Seizures: 3% saline 100 mL over 10 min, repeated once or twice; cap the 24-hour rise at 10 mEq/L.
The patient
78-year-old man, 76 kg, for monopolar TURP of an 85 g prostate under spinal anaesthesia, with 1.5% glycine irrigation.
Stable angina only after three flights of stairs; prostatic hypertrophy with retention and a catheter.
Drugs: tamsulosin, aspirin, bisoprolol, atorvastatin.
Vitals: BP 142/80, HR 64, SpO2 96% on air, Na+ 139 mEq/L.
The examiner asks
Answer aloud, then press Show.
Consider
What are your concerns?
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A 78-year-old with angina, for monopolar TURP of a large prostate under spinal. Patient
At 78 I record his cognition first, so later confusion can be judged against it.
Glycine enters through opened prostate veins, about 10–30 mL for every minute of resection. Surgery
His 85 g gland is over 45 g, which raises morbidity, as does resection beyond 90 minutes.
ACC/AHA: elective; no active condition; RCRI 1 for angina; over 4 METs, so he proceeds. Disease
Plan
How will you run the case?
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A spinal keeps him awake and talking, so his mind is my early warning for TURP syndrome. (Surgery)
Irrigant in and out measured; at 1000 mL absorbed, we pause to check his sodium and mind.
Over 2000 mL absorbed and the operation stops.
Bag kept low so bladder pressure stays under 15–25 mmHg.
Irrigation beyond an hour only after I've reassessed him.
Bipolar resection with saline removes the low-sodium risk, though overload remains.
Crisis
Seventy minutes in, he becomes restless and confused. BP 184/96, HR 48. What do you do?
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Confusion, hypertension and bradycardia late in resection: TURP syndrome from fluid overload. (Crisis)
The surgeon stops, controls bleeders and finishes fast; irrigation off.
Blood gas now for sodium, glucose and haemoglobin; osmolality to the lab.
Oxygen and listen for crackles; if he's overloaded, a loop diuretic clears free water.
Fluid restricted; no hypotonic fluid for his confusion.
Blurred vision would point to glycine acting on his retina.
Abdominal pain or poor irrigant return makes me think of bladder perforation.
Crisis
He has a generalised seizure. Sodium is 108 mEq/L. What now?
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Acute severe hyponatraemia with seizure: airway, oxygen, and stop the seizure. Crisis
Midazolam 1–5 mg IV for the seizure.
3% saline 100 mL over 10 minutes, repeated once or twice if he's still seizing.
Aim for a 2–3 mEq/L rise now, then no more than 10 in 24 hours.
Magnesium 1–2 g IV over 15 minutes; glycine excites NMDA receptors and dilution lowers magnesium.
Intubate if he can't protect his airway; ICU with sodium every few hours. After surgery
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.
Same topic, another patient
Run these after the main case when you have time. Same skills, a different patient or setting.
Another patient · Medical and endocrine disease. Irrigation fluid absorption (TUR syndrome) during prostate resection. Same irrigant absorption with cardiac risk work-up and visual loss
Know this first
TUR syndrome in an awake patient: rising BP with wide pulse pressure, bradycardia and confusion.
Limit resection to under an hour; irrigant bag no higher than 30 cm, then 15 cm near the end.
Glycine 1.5% is about 200 mOsm/L; it can cause visual disturbance and hyperammonaemic confusion.
Severe symptoms with sodium below 120: 3% saline; mild symptoms above 120: fluid restriction and furosemide.
The patient
74-year-old man, 82 kg, for transurethral prostate resection under spinal anaesthesia, with 1.5% glycine irrigation.
Ischaemic heart disease: stable angina only after two flights of stairs; EF 45%.
Drugs: aspirin, bisoprolol, atorvastatin, tamsulosin.
Vitals: BP 138/80, HR 60, SpO2 96% on air, RR 14; Na 139 mmol/L, Hb 13.2 g/dL.
The examiner asks
Answer aloud, then press Show.
Consider
What are your considerations?
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A 74-year-old with ischaemic heart disease, for TURP under spinal with glycine irrigation. Patient
At 74 with an EF of 45%, absorbed irrigant will overload him quickly; I also watch for delirium.
Spinal lets me follow his mental state; a block to T10 avoids hiding perforation pain. Surgery
Glycine is hypotonic, about 200 mOsm/L; through open venous sinuses it dilutes his sodium and fills him up. Disease
Glycine itself can blur vision and, through ammonia, cloud his consciousness.
Prepare
Take me through his cardiac risk assessment.
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I'd use the ACC/AHA stepwise approach, applied to him. Disease
Urgency: elective, so there's time to assess him properly. Stem trigger
Any active cardiac condition? He has none: angina is stable, no decompensated failure, severe valve lesion or serious arrhythmia. Disease
Risk score: TURP is low-risk surgery; his coronary disease alone gives an RCRI of 1.
Functional capacity: angina only after two flights means more than 4 METs.
Decision: low risk, so proceed; bisoprolol continued, aspirin decided with the urologist.
Plan
How will you run the case to reduce the risk?
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Resection kept under an hour; irrigant bag at 30 cm, lowered to 15 cm near the end. Surgery
No hypotonic IV fluid; spinal hypotension treated with phenylephrine 50–100 mcg, not litres of fluid. Disease
Irrigant in versus out tracked; a 1–1.5 L deficit raises his neurological risk. Surgery
Warmed irrigation to limit his heat loss and shivering.
Blood loss is hidden in irrigant, so vital signs and serial haemoglobin guide transfusion.
Perforation clues: less irrigant coming back, abdominal or shoulder pain.
Crisis
Seventy minutes into the resection he becomes confused and nauseated. BP 178/100, HR 48. Your actions?
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TUR syndrome: high pressure, slow pulse and confusion in an awake patient. Crisis
Tell the surgeon: stop resecting, secure haemostasis, and finish quickly. Surgery
Oxygen; urgent sodium, osmolality, glucose, creatinine, blood gas and a 12-lead ECG. Crisis
Rule out perforation: irrigant return and his abdomen checked.
If sodium is above 120 and symptoms mild: fluid restriction and furosemide for the overload.
Arterial line if he becomes unstable, and HDU afterwards. After surgery
Crisis
In recovery he says he can't see, then has a generalised seizure. Na 114 mmol/L, SpO2 89%. What now?
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Severe TUR syndrome: acute sodium below 120 with a seizure; glycine adds his visual loss. Crisis
Airway, 100% oxygen; midazolam 1–5 mg IV to end the seizure.
3% saline: 100 mL bolus for the seizure, then no faster than 100 mL/h.
Stopped once symptoms settle or sodium passes 120; his hyponatraemia is acute, so rapid correction is safe.
Furosemide only for clear overload, such as pulmonary oedema.
Intubate if he can't protect his airway; ICU with hourly sodium checks. After surgery
Fatal mistakes
Carrying on the resection after symptoms start.
Overshooting his sodium with hypertonic saline, or giving it for mild symptoms.
Sedating his confusion as anxiety.
Checked against: Barash 9e · Miller 10e · Acute severe iatrogenic hyponatremia: a case report (2019)