Original Contributions
Transurethral resection syndrome: effect of the introduction into clinical practice of a new method for monitoring fluid absorption

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Abstract

Study Objective: To determine the effects of introduction of a new monitoring system for fluid absorption during transurethral resection of the prostate (TURP) using an irrigating solution containing 0.5% alcohol.

Study design: Prospective clinical investigation, with implementation of statistical process control.

Setting: Inpatients for TURP at a major non-university teaching hospital.

Patients: 312 male ASA physical status I, II, III, and IV patients scheduled for TURP.

Interventions: Intraoperative breath alcohol levels were measured for detection of fluid absorption.

Measurements and Main Results: Calculation of the amount of fluid absorbed using measured breath alcohol values. Process variability (i.e., numbers of patients with significant fluid absorption) was defined by statistical process control tools. No trend change of prevalence of fluid absorption was noted until 150 procedures had been completed. Reduction of prevalence of significant fluid absorption was noted and no patients were treated postoperatively in the intensive care unit. No relevant side effects were seen in patients with significant fluid absorption. No mortality and no severe clinical morbidity was seen after the introduction of the new monitoring.

Conclusion: Using an irrigating fluid marked with 0.5% ethanol resulted in a decreased prevalence of fluid absorption over time.

Introduction

Endoscopic transurethral resection of the prostate (TURP) is a commonly used surgical procedure to treat benign or cancerous enlargements of the prostate. One side effect is known as transurethral resection (TUR) syndrome, a condition caused by excessive absorption of hypotonic bladder irrigating fluid.

Excessive absorption of irrigating solution leads to fluid overload and dilution of plasma electrolytes and clotting factors. The resulting hyponatremia and hypervolemia can cause major morbidity and mortality.1 Several methods have been proposed to quantify the amount of systemic irrigating fluid absorption; these include measuring the inflow and outflow volumes, body weight, measuring serial plasma concentrations of glucose, mannitol, sorbitol, and glycine, and using radioisotopes in the irrigating solution.2, 3 In 1986, adding alcohol to the irrigating fluid and measuring end-tidal alcohol concentration was proposed as a routine monitoring method.4 Considering that absorption volumes in excess of 1000 ml are common, irrigating solutions containing 1% and 2% alcohol can have systemic side effects, with sensorial disturbances.5, 6 Alcohol intoxication can make it difficult to recognize the central nervous sign of hyponatremia.4, 7 Thus, the aim of this study was to examine: (1) the utility of a 0.5% alcohol-containing irrigating solution to detect small amounts of fluid absorption and (2) the possible reduction of fluid absorption when monitoring the absorption by an alcohol irrigating solution using statistical methods of process control.

Section snippets

Materials and methods

A 0.5% alcohol and 4% glucose containing electrolyte-free irrigating solution was used in 312 consecutive male patients undergoing TURP. The Kantonsspital Ethics Committee approved the change of practice, and each patient gave verbal informed consent to undergo the procedure.

End-tidal alcohol concentrations were determined at 10-minute intervals during surgery. A portable electrochemical alcohol analyzer (Alcomed 3010, Biotest Co., Frankfurt, Germany) was used to measure ethanol concentrations.

Results

Demographic data of the patient population are summarized in Table 1. End-tidal alcohol concentrations were observed in 47.8% of all the patients, indicating fluid absorption. When absorption occurred, maximum values typically were recorded 30 to 40 minutes after the start of surgery (Figure 1). Sudden peak concentrations due to the direct IV route (periprostatic veins) were observed in single cases. Figure 1 demonstrates the time course of prevalence of absorption. The mean absorbed volume

Discussion

Measurement of the extent of systemic fluid uptake in TURP by marking the irrigating solution with alcohol and measuring end-tidal alcohol concentration was introduced into clinical practice in 1986.4 Initially, we also used 2% alcohol-containing irrigating solution. Because the use of the breath analyzer was somewhat cumbersome, it was not accepted by our staff for routine clinical application. With the advent of a more sensitive analyzer that was easy to use (Alcomed 3010, Biotest Co.,

Acknowledgements

We would like to thank Beat Kaiser, CRNA, Lucerne, for his enthusiasm and help performing this investigation, and Rom Stevens, MD, Chicago, for editorial assistance.

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