TURP syndrome

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
• Rarer 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

Evaluation

• CMP
  • 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 elevation
  • Due to deamination of glycine and serine
• Serum osmolarity
  • Osmolar gap elevated
    • Due to glycine
• CXR
  • Signs of volume overload, pulmonary edema
• ECG
  • +/- arrhythmias if severe

Management

• Address 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

See Also

• Hyponatremia

References

https://litfl.com/turp-syndrome/