Journal of Clinical Anesthesia (2006) 18, 245 – 250
Original contribution
Comparison of hemodynamic profiles in transurethral
resection of prostate vs transurethral resection of
urinary bladder tumors during spinal anesthesia:
a bioimpedance study
Tiberiu Ezri MDa,h,*, Nidal Issa MDb, Deeb Zabeeda MDa,
Benjamin Medalion MDc, Alexander Tsivian MDd, Reuven Zimlichman MDe,f,
Peter Szmuk MDg,h, Shmuel Evron MDa,h
a
Department of Anesthesia, Wolfson Medical Center, affiliated to Sackler Medical School, Tel Aviv University, 58100 Israel
Department of Surgery bAQ, Wolfson Medical Center, affiliated to Sackler Medical School, Tel Aviv University, 58100 Israel
c
Department of Cardiothoracic Surgery, Wolfson Medical Center, affiliated to Sackler Medical School,
Tel Aviv University, 58100 Israel
d
Department of Urology, Wolfson Medical Center, affiliated to Sackler Medical School, Tel Aviv University, 58100 Israel
e
Department of Internal Medicine, Wolfson Medical Center, affiliated to Sackler Medical School, Tel Aviv University, 58100 Israel
f
Institute of Physiologic Hygiene, Wolfson Medical Center, affiliated to Sackler Medical School, Tel Aviv University,
58100 Israel
g
Department of Anesthesiology, the University of Texas Medical School at Houston, TX 77030, USA
h
Outcomes Researchk Institute, University of Louisville, KY 40202, USA
b
Received 29 November 2004; accepted 21 December 2005
Keywords:
TURP;
TURT;
Hemodynamics;
Hypertension;
Cardiac output;
Thoracic bioimpedance
Abstract
Study Objective: Transurethral resection of prostate (TURP) is more frequently associated with
perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT)
because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared
the patients’ intraoperative hemodynamic profiles (including the incidence of hypertension) during
TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method.
Design: Prospective single-blind study.
Setting: University hospital.
Patients: 80 (40 in each group) men, ASA physical status I and II.
Interventions: Patients underwent TURP or TURT surgery with spinal anesthesia.
Measurements: Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance
were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline
* Corresponding author. Department of Anesthesia, Wolfson Medical Center, Holon, 58100, Israel. Tel.: +3 5028229; fax: +03 5028218.
E-mail address: [email protected] (T. Ezri).
URL: www.or.org
0952-8180/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2005.12.008
246
T. Ezri et al.
value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively,
and postoperatively.
Main Results: Transurethral resection of prostate patients received more irrigating fluid (7900 F
2310 vs 5650 F 21 560, P b 0.05) and had a higher calculated volume of fluid absorbed: 638 F 60 vs
303 F 40 mL for the TURT patients ( P b 0.05). Mean arterial pressures were higher with TURP,
30 minutes after the onset of surgery and at the end of the procedure (111 F 15 vs 100 F 10 and
109 F 14 vs 99 F 14 mmHg, respectively; P b 0.05). However, there was no hypertension in either
group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic
patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 F 2.6 mEq/L
baseline to 134.1 F 3.5 mEq/L, P b 0.05) and was lower postoperatively in the TURP group
compared with TURT (134.1 F 3.5 vs 137.2 F 2.9 mEq/L, P = 0.04).
Conclusions: Although more irrigating fluid was absorbed in the TURP group, there were no
episodes of hypertension in either group.
D 2006 Elsevier Inc. All rights reserved.
1. Introduction
Transurethral resection of prostate (TURP) or transurethral resection of bladder tumors (TURT) might be
associated with hyponatremia and hemodynamic disturbances as a result of bladder irrigation and excessive intravascular absorption of glycine into the circulation [1,2]. This
may lead to circulatory overload, toxic effects including
neurologic manifestations [1,2], dilution of electrolytes and
proteins, and impairment of renal function [1-3]. The
diagnosis of transurethral resection (TUR, TURP or TURT)
syndrome is based upon clinical signs and laboratory
findings of dilutional electrolyte disturbances [1-3].
Impedance cardiography has been proposed as a simple
and readily reproducible noninvasive technique for the
determination of cardiac output (CO) and intrathoracic fluid
content [4,5].
Considering that fluid overload might be accompanied
by hypertension and other cardiovascular disturbances, we
therefore compared the intraoperative hemodynamic profiles
of the patients undergoing TURP surgery vs those having
TURT, both performed under spinal anesthesia, by using the
bioimpedance method.
2. Materials and methods
After obtaining the institutional review board approval
and patient’s written informed consent, we included in
this prospective single-blind study, 80 men (40 in each
group), American Society of Anesthesiologists (ASA) I to II
patients scheduled to undergo TURP or TURT, during
spinal anesthesia.
Excluded from the study were patients with a history of
heart failure or an ejection fraction of less than 50% (if data
were available) and patients receiving diuretics.
Before the performance of spinal anesthesia, a bolus of
10 mL/kg of lactated Ringer’s solution was administered.
During surgery, lactated Ringer’s solution was given at a rate
of 5 mL/kg per hour. Spinal anesthesia (and data measure-
ments and recording) was carried out by an anesthesiologist
bblindedQ to the type of surgery. The patient was placed in
sitting position and spinal anesthesia was performed at L3-4
or L4-5 intervertebral space with a 26-gauge pencil point
needle. Hyperbaric bupivacaine (12.5 mg) along with 20 lg
fentanyl was injected into the subarachnoid space. Patients
with incomplete or failed spinal anesthesia were subsequently
excluded from the study and received general anesthesia.
Mild discomfort was managed with aliquots of 50 lg of
intravenous (IV) fentanyl.
Irrigating fluids (1.5% glycine) were administered with
the same irrigating systems. The height at which the
irrigating fluid bag was held and the pressure applied on
the bag were similar in all patients.
2.1. Measurements
The primary end points of the study were the number of
episodes of hypertension (defined as changes of N30% from
the baseline, ie, preanesthetic/before spinal anesthesia and
the IV fluid bolus) and the number of episodes of changes
greater than 30% from the baseline value in heart rate (HR),
cardiac index (CI), and systemic vascular resistance (SVR).
Another end point was the need for hemodynamic pharmacologic interventions to correct hypertension. If it
occurred, hypertension would have been treated with
aliquots of 2.5 mg labetalol if the HR was more than
60 beats per minute or 2.5 mg hydralazine if the HR was
less than 60 beats per minute. If hypotension occurred, it
would have been treated with 5 mg ephedrine IV. Bradycardia, defined as a HR of less than 45 beats per minute with
mean arterial pressure (MAP) of more than 60 mmHg or
less than 60 beats per minute associated with MAP of
less than 60 mmHg, was treated with 0.5 mg IV atropine.
Also measured were preoperative (before spinal anesthesia
and the IV fluid bolus, baseline value), intraoperative (at the
end of surgery), and postoperative (one hour after
surgery) concentrations of serum sodium, hemoglobin, and
the amount of fluid input (IV lactated Ringer’s solution and
1.5% glycine solution for bladder irrigation).
Hemodynamics under spinal anesthesia for TURP vs TURT
Additional variables recorded included demographics,
upper sensory level of spinal anesthesia, and hemodynamic
variables, including MAP and HR, measured noninvasively
and recorded before spinal anesthesia, every 5 minutes
thereafter till the end of surgery, 5 minutes after elevating
the legs to lithotomy position, and 5 minutes after lowering the
legs from the stirrups to supine position (end of surgery). At
the same time points, CI was measured with the thoracic
bioimpedance method (Model NCCOM3; BoMed Medical
MFG Ltd, Irvine, CA, USA). Systemic vascular resistance was
calculated from the standard formula. Axillary temperatures
were measured, and the patients’ temperatures were preserved
with fluid warmers and forced-air warming blankets.
Intraoperatively, clinical follow-up was performed for
neurologic signs of TUR syndrome (excessive somnolence,
convulsions). Postoperatively, patients were followed-up
clinically for potential neurologic (seizures, coma) and
cardiac complications (ie, myocardial ischemia or infarction
and pulmonary edema) of TUR syndrome. A 12-lead
electrocardiography was performed one hour and 24 hours
after surgery.
No input-output balance and no weighing of the patient
immediately after surgery were carried out.
Because sodium is mainly distributed to the extracellular
fluid (ECF) that has a volume equal to 20% of the body
weight [6], we estimated (calculated) the volume of
irrigating fluid absorbed, by using a simple formula that
considers that the percentage by which the volume of ECF
increased (because of fluid absorption), equals the percentage of decrease in plasma sodium:
fluid absorbed ðECF excessÞ ¼ % decrease in sodium
ECF ð0:2 body weightÞ
that is, if sodium decreased from 140 to 134 mEq/L,
this represents a 4% decrease from the baseline value of
sodium; thus, for a 70-kg patient, the volume excess of the
ECF (ie, the volume of absorbed fluid) will be 4 0.2 70/100 = 0.56 L.
2.2. Data analysis
Data were evaluated for normal distribution using the
Kolmogorov-Smirnov test. Continuous variables with distribution significantly differing from normal were compared
using the Mann-Whitney U or median tests. Categorical
data were described using frequency counts and percentages
and compared using v 2 (with Yates correction) or Fisher’s
exact tests, as appropriate. All tests were considered
significant at P b 0.05. The 2 groups were compared with
univariate analysis. Dynamic chronological changes between and within groups were analyzed with the general
linear model for repeated measurements.
To calculate the necessary sample size for the study, a
power analysis was performed. We defined a difference of at
least 15% of MAP, HR, and CI between groups, with pooled
247
SD of 15 mmHg, 10 beats per minute, and 0.5 L d min1 d
m2 for MAP, HR, and CI, respectively, to be of clinical
importance. To achieve an 80% power to detect such a
difference with an alpha of 0.05, at least 17 patients were
calculated to be required in each group.
3. Results
No differences were encountered in patients’ demographic characteristics, hemoglobin concentration, upper
sensory level of the block, use of IV fentanyl, and duration
of surgery. No patient was subsequently excluded from the
study because of inadequate spinal anesthesia.
There were significantly more diabetic patients in the
TURP group and more coronary patients in the TURT
group. Transurethral resection of prostate patients received a
larger total amount of irrigating fluid than the TURT
Table 1
urements
Demographics, laboratory, and temperature meas-
Group variable
TURP
(n = 40)
TURT
(n = 40)
P
Age (y)
BMI (kg/m2)
Weight (kg)
Height (cm)
Upper sensory
level
ASA risk
class (%)
I
II
Diabetes
mellitus (%)
Hypertension (%)
Coronary
disease (%)
Duration of
surgery (min)
Total IV
fluids (mL)
Total irrigation
fluids (mL)
Preoperative
sodium (mEq/L)
Intraoperative
sodium (mEq/L)
Postoperative
sodium (mEq/L)
Hemoglobin
24 h after
surgery (g/dL)
Temperature (8C)
73 F 7
27 F 4
79.8 F 5
172 F 9
T8 (T4-T10)
71 F 10
25 F 4
75.7 F 7
174 F 7
T7 (T3-T9)
0.45
0.13
0.1
0.1
0.5
0.5
10
90
35
20
80
5
0.018*
75
15
45
45
0.053
0.038*
45F13
39F24
0.28
810 F 320
800 F 270
0.3
7900 F 2310
5650 F 2160
0.003*
140 F 2.6
139 F 2
0.5
136 F 3
138 F 3
0.2
134 F 2.9
137 F 3.5
0.04*
13.4 F 1.2
13.8 F 1
0.2
36.5 F 0.4
36.8 F 0.2
0.16
Values are presented as means F SD or median (range). BMI indicates
body mass index.
* Statistically significant data ( P b 0.05).
248
T. Ezri et al.
patients (7900 F 2315 vs 5650 F 2159 mL, P b 0.05). The
estimated (calculated) amount of absorbed fluid was 638 F
60 mL in the TURP group and 303 F 40 mL in the TURT
group ( P b 0.05).
No patient had episodes of hypertension, and no patient
required pharmacologic interventions.
Mean arterial pressures were higher with TURP
30 minutes after the onset of surgery, although the upper
sensory level of the spinal block was similar between the
groups. By this time, 5500 F 1240 vs 3600 F 1320 mL
irrigating fluid was used. Mean arterial pressures were also
higher with TURP at the end of the procedure, with the legs
lowered from the stirrups (111 F 15 vs 100 F 10 and 109 F
14 vs 99 F 14 mmHg, respectively; P b 0.05).
Table 2
Hemodynamic measurements
Group variable
MAP (mmHg)
Baseline
30 min within
surgery
At the end of
surgery
Mean
intraoperative
Maximum
Minimum
TURP (n = 40)
TURT (n = 40)
P
114 F 14
111 F 15
107 F 12
100 F10
0.06
0.018*
109 F 14
99 F 14
0.023*
101 F 11
97 F 15
0.3
124 F 13
100 F 16
119 F 14
91 F 13
HR (beats per minute)
Baseline
69 F
30 min within
66 F
surgery
At the end
66 F
of surgery
Mean
66 F
intraoperative
Maximum
80 F
Minimum
57 F
13
14
72 F 9
66 F 9
0.48
0.9
16
71 F 11
0.3
10
69 F 5
0.5
18
10
80 F 11
58 F 10
1
0.7
1.3
1.1
3.1 F 0.8
2.6 F 0.8
0.53
0.4
1.2
2.8 F 0.7
0.47
1
2.9 F 0.5
0.5
cm 5 )
1780 F 630
1604 F 500
1850 F 602
1620 F 411
0.9
0.7
1696 F 555
1666 F 498
0.9
1650 F 500
1635 F 350
0.8
CI (L d min 1 d m 2 )
Baseline
3.3 F
30 min within
2.9 F
surgery
At the end
3F
of surgery
Mean
3F
intraoperative
SVR (dynes d s d
Baseline
30 min within
surgery
At the end
of surgery
Mean
intraoperative
0.24
0.049*
* Statistically significant data ( P b 0.05).
Fifteen patients with TURP vs 6 with TURT ( P = 0.03)
developed postoperative hyponatremia. Plasma sodium
decreased more significantly within the TURP group
(140.4 F 2.6 mEq/L baseline to 134.1F3.5 mEq/L
postoperatively, Pb 0.05) and was lower postoperatively
in the TURP group when compared with TURT (134.1 F
3.5 vs 137.2 F 2.9 mEq/L, P= 0.04). No patient had plasma
sodium of less than 120 mEq/L.
When we compared the hemodynamic data of the
21 patients in whom hyponatremia was found to that of
the remaining 59 normonatremic patients, no significant
differences were found in the mean intraoperative values of
the hemodynamic variables: MAP was 100 F 12 vs 98 F
13 mmHg (hyponatremic vs nonhyponatremic group, P =
0.5), CI was 2.9 F 0.7 vs 2.9 F 0.4 L d min1 d m2 ( P =
0.9), HR was 70 F 8 vs 67 F 4 BPM ( P = 0.5), and
the SVR was 1590 F 480 vs 1610 F 280 dynes d s d cm5
( P = 0.6). Also, as previously mentioned, no patient had
hypertension and no patient required pharmacologic intervention when we compared these 2 subgroups.
Demographic data, sodium values, and hemodynamic
measurements are summarized in Tables 1 and 2.
No patient developed neurologic or cardiac complications postoperatively.
4. Discussion
The TUR syndrome is a common cause of hyponatremia
in hospitalized patients [7]. Because the prostatic gland
contains large venous sinuses and because of the chance for
prostate capsule perforation, excessive amounts of irrigating
fluids might be absorbed into the circulation during TURP
[8], causing electrolyte disturbances; hypervolemia, which
may deteriorate to pulmonary edema; heart failure; and even
cardiorespiratory arrest [9-11]. If TURT patients have
increased irrigating fluid absorption, it mainly occurs later,
by the extravascular route (perforation of urinary bladder),
which gives rise to a drop in plasma sodium level, one to
2 hours after surgery [12]. This makes it somewhat problematic to compare sodium between the groups. However,
none of our patients had clinically diagnosed bladder perforation but still had a slight decrease in serum sodium levels.
Our hypothesis that intraoperative hypertension and other
hemodynamic disturbances would be more frequent with
TURP as compared with TURT because of a greater
potential for irrigating fluid absorption was not confirmed
by the results of the study. Both groups of patients were
hemodynamically stable throughout surgery. This may be
explained by a relatively small total amount of absorbed
fluid (although significantly higher with TURP surgery).
We assessed this assumption in awake, ASA I to II
patients during spinal anesthesia. It has been demonstrated
that the absorption of irrigation fluid during TURP is
significantly increased among spontaneously breathing
patients during regional anesthesia as compared with patients
Hemodynamics under spinal anesthesia for TURP vs TURT
undergoing general anesthesia with positive pressure ventilation [13]. The authors concluded that the markedly lower
central venous pressure before the start of irrigation should
be considered as a possible cause of this effect. In our study
groups, the use of spinal anesthesia enabled neurologic
follow-up, but it was also the reason for not using invasive
monitoring. That was one of our reasons for using bioimpedance hemodynamic monitoring in this study.
A larger amount of irrigating fluid was used and
absorbed in the TURP patients. This led to lower serum
sodium levels in this group of patients. The relative
hypervolemia caused thereby might at least partially prevent
the spinal induced hypotension. Indeed, MAP was higher in
TURP as compared with TURT after lowering the legs from
the stirrups, demonstrating the lack of hypovolemia in both
groups of patients and especially in the TURP group. Also,
no episodes of hypertension or changes (as defined in the
Methods section) in other hemodynamic variables were
encountered in either of the groups, and there was no need
for hemodynamic pharmacologic interventions.
The cardiovascular pathophysiology of TURP syndrome
is compound and possibly involves a direct cardiac depressant effect of glycine [14]. In healthy volunteers, using
Doppler ultrasonography, Nilssen et al [15] showed a
decrease in HR and CO and an increase in MAP, suggesting
an increase in SVR. None of these changes occurred in our
patients, possibly indicating the counterbalancing effect
between spinal anesthesia, appropriate hydration, small
volume of absorbed fluid, and the lack of preoperative
cardiac failure.
Spinal anesthesia may affect the patient’s hemodynamics
by several mechanisms [16]. Hypotension was apparently
precluded in our patients by obviating hypovolemia with
adequate fluid preloading, lithotomy position, intravascular
absorption of glycine, or a combined effect of the three. The
opposite might also be true, that is, the cardiovascular
depressant effect of glycine would have been ameliorated by
the afterload reduction caused by spinal anesthesia.
In our experience, patients undergoing TURP/TURT
procedures during spinal anesthesia have few, if any,
significant hemodynamic changes. One possible explanation
for this might be the positioning of the patient in lithotomy
(and therefore increasing the venous return to the heart)
immediately after performance of spinal anesthesia, thus,
before spinal anesthesia had reached its peak effect.
Another explanation for the hemodynamic stability is the
relatively small volume of fluid absorbed into the circulation. The volume absorbed in the TURP patients was higher
than in the TURT group but was close to the average
volume reported in the literature. The average amount of
solution absorbed during a TURP is 0.6 L [17]; however, up
to 8 L [18] of the irrigation solution may be absorbed, and
the amount of absorbed fluid is one of the critical factors for
the development of hemodynamic disturbances.
Another contributing factor to the perioperative physiological disturbances related to the use of irrigating solutions
249
during TURP is rapid central cooling [19]. Hypothermia was
prevented in our patients; therefore, no deleterious hemodynamic effects related to hypothermia were recorded.
Because invasive monitoring is not standard and routine
in these surgeries and the study was performed in awake
patients, we chose to use the thoracic bioimpedance
technique for noninvasive measurement of cardiac performance of our patients.
Thoracic bioimpedance technology is based on detecting
changes in impedance to small electrical currents. A
constant alternating current is passed through the patient’s
chest and electrical impedance is measured. The change in
thoracic blood volume causes changes in impedance
between the 8 electrical patches placed on the neck and
the thorax of the patient. On the basis of changes in
impedance, the computer calculates CO. By measuring the
maximum rate of change of thoracic impedance during
systole, timed from the electrocardiogram, stroke volume is
calculated with the Sramek-Bernstein formula. Cardiac
output is then calculated from the product of HR and stroke
volume, averaged over 16 cardiac cycles [20,21].
Cardiac output measurements obtained with bioimpedance correlate with those obtained by thermodilution
[22,23]. Moreover, the bioimpedance method is useful for
noninvasive hemodynamic monitoring in regional anesthesia [24-26]. The impedance method has been validated with
the dye dilution technique during epidural or general
anesthesia for cesarean delivery. Milsom et al [27] showed
that there was no significant difference between the mean
changes in stroke volume as determined by the 2 techniques
during serial measurements.
Measurement pitfalls with the cardiac bioimpedance
technique may be caused by incorrect placement of the
electrodes, dressing covering internal jugular catheters,
thoracotomy wounds, and chest drains [20]. Positive
pressure ventilation and the presence of endotracheal tubes
and sternal wires may also affect bioimpedance measurements by affecting the rate of change of thoracic impedance
[21]. None of these was present in our patients.
The use of thoracic bioimpedance measurements is also
limited in uncooperative patients or those with excessive
movement, in hemodynamically significant valvular disease
or in severe deformation of the chest wall [4].
One limitation of our study includes some differences in
study population regarding underlying illnesses such as
diabetes mellitus, hypertension, and coronary artery disease.
The lack of measuring of the exact volume of absorbed
irrigating fluid is another limitation. This is not easy to accomplish and requires either monitoring of the exhaled
alcohol [28], weighing the patient before and after the
procedure, or subtracting the volume of fluid coming out
from what was used. Measurement of fluid output (irrigating
fluid, urine, blood, and prostate tissue) in our urology surgery setting is cumbersome and imprecise. As we did not
measure the fluid output nor could we measure the patients’
weight immediately in the postoperative period, we decided
250
to use a simple formula for estimation of the amount of fluid
absorbed. By this calculation, we found that fluid absorption
was more accentuated in TURP patients as compared with
that in TURT patients.
Our patients could successfully handle the small volume
loads, presumably owing to their good preoperative left
ventricular function and owing to the complex interaction
between spinal anesthesia, fluid loss, and fluid gain, each
counterbalancing the other.
Another possible limitation of this study is the lack of use
of monitoring (ie, pulmonary artery catheter measurements)
for comparison with the bioimpedance measurements.
However, by using the bioimpedance cardiac monitoring,
invasive monitoring in awake patients undergoing relatively
minor surgery was considered unnecessary.
Although fluid absorption was more pronounced and
sodium levels were lower in the TURP patients, there were
no episodes of hypertension in either of the groups.
These results did not confirm our hypothesis that TURP
surgery might be associated with more episodes of
hypertension and other hemodynamic disturbances when
compared with TURT surgery.
We believe that routine thoracic bioimpedance monitoring may help understand the complexity of the hemodynamic changes associated with TURP and TURT surgeries
and may improve our ability to manage patients undergoing
these procedures.
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