TURP syndrome: Difference between revisions
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*Complication seen after transurethral resection of prostate when large volumes of glycine-based irrigation fluids absorbed through venous sinuses, causing volume overload and hyponatremia, as well as CNS effects due to glycine | *Complication seen after transurethral resection of prostate when large volumes of glycine-based irrigation fluids absorbed through venous sinuses, causing volume overload and hyponatremia, as well as CNS effects due to glycine | ||
**Glycine inhibits GABA receptors and potentiates NMDA receptors | **Glycine inhibits GABA receptors and potentiates NMDA receptors | ||
* | *More rare currently due to changes in irrigation fluid composition | ||
*Can also be seen after other procedures that require large volume irrigation, such as hysteroscopy | *Can also be seen after other procedures that require large volume irrigation, such as hysteroscopy | ||
| Line 13: | Line 13: | ||
*Tachypnea, [[pulmonary edema]], [[hypoxia]], [[respiratory distress]] | *Tachypnea, [[pulmonary edema]], [[hypoxia]], [[respiratory distress]] | ||
*[[Nausea/vomiting]] | *[[Nausea/vomiting]] | ||
*Hemolysis | *[[hemolytic anemia|Hemolysis]] | ||
*[[AKI]] | *[[AKI]] | ||
*[[Bradycardia]] (reflex from fluid absorption), [[dysrhythmia]] | *[[Bradycardia]] (reflex from fluid absorption), [[dysrhythmia]] | ||
*[[Visual disturbances]] ([[visual loss]], fixed pupils) | *[[Visual disturbances]] ([[visual loss]], fixed pupils) | ||
*[[Confusion]], [[seizure]], [[coma]] | *[[Confusion]], [[seizure]], [[coma]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
==Evaluation== | ==Evaluation== | ||
* | *Metabolic panel | ||
**[[Hyponatremia]], iso or mildly hypo-osmolar | **[[Hyponatremia]], iso- or mildly hypo-osmolar (due to dilutional effect of large volume fluid as well as natriuresis) | ||
**[[Hypocalcemia]] (due to precipitation of calcium with metabolites of glycine as oxalate crystals) | |||
**[[Hypocalcemia]] | |||
*CBC | *CBC | ||
**Hemodilution | **Hemodilution | ||
**+/- [[hemolytic anemia|hemolysis]] | **+/- [[hemolytic anemia|hemolysis]] | ||
*Ammonia | *Ammonia | ||
** | **Elevated due to deamination of glycine and serine | ||
*Serum osmolarity | *Serum osmolarity | ||
**Osmolar gap elevated | **Osmolar gap elevated due to glycine | ||
*[[CXR]] - Signs of volume overload, pulmonary edema | |||
*[[CXR]] | *[[ECG]] - May have arrythmias in severe cases | ||
*[[ECG]] | |||
==Management== | ==Management== | ||
* | *ABCs - address [[pulmonary edema]], [[dysrhythmias]] | ||
*Volume overload: [[furosemide]] IV | *Volume overload: [[furosemide]] IV | ||
*[[Hyponatremia]]: | *[[Hyponatremia]]: | ||
| Line 48: | Line 43: | ||
**Goal to raise Na+ by 10-12mmol over 24h | **Goal to raise Na+ by 10-12mmol over 24h | ||
**Rapid increase in Na+ not concerning (as may occur with glycine metabolism) UNLESS there is sudden change in osmolality | **Rapid increase in Na+ not concerning (as may occur with glycine metabolism) UNLESS there is sudden change in osmolality | ||
*[[Seizure]] | *[[Seizure]] | ||
**[[Benzodiazepines]] +/- [[AEDs]] | **[[Benzodiazepines]] +/- [[AEDs]] | ||
| Line 63: | Line 57: | ||
==External Links== | ==External Links== | ||
*[https://litfl.com/turp-syndrome/ Life in the Fast Lane - TURP Syndrome] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Urology]] [[Category:Surgery]] [[Category:FEN]] | [[Category:Urology]] | ||
[[Category:Surgery]] | |||
[[Category:FEN]] | |||
Latest revision as of 16:55, 29 September 2019
Background
- Complication seen after transurethral resection of prostate when large volumes of glycine-based irrigation fluids absorbed through venous sinuses, causing volume overload and hyponatremia, as well as CNS effects due to glycine
- Glycine inhibits GABA receptors and potentiates NMDA receptors
- More rare currently due to changes in irrigation fluid composition
- Can also be seen after other procedures that require large volume irrigation, such as hysteroscopy
Clinical Features
- Onset 15min-24h post-op
- May range in severity from mild to life-threatening
- Typically lasts hours but neuro symptoms may last longer if complicated
- Headache, restlessness
- Burning sensation in face/hands,
- Tachypnea, pulmonary edema, hypoxia, respiratory distress
- Nausea/vomiting
- Hemolysis
- AKI
- Bradycardia (reflex from fluid absorption), dysrhythmia
- Visual disturbances (visual loss, fixed pupils)
- Confusion, seizure, coma
Differential Diagnosis
Evaluation
- Metabolic panel
- Hyponatremia, iso- or mildly hypo-osmolar (due to dilutional effect of large volume fluid as well as natriuresis)
- Hypocalcemia (due to precipitation of calcium with metabolites of glycine as oxalate crystals)
- CBC
- Hemodilution
- +/- hemolysis
- Ammonia
- Elevated due to deamination of glycine and serine
- Serum osmolarity
- Osmolar gap elevated due to glycine
- CXR - Signs of volume overload, pulmonary edema
- ECG - May have arrythmias in severe cases
Management
- ABCs - address pulmonary edema, dysrhythmias
- Volume overload: furosemide IV
- Hyponatremia:
- Hypertonic saline only if severe neuro manifestations (e.g. seizures) AND serum osmolality <260
- Goal to raise Na+ by 10-12mmol over 24h
- Rapid increase in Na+ not concerning (as may occur with glycine metabolism) UNLESS there is sudden change in osmolality
- Seizure
- Benzodiazepines +/- AEDs
- Consider magnesium (NMDA receptor stabilization)
- Hypocalcemia- replete
- Monitor hemoglobin, transfuse pRBCs PRN
- May require dialysis in severe cases
Disposition
- ICU