TURP Syndrome cause, presentation and preventive measures

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TURP syndrome causes clinical features prevention irrigation fluid guidelines

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TURP syndrome

TURP syndrome is acute dilutional hyponatremia with fluid overload caused by systemic absorption of irrigation fluid during transurethral resection of the prostate. It can occur intraoperatively or within 24 hours.
Miller's Anesthesia, 10e, p. 6373.

Cause and risk factors

During resection, prostatic venous sinuses are opened. Irrigation fluid can then enter the circulation, particularly when it is hypotonic and electrolyte-free, such as glycine, sorbitol, or mannitol solutions used with monopolar resection.

This produces:

Water intoxication and acute dilutional hyponatremia
Intravascular volume expansion causing circulatory overload
Hypo-osmolality, leading to cerebral edema
Irrigant-specific toxicity:
- Glycine: visual disturbance, encephalopathy, seizures; metabolism may cause hyperammonemia
- Sorbitol: hyperglycemia
- Mannitol: volume expansion

Risk factors

Long resection time, especially >1 hour
Large prostate or extensive resection
High irrigation-bag height and high intravesical pressure
Large volume of irrigant used or absorbed
Open venous sinuses and capsular perforation
Reduced cardiac or renal reserve

Miller's Anesthesia, 10e, p. 6373; Morgan and Mikhail's Clinical Anesthesiology, 7e, pp. 1302-1303.

Clinical presentation

Manifestations reflect fluid overload, acute hyponatremia, hypo-osmolality, and sometimes glycine toxicity.

Early features

Nausea and vomiting
Headache
Restlessness, anxiety, agitation
Blurred vision or transient visual loss, classically with glycine
Confusion, reduced alertness

Cardiorespiratory features

Initially hypertension and bradycardia from volume expansion
Dyspnea, hypoxemia/cyanosis
Pulmonary edema and heart failure
Arrhythmias
Later, hypotension and shock may occur

Severe neurologic features

Marked confusion or obtundation
Seizures
Coma
Death if untreated

Laboratory findings include a rapid fall in serum sodium, low serum osmolality, and hemodilution. Severe hyponatremia may cause cerebral edema.

Prevention

Prefer bipolar TURP with isotonic saline irrigation
This avoids the hypo-osmolar hyponatremia associated with electrolyte-free hypotonic fluids. Saline absorption can still cause volume overload.
Limit duration and extent of resection
Reassess carefully if irrigation/resection exceeds about 1 hour. Stage a large resection when needed.
Use the lowest effective irrigation pressure
Keep intravesical pressure low, avoid excessive height of the irrigation bag, ensure unobstructed outflow, and avoid bladder overdistension.
Monitor irrigant fluid balance
Measure fluid instilled versus recovered. A large unexplained fluid deficit suggests systemic absorption.
Stop or pause surgery if absorption is substantial
Assess serum sodium and clinical state if there is concern for absorption. The textbook guidance advises stopping surgery at lower absorption thresholds, especially in women, and terminating for very high volumes.
Miller's Anesthesia, 10e, p. 6373.
Use regional anesthesia where appropriate
Spinal anesthesia may allow earlier recognition of nausea, visual symptoms, agitation, or confusion in an awake patient. Sedation should not mask these warning signs.
Monitor high-risk patients closely
Monitor ECG, blood pressure, oxygenation, fluid balance, and check serum electrolytes when resection is prolonged or absorption is suspected.

Memory line:
TURP syndrome = absorbed hypotonic irrigant → hypervolemia + acute hyponatremia + cerebral/pulmonary edema.

Write a note on artificial nutritional support

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ASPEN safe practices enteral parenteral nutrition support indications complications monitoring

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Artificial Nutritional Support

Artificial nutritional support is the provision of nutrients by routes other than normal oral eating when oral intake is impossible, inadequate, unsafe, or insufficient to meet metabolic requirements. It aims to prevent or treat malnutrition, preserve lean body mass, support wound healing and immunity, and improve recovery.

The two major forms are:

Enteral nutrition (EN): nutrients delivered into the gastrointestinal tract through a tube.
Parenteral nutrition (PN): nutrients delivered intravenously, bypassing the gastrointestinal tract.

Principle: If the gut is functional and can be used safely, enteral nutrition is preferred. Parenteral nutrition is reserved for patients with a non-functioning or inaccessible gut.
Sabiston Textbook of Surgery, 22e, p. 153; Tietz Textbook of Laboratory Medicine, 7e, p. 1016.

Indications

Artificial nutrition is considered in patients with:

Inadequate oral intake for a prolonged period or anticipated inability to eat
Established malnutrition or high risk of malnutrition
Hypermetabolic states, such as major trauma, burns, sepsis, or cancer
Dysphagia due to stroke, neurological disease, or head and neck malignancy
Critical illness requiring ventilatory support
Major gastrointestinal surgery, especially when prolonged fasting is expected
Malabsorption or increased nutrient losses

Before starting support, assess nutritional status, disease severity, anticipated duration of poor intake, fluid status, electrolyte abnormalities, renal/hepatic function, and risk of refeeding syndrome.

1. Enteral nutrition

Definition

Enteral nutrition provides nutritionally complete liquid feeds directly into the stomach or small intestine.

Routes

Short-term routes

Nasogastric (NG) tube: nose to stomach
Nasojejunal or nasoduodenal tube: nose to small bowel
Orogastric tube: often in intubated patients

Long-term routes

Percutaneous endoscopic gastrostomy (PEG)
Gastrostomy
Jejunostomy

Indications

Enteral feeding is indicated when the patient cannot take sufficient food orally but has a functioning gastrointestinal tract, for example:

Dysphagia after stroke
Reduced consciousness with a protected airway
Head and neck cancer
Neurological disorders such as motor neuron disease
Critically ill patients with a functioning gut
Severe malnutrition with inadequate oral intake
Postoperative patients in whom oral intake is delayed but bowel function is usable

Advantages

More physiological and generally safer than PN
Maintains gut mucosal integrity and intestinal motility
Reduces bacterial translocation from the gut
Usually causes fewer infective complications than PN
Less expensive
Can be used for prolonged nutritional support

Methods of administration

Continuous feeding: pump-controlled, usually best tolerated in hospitalized or critically ill patients
Intermittent feeding: feed given over 20 to 30 minutes at intervals
Bolus feeding: larger volumes at intervals, suitable only for gastric feeding and stable patients

Feeds are usually started at a low rate and advanced gradually according to tolerance. The head of the bed should be elevated by about 30 to 45 degrees to reduce aspiration risk.
Sabiston Textbook of Surgery, 22e, p. 153.

Contraindications to enteral feeding

Intestinal obstruction
Bowel perforation
Intestinal ischemia
Severe uncontrolled gastrointestinal bleeding
Severe ileus
High-output fistula where feeding distal to the fistula is not possible
Intractable vomiting or severe diarrhea
Severe hemodynamic instability or shock

Complications of enteral nutrition

Mechanical

Tube malposition or displacement
Nasal, pharyngeal, or esophageal injury
Tube blockage
Gastrostomy-site infection or leakage

Pulmonary

Regurgitation and aspiration pneumonia

Gastrointestinal

Nausea, vomiting, abdominal distension
Diarrhea or constipation
Cramps and bloating

Metabolic

Hyperglycemia
Electrolyte imbalance
Fluid overload or dehydration
Refeeding syndrome

Prevention includes confirming tube position before use, maintaining head elevation, regular flushing of the tube, aseptic care of the stoma, and gradual initiation of feeds.

2. Parenteral nutrition

Definition

Parenteral nutrition supplies nutrients directly into the bloodstream through a venous catheter. It may be:

Supplementary PN: complements inadequate oral or enteral intake.
Total parenteral nutrition (TPN): provides the entire nutritional requirement intravenously.

Indications

PN is indicated when enteral feeding is contraindicated, impossible, or inadequate because of gastrointestinal dysfunction. Common indications include:

Intestinal obstruction
Paralytic ileus
Short-bowel syndrome or extensive intestinal resection
Severe malabsorption
High-output enterocutaneous fistula
Severe inflammatory bowel disease when enteral feeding cannot be tolerated
Severe intestinal dysmotility
Prolonged bowel rest required after certain surgical conditions

Tetz Textbook of Laboratory Medicine, 7e, p. 1016.

Routes of administration

Peripheral parenteral nutrition (PPN): for short-term use and lower-osmolarity solutions. It has limited caloric capacity and may cause thrombophlebitis.
Central parenteral nutrition: via a central venous catheter, PICC, tunneled catheter, or implanted port. This permits concentrated, high-osmolarity feeds and is used for longer duration or full nutritional requirements.

Composition of PN

A typical PN prescription is individualized and contains:

Water
Glucose as carbohydrate
Amino acids as protein source
Lipid emulsion as calorie and essential-fatty-acid source
Electrolytes: sodium, potassium, calcium, magnesium, phosphate
Vitamins and trace elements
Sometimes insulin, depending on glucose control

Complications of parenteral nutrition

Catheter-related

Pneumothorax, arterial puncture, air embolism during insertion
Catheter occlusion or thrombosis
Catheter-related bloodstream infection and sepsis

Metabolic

Hyperglycemia or hypoglycemia
Hypertriglyceridemia
Electrolyte disturbances
Fluid overload
Acid-base disorders
Refeeding syndrome

Hepatobiliary

Fatty liver and cholestasis
Abnormal liver enzymes
Gallbladder sludge or gallstones with long-term PN

PN requires strict aseptic technique, catheter care, and regular biochemical monitoring.
Bailey and Love's Short Practice of Surgery, 28e, p. 360.

Refeeding syndrome

Refeeding syndrome is a potentially life-threatening metabolic complication occurring after nutrition is started in severely malnourished or starved patients.

Carbohydrate administration increases insulin secretion and drives phosphate, potassium, and magnesium into cells. The characteristic abnormality is hypophosphatemia. It may cause:

Cardiac arrhythmias and heart failure
Muscle weakness
Respiratory failure
Confusion, seizures, or coma
Fluid retention and edema

Prevention

Identify high-risk patients before feeding
Correct major electrolyte and fluid deficits
Give thiamine before and during initial feeding
Start feeding slowly and advance gradually
Monitor phosphate, potassium, magnesium, glucose, fluid balance, and clinical status closely

Refeeding syndrome may occur with either enteral or parenteral nutrition.
Schwartz's Principles of Surgery, 11e, p. 52.

Monitoring during artificial nutritional support

Monitor:

Daily clinical examination and fluid balance
Body weight and nutritional intake
Blood glucose
Serum electrolytes, especially phosphate, potassium, and magnesium
Renal and liver function tests
Full blood count when indicated
Serum triglycerides in patients receiving intravenous lipids
Enteral-feed tolerance: vomiting, distension, bowel movements, aspiration risk
Catheter site and signs of infection in PN

Artificial nutrition should be prescribed and monitored by a multidisciplinary nutrition-support team, including clinicians, nurses, dietitians, pharmacists, and laboratory specialists.

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