Management of Hypotension Following TURP
For hypotension following TURP, perform a passive leg raise test to determine fluid responsiveness, and treat with appropriate volume expansion if positive; otherwise, use vasopressors or inotropes based on the underlying hemodynamic cause. 1
Initial Assessment and Stabilization
- Immediately evaluate for signs of TURP syndrome (dilutional hyponatremia) which is a unique and potentially life-threatening complication 1
- Check vital signs, mental status, and obtain urgent electrolytes (particularly sodium levels)
- If patient shows signs of end-organ dysfunction (altered mental status, cyanosis, hypoxemia), transfer to a high acuity care setting 1
Diagnostic Algorithm
Perform passive leg raise (PLR) test:
- Elevate patient's legs to 45° for 1-2 minutes
- Monitor for hemodynamic response (improved blood pressure)
- PLR has 88% sensitivity and 92% specificity for predicting fluid responsiveness 1
Check serum sodium levels:
- Hyponatremia (<135 mmol/L) suggests TURP syndrome
- Severe hyponatremia (<125 mmol/L) requires immediate intervention 2
Assess for other causes:
- Bleeding/hypovolemia
- Vasodilation from anesthesia
- Cardiac dysfunction
- Fluid extravasation into peritoneal cavity 3
Treatment Based on Etiology
If PLR test is positive (fluid responsive):
- Administer IV fluid bolus (500 mL crystalloid)
- Monitor response and repeat if necessary
- Note: Research shows only about 54% of postoperative hypotension cases are fluid responsive 1
If PLR test is negative (not fluid responsive):
- Consider vasopressor therapy:
- Phenylephrine: Preferred if tachycardia is present (can cause reflex bradycardia)
- Ephedrine: Better if bradycardia is present
- Norepinephrine: For persistent hypotension
If TURP syndrome is suspected:
- Administer 3% hypertonic saline for severe hyponatremia 2, 4
- Correct sodium levels gradually to avoid central pontine myelinolysis
- Consider intubation and ventilation if respiratory compromise is present 2
- In severe cases with multiple organ dysfunction, hemodialysis may be required 5
If abdominal distension is present:
- Evaluate for fluid extravasation into peritoneal cavity
- Consider percutaneous drainage if significant fluid accumulation is detected 3
Monitoring and Follow-up
- Continuous hemodynamic monitoring
- Serial electrolyte measurements until stabilized
- Monitor for signs of bleeding (check hemoglobin/hematocrit)
- Transesophageal Doppler ultrasonography can be useful for hemodynamic monitoring in patients under general anesthesia 6
Pitfalls and Caveats
- Do not assume all post-TURP hypotension is due to hypovolemia; approximately 50% of cases require vasopressor or inotropic support rather than fluid administration 1
- Avoid excessive fluid administration in non-responsive patients as this may worsen TURP syndrome
- Be vigilant for delayed presentation of TURP syndrome (can occur up to 24 hours postoperatively)
- Standard signs of hypovolemia are not reliable predictors of fluid responsiveness in the postoperative setting 1