What is the management approach for a patient with TURP (Transurethral Resection of the Prostate) syndrome?

TURP Syndrome Management

Immediately stop the procedure, administer hypertonic saline (3% NaCl) for symptomatic hyponatremia, provide respiratory support with supplemental oxygen or mechanical ventilation as needed, and use loop diuretics (furosemide 20mg IV) to promote fluid excretion while closely monitoring serum sodium and hemodynamics. 1, 2, 3

Immediate Recognition and Procedure Termination

• Stop the TURP procedure immediately upon recognizing signs of TURP syndrome, as the first critical step is controlling bleeding and suspending the operation to prevent further irrigant absorption 4
• Monitor for classic presenting signs including confusion, nausea, hypertension, visual disturbances, bradycardia, arterial hypotension, cyanosis, and altered mental status progressing to coma 2, 5
• Recognize that symptoms can range from asymptomatic hyponatremia to convulsions, coma, and death depending on the severity of fluid absorption 4

Hyponatremia Correction Protocol

• Administer 3% hypertonic saline (150 mL) for symptomatic or severe hyponatremia (sodium <120 mmol/L), as this addresses the core pathophysiology of dilutional hyponatremia from irrigant absorption 3, 5
• Avoid overly rapid correction of sodium levels, as this can lead to osmotic demyelination syndrome; aim for gradual correction while treating acute symptoms 3
• Serial monitoring of serum sodium levels is essential, with initial values in TURP syndrome cases ranging from 90-125 mmol/L in reported severe cases 4, 5

Respiratory Management

• Provide supplemental oxygen immediately, with FiO2 of 70-100% if hypoxemia is present (pO2 <60 mmHg) 3
• Initiate non-invasive positive pressure ventilation (CPAP-PSV with +5 cmH2O PEEP, 8 cmH2O pressure support) for pulmonary edema before progressing to intubation if the patient can protect their airway 3
• Proceed to endotracheal intubation and mechanical ventilation for patients with coma, severe respiratory failure, or inability to maintain adequate oxygenation with non-invasive measures 3, 5

Fluid and Diuretic Management

• Administer furosemide 20mg intravenously to promote diuresis and excretion of excess absorbed irrigant fluid, particularly important in patients developing pulmonary edema 3
• Restrict further IV fluid administration to avoid exacerbating hypervolemia; maintain crystalloid at minimal rates (1-4 ml/kg/hr) only as needed 6
• Consider sodium bicarbonate (100 mL of 8.4% solution) if metabolic acidosis develops (pH <7.25), as seen in severe cases 3

Hemodynamic Monitoring and Support

• Continuously monitor vital signs, including heart rate, blood pressure, oxygen saturation, and urine output throughout the acute management phase 2, 6
• Consider advanced hemodynamic monitoring (transesophageal Doppler or invasive monitoring) for severe cases to guide fluid management and detect acute hypervolemia 7
• Treat bradycardia and hypotension with appropriate vasopressors if they persist despite correction of hyponatremia and volume status 5

Laboratory Monitoring

• Obtain immediate serum sodium, serum osmolality, arterial blood gas, and complete metabolic panel upon suspicion of TURP syndrome 3, 5
• Monitor for severe hyponatremia (sodium 90-125 mmol/L), decreased serum osmolality (<240 mOsmol/kg), and metabolic acidosis in affected patients 4, 3
• Serial electrolyte monitoring every 2-4 hours during acute management to guide sodium correction and assess response to treatment 3

Prevention Considerations

• The incidence of TURP syndrome is 0.78-1.4% with modern techniques, but can be minimized by limiting resection time to under 90 minutes and using bipolar TURP when available 2, 3
• Bipolar TURP has a reduced risk of TUR syndrome compared to monopolar TURP due to the ability to use isotonic saline irrigation rather than hypotonic glycine solutions 1, 8
• Multiple cystoscopic applications in the same session may facilitate development of TURP syndrome and should be avoided when possible 4

Critical Pitfalls to Avoid

• Do not delay treatment waiting for laboratory confirmation—begin empiric management based on clinical presentation, as severe cases can rapidly progress to cardiovascular collapse and death 4, 3
• Avoid using glycine 1.5% irrigation solutions, as they are associated with higher incidence of TUR syndrome and cardiac toxicity compared to glucose 5% or normal saline 0.9% 8
• Do not administer hypotonic fluids during the acute phase, as this will worsen hyponatremia and cerebral edema 3