Does a post-operative TURP (Transurethral Resection of the Prostate) patient with hyponatremia need correction?

Post-TURP Hyponatremia at 119 mEq/L Requires Immediate Correction

Yes, a post-operative TURP patient with sodium of 119 mEq/L absolutely requires correction, as this represents severe hyponatremia that can progress to life-threatening complications including seizures, coma, and death. 1, 2

Immediate Assessment

Evaluate symptom severity first - this determines the urgency and aggressiveness of correction 1:

• Severe symptoms (confusion, altered consciousness, seizures, coma, respiratory distress): Medical emergency requiring immediate hypertonic saline 1, 3
• Moderate symptoms (nausea, vomiting, headache, lethargy, gait instability): Requires monitored correction 1, 3
• Asymptomatic: Still requires treatment given the severity of hyponatremia at 119 mEq/L 1, 2

Determine acuity - TURP syndrome typically causes acute hyponatremia (<48 hours), which is critical because acute hyponatremia causes more severe symptoms at the same sodium level and can be corrected more rapidly than chronic hyponatremia 1, 3

Treatment Algorithm Based on Symptoms

For Severe Symptomatic Hyponatremia

Administer 3% hypertonic saline immediately with a target correction of 6 mmol/L over 6 hours or until severe symptoms resolve 1, 2:

• Give 100 mL boluses of 3% saline over 10 minutes, repeatable up to three times at 10-minute intervals until symptoms improve 1
• Critical safety limit: Total correction must not exceed 8 mmol/L in 24 hours to prevent osmotic demyelination syndrome 1, 2
• Monitor serum sodium every 2 hours during initial correction 1, 2

For Moderate Symptoms or Asymptomatic

Isotonic saline (0.9% NaCl) for volume repletion is appropriate, as TURP syndrome involves both hyponatremia and hypervolemia from absorbed irrigation fluid 1, 4:

• Initial infusion rate: 15-20 mL/kg/h, then 4-14 mL/kg/h based on response 1
• Target correction rate: 4-8 mmol/L per day, maximum 8 mmol/L in 24 hours 1, 2
• Monitor sodium every 4 hours after resolution of severe symptoms 1

Special Considerations for TURP Syndrome

TURP syndrome is multifactorial - it involves not just absorption of hypotonic irrigation fluid, but also stress-related ADH release, creating a combined picture of hypervolemia with impaired free water excretion 5, 4:

• The absorbed irrigation fluid (glycine, sorbitol, or mannitol solutions) creates an "osmolal gap" that can mask the true severity of hypoosmolality 6
• Patients may develop hyperglycinemia, hyperammonemia, and hypocalcemia in addition to hyponatremia 4
• Cardiovascular complications include hypotension and bradycardia 4

Consider hemodialysis for severe cases, particularly if 4, 6:

• Profound hemodynamic instability (severe hypotension, bradycardia)
• Coma or severe neurological symptoms
• Concurrent renal failure
• Need for rapid correction while removing absorbed solutes (sorbitol, mannitol)

Critical Safety Guidelines

Never exceed 8 mmol/L correction in 24 hours - this is the single most important principle to prevent osmotic demyelination syndrome 1, 2:

• If 6 mmol/L are corrected in the first 6 hours, only 2 mmol/L additional correction is allowed in the next 18 hours 1
• Watch for signs of osmotic demyelination syndrome (dysarthria, dysphagia, oculomotor dysfunction, quadriparesis) typically occurring 2-7 days after rapid correction 1, 2

Acute hyponatremia (<48 hours) can be corrected more rapidly than chronic hyponatremia without risk of osmotic demyelination, but the 8 mmol/L/24-hour limit still applies 1

Common Pitfalls to Avoid

• Ignoring asymptomatic severe hyponatremia - sodium of 119 mEq/L carries a 60-fold increased mortality risk and requires treatment even without symptoms 1, 3
• Using hypotonic fluids - this will worsen hyponatremia in the setting of elevated ADH 1, 5
• Overcorrection - exceeding 8 mmol/L in 24 hours risks devastating osmotic demyelination syndrome 1, 2
• Inadequate monitoring - sodium levels must be checked every 2 hours initially during active correction 1, 2