absorption of irrigating fluid increased intravascular pressure increased bleeding

Any factor which increases peripheral venous pressure increases bleeding from prostatic bedStraining during light anaesthesia (GA)Shivering, coughing during regional

anaesthesia

Regional anaesthesia is associated with as much bleeding as deep GA as vasodilatation increases venous pooling

Other possible reasons for excessive bleeding:

Dilutional thrombocytopenia

Local release of fibrinolytic agents : plasminogen and urokinase from mucosa of LUT

○ Sudden loss of blood without clots, bleeding from skin puncture site, sub mucosal h’ge m/b seen

○ Treated with EPSILON AMINOCAPOIC ACID 4-5 g during the first hour and followed by 1 g /hr for the next 24 hr

Prostatic particles rich in thromboplastin, that enter bloodstream during surgery can trigger DIC.

ESTIMATION OF BLOOD LOSS :Visual estimation is inaccurate d/t mixingHypotention & tachycardia are delayed d/t

increased circulatory volumeEstimated to be 200-2000 with an average of

~500ml.Serial hematocritHb assessment in suction bottle fluid

Factors increasing mortality Age > 80 yrs Resection time > 150 min Resected tissue > 60 g Presence of azotemia ( 6 times increase) Mortality rate – 0.2-0.8 %

Thank you….THANKYO

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