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Chapter 5: Fluids and Electrolytes

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A 70-year-old patient underwent transurethral resection of the prostrate. An irrigating solution (of 1.5% glycine) was used to distend the urethra and to obtain a clear surgical field. Postoperatively, he becomes agitated, begins to vomit, and develops muscle twitching, bradyarrythmias, hypertension, and respiratory failure. What is the most likely cause of his symptoms?

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(A) Hyperglycinemia

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(B) Urosepsis

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(C) Hyponatremia

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(D) Hypoxia

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(E) Hypertensive crisis

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(C) Transurethral resection of the prostate (TURP) syndrome occurs from a combination of fluid overload, hyperosmolality, and hyponatremia following endoscopic surgical procedures. The syndrome has been reported in 1–2% of patients undergoing TURP and has a reported mortality rate of 0.2–0.8%.

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The syndrome is attributed to varying degrees of absorption of the irrigating fluid (300 mL to 4 L) via the exposed or open vascular bed of the prostate, resulting in electrolyte abnormalities based on the irrigation solution being used. The severity of the syndrome depends on the volume of solution absorbed as well as the nature of the irrigating solution. Early symptoms include parasthesia (prickling and burning sensation of the skin) of the face and neck, transient blindness, hypertension and chest pain, nausea, and vomiting, followed by signs of encephalopathy—confusion, apprehension, muscular twitching, and altered consciousness. Grand mal seizures, severe hypotension, bradyarrythmias, pulmonary edema, and cardiac arrest may supervene in the most severe cases.

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There is usually severe hyponatremia due to the inability to use physiologic saline during endoscopic procedures because of the interference of the ionic solution content with the electrocautery current. Therefore, the hyponatremia is dilutional and is seen in nearly all cases along with hyperglycemia. When glycine is used for irrigation, its metabolism results in hyperammonemia, which leads to more pronounced encephalopathy. Finally, hyperkalemia results from the transcellular fluid shifts and may contribute to the arrhythmias and hemodynamic instability in this syndrome.

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BIBLIOGRAPHY

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Hawary A, Mukhtar K, Sinclair A, Pearce I. Transurethral resection of the prostate syndrome: almost gone but not forgotten. J Endourol 2009;23(12):2013–2020.

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A 28-year-old male presents to the emergency room after falling while working in the yard. He complains of feeling weak and dizzy when he stands up. His supine blood pressure (BP) is 120/60 mmHg with a heart rate of 96 bpm. On standing, he has a BP of 85/30 mmHg and a heart rate of 120 bpm. He states he was fine earlier in the day and drank fluids to try to avoid dehydration. The rest of his examination is unremarkable except for a small laceration on his right elbow. X-rays did not reveal a fracture. ...

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