Can I give torsemide (Dytor) to a patient undergoing transurethral resection of the prostate (TURP) tomorrow?

Can Torsemide (Dytor) Be Given to a Patient Undergoing TURP Tomorrow?

Yes, torsemide can be given to a patient undergoing TURP tomorrow, but only if there is a compelling clinical indication (such as acute heart failure or severe fluid overload) that outweighs the risks of perioperative diuretic use. However, routine administration of diuretics immediately before TURP should generally be avoided due to concerns about fluid and electrolyte management during the procedure.

Key Considerations for Perioperative Diuretic Use

Fluid and Electrolyte Management Concerns

• Torsemide causes dose-related increases in BUN, creatinine, and uric acid, with mean increases in serum creatinine of 0.05 mg/dL and BUN of 1.8 mg/dL in clinical trials 1

• The most common electrolyte disturbance is hypokalemia, occurring in a dose-related manner, with approximately 1.5% of patients developing serum potassium below 3.5 mEq/L 1

• TURP requires careful fluid balance monitoring during the procedure, with maintenance crystalloid administration at 1-4 ml/kg/hr recommended by the American College of Surgeons 2

• Preoperative volume depletion from diuretics can complicate intraoperative hemodynamic management and increase the risk of hypotension and worsening renal function 1

Bleeding Risk Considerations

• Post-TURP bleeding is the most common complication, requiring continuous bladder irrigation with large-caliber catheters (20-24 Fr) and potentially endoscopic intervention 3, 4

• Immediate postoperative bleeding (within 24 hours) typically represents inadequate hemostasis, while delayed bleeding (7-14 days) suggests eschar separation or infection 3

• Patients with volume depletion or electrolyte abnormalities may have impaired hemostasis and increased bleeding risk 4

Specific Clinical Scenarios

If the patient has acute heart failure or severe volume overload:

• Continue torsemide but ensure electrolytes (especially potassium) are checked and corrected before surgery 1
• Coordinate with anesthesia regarding intraoperative fluid management 2
• Ensure adequate hydration status is maintained to avoid hypotension during spinal/general anesthesia 1

If the patient is on chronic diuretic therapy for hypertension or mild heart failure:

• Consider holding the morning dose on the day of surgery to avoid excessive diuresis and volume depletion 2
• Resume diuretics postoperatively once adequate urine output is established and bleeding is controlled 2

If there is no compelling indication for diuretic use:

• Hold torsemide the day before and day of surgery 2
• Resume once the patient is stable postoperatively with adequate oral intake 2

Practical Algorithm for Decision-Making

1. Assess the indication for torsemide:

   • Acute decompensated heart failure or pulmonary edema → Continue with close monitoring 1
   • Chronic stable heart failure or hypertension → Hold morning dose on day of surgery 2
   • No clear indication → Discontinue 2

2. Check preoperative electrolytes:

   • Correct potassium to >3.5 mEq/L before proceeding 1
   • Ensure adequate hydration status (assess BUN/creatinine ratio) 1

3. Coordinate with anesthesia:

   • Inform anesthesia team of diuretic use and volume status 2
   • Plan for goal-directed fluid therapy during procedure 2

4. Postoperative management:

   • Monitor for TUR syndrome (hyponatremia, confusion, cardiovascular instability) 2
   • Use balanced crystalloid solutions (lactated Ringer's) for maintenance fluids 2
   • Resume diuretics only after bleeding is controlled and adequate urine output established 4

Common Pitfalls to Avoid

• Do not routinely continue diuretics without assessing volume status and electrolytes preoperatively 1

• Avoid excessive fluid restriction in patients on chronic diuretics, as this increases the risk of acute kidney injury perioperatively 2

• Do not resume diuretics immediately postoperatively if there is ongoing hematuria or concern for bleeding, as volume depletion can worsen hemodynamic instability 4

• Ensure potassium supplementation is adequate before surgery, as hypokalemia increases the risk of cardiac arrhythmias during anesthesia 1