2. HISTORY
69 year old male patient, hailing from Dhayari, farmer by
occupation, presented with complaints of
Increased frequency of micturition x 2 years
Dribbling of urine during micturition x 2 years
And feeling of sensation of incomplete bladder emptying and
weak urine stream
3. HISTORY OF PRESENT ILLNESS
Patient is a known case of HTN since 6 years on regular medications. He is on the following
drugs
T. Amlodipine + Telmisartan(5+40) OD
T. Metoprolol 12.5 mg OD
He can climb 2 flight of stairs which is suggestive of METS>4
Patient was apparently alright 2 years back when he noticed increase frequency of
micturition associated with history of waking up at night with urge to pass urine. He also gives
history of sense of incomplete bladder emptying post micturition. He gives history of hospital
admission 7 days back for prostatic biopsy.
No h/o pain while micturition or blood in urine
No h/o significant weight loss or loss of appetite
No h/o fever, abdominal pain, vomiting
No h/o previous catheterization
No h/o IHD, dyslipidemia, CVA, malignancy
No h/o bronchial asthma, thyroid, Kochs or Kochs contact
4. ⮚ PERSONAL HISTORY
He has a mixed diet. He has disturbed sleep due to awakening
to pass urine. His bowel and bladder habits are normal. He is a
non smoker and non alcoholic.
⮚ DRUG HISTORY
T. Amlodipine + Telmisartan(5+40) OD
T. Metoprolol 12.5 mg OD
No known drug allergy
⮚ SURGICAL HISTORY
H/o prostate biopsy 7 days back
⮚ FAMILY HISTORY
No h/o similar complaints among family members.
5. GENERAL EXAMINATION
Patient is comfortable in sitting as well as supine position.
Conscious, well oriented in time, place and person
Averagely built, well nourished
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Patient is afebrile
PR- 76bpm, regular in rate, rhythm, normal in volume and
character
No radio-radial or radio-femoral delay
All peripheral pulses well felt
BP- 150/80 mmHg in right brachial artery in sitting position and
144/82 mmHg in supine position. No positional variation
RR- 14/min, regular, abdomino-thoracic
Saturation- 98% on room air
JVP not raised
6. Patient has been catheterized after hospital admission
Spine- appears normal and interspinous spaces well felt
Thyroid normal
Airway- No loose or missing teeth, no artificial dentures
-mouth opening > 3 finger breadth
-mallampati class 1
-neck movements adequate
All other systems- WNL
7. DIAGNOSIS
69 year old male patient, known hypertensive
with complaints of increased frequency,
dribbling of urine, sense of incomplete bladder
emptying is probably a case of benign prostatic
hyperplasia posted for TURP
9. AGE-RELATED PHYSIOLOGICAL
CHANGES
• Three Groups of Physiological Changes
1)Changes in autonomic functions and cellular
homeostasis e.g.
temperature, blood volumes and Endocrine
changes
2) Reduction in organic mass
e.g. brain, liver ,kidneys, bones and muscles
3)Reduction in organic
functional reserve e.g. lungs and heart
• Systems Affected
Cardiovascular system
Respiratory System
Central nervous system
Genitourinary System
Gastrointestinal System
Endocrine System
Skin and Musculoskeletal System
Body temperature regulation
Immune System
20. ANAESTHETIC GOALS
1) Keep blood pressure – 20 to 30% of baseline
2)Pressure gradient between distended bladder and prostatic venous plexus
should be maintained
3) Heart rate- between 60-100/min
4) Maintain pre load
5)Maintain afterload
6)Maintain haematocrit>28%
7)Maintain temperature >35.4 degree Celsius
8)Continuous mental monitoring – for detection of complications
22. PREPARATION OF THE PATIENT
1) Inform and counselling of patient regarding anaesthesia ,complication and
surgical procedure
2) Instructions to the patient regarding Drugs to be continued or to be hold
on the day of surgery
3) Low dose benzodiazepine on the night prior to surgery
4) NPO orders
• On the day of surgery
1)Check Sr.Na,K,
2)Fasting blood sugar
3)Availability of blood products
4)NPO status
5) Wide bore IV access
23. • 5 lead ECG
• Pulse-oximeter
• NIBP
• Temperature probe
• Invasive BP
monitoring:
indicated in patient
with cardiac
dysfunction
• Forced air warmers
• Fluid warmer
• Ambient OT
temperature
• Emergency drugs
• Airway equipments
• Suction
• O2 delivery devices
Choice of fluid
Balanced salt
solution
0.9% Normal saline
OT preparation Monitoring
25. • SURGICAL TECHNIQUE: Special cystoscope with diathermy loop with
continuous irrigation used. Prostatic tissue resected and simultaneously
hemostasis is achieved.
• COMPLICATIONS
Rupture of prostatic capsule.
Overabsorption of irrigating fluid- water intoxication
Bladder distension
Bladder perforation
30. FACTORS AFFECTING RATE OF
ABSORPTION OF FLUID
• RULE OF 60
• Duration of surgery- 60 minutes
• Age of patient- more than 60 years
• Size of prostate gland – more than 60 grams
• Height of irrigation fluid- 60cm above pubic symphysis
• Hydrostatic pressure- 60 cm of H20
33. REGIONAL ANAESTHESIA
ADVANTAGES
• Allows monitoring of mentation and early signs of TURP Syndrome.
• Detection of bladder perforation.
• Promotes peripheral vasodilatation and reduces circulatory overload.
• Reduces blood loss, requiring fewer blood transfusions.
• Good postoperative analgesia.
• Neuroendocrine and immune responses are better preserved.
• Reduces incidence of postoperative DVT/PE.
• Lower cost
DISADVANTAGES
• Hypotension.
• Obturator reflux cannot be obtunded.
• Incidence of TURP syndrome more in regional anaesthesia.
34. GENERAL ANAESTHESIA
ADVANTAGES
• Useful for patients who are unable to lie supine.
• Useful for patients with neuromuscular diseases and pulmonary compromise.
DISADVANTAGES
• Risk of aspiration.
• Postoperative analgesia needed.
• Unable to monitor mental status.
• Reduced FRC due to lithotomy position.
• Postoperative nausea and vomiting
35. EPIDURAL ANAESTHESIA
BENEFITS OF EPIDURAL ANESTHESIA
• Ability to titrate the drug to the effective level of sensory block.
• Help reduce chronic pain levels.
• Intraoperative anaesthesia and postoperative analgesia.
• Less respiratory depression.
• Less hemodynamic instability.
• Less incidence of higher block.
40. TURP SYNDROME
SYMPTOMS
• CNS manifestations- Disorientation, restlessness, confusion, agitation,
drowsiness, convulsions and coma. Due to water intoxication, dilutional
hyponatremia and hypoosmolality.
• CVS manifestations- Dyspnoea, pulmonary congestion, pulmonary oedema,
and cardiac overload. Due to fluid overload and the negative ionotropic
effect of hyponatremia.
• Haemolysis
• Hypothermia
41. MANAGEMENT
1. Administer 100% oxygen.
2. Ask surgeon to stop the surgery, after achieving hemostasis.
3. Airway, breathing, circulation.
4. Management of hyponatremia
• Inj. Furosemide 20mg bolus , followed by upto 40mg. Inj. Mannitol 20% as an
alternative.
• Intravenous Hypertonic Saline 3%( Na+- 512meq/L)
• Sodium estimation- 60% of body weight*2 (amt in ml will raise sodium by 1meq/L/hr.
• Rate of infusion 100ml/hr.
• Rate of correction-1-1.5meq/hr
42. WHAT ARE THE INDICATORS FOR EARLY
DETECTION OF FLUID ABSORPTION?
49. Monitor for signs and symptoms of TURP syndrome
• Serial monitoring of Sr. sodium, calcium, magnesium, osmolarity, ABG
• Monitor coagulation profile
• Assess blood loss
• Provide adequate analgesia
• Monitor for postoperative cognitive dysfunction
