కార్డియోవాస్కులర్ డిసీజెస్ & డయాగ్నోసిస్

Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia

Abstract

Ahmed N. Ghanem

Hypothesis: The transurethral resection of the prostate (TURP) syndrome is defined as severe vascular hypotension reaction that complicates endoscopic surgery as a result of massive irrigating fluid absorption causing severe acute dilution hyponatraemia (HN) of <120 mmol/l. The vascular shock is usually mistaken for one of the recognized shocks and Volumetric Overload Shock (VOS) type 1 (VOS1) is overlooked.

Objective: To report VOS and its successful treatment of hyper-tonic sodium therapy (HST) that is lifesaving. To report that Starling's law is wrong and the correct replacement is the hydrodynamic of the porous orifice (G) tube.

Methods: We conducted the following studies:

1.             Prospective study on 100 consecutive TURP patients among whom 10 developed the TURP syndrome with acute dilution HN and vascular shock.

2.             A case series of 23 TURP syndrome cases.

3.             A physics study on the hydrodynamic of the G tube.

Results: The TURP syndrome is defined as severe vascular hypotension reaction that complicates endoscopic surgery as a result of massive irrigating fluid absorption causing severe acute dilution HN of <120 mmol/l. The vascular shock is usually mistaken for one of the recognized shocks and Volumetric Overload Shock type 1 (VOS1) is overlooked making Volumetric Overload Shock Type 2 (VOS2) unrecognizable. In adults VOS1 is induced by the infusion of 3.5-5 liters (Figure 1) of sodium-free fluids and is known as TURP syndrome or HN shock. VOS2 is induced by 12-14 liters of sodium-based fluids and is known as the adult respiratory distress syndrome. The most effective treatment for VOS1 and VOS2 is HST of 5%NaCl and/or 8.4%NaCo3. The literature on TURP syndrome is reviewed and the underlying patho-etiology is discussed. Starling's law proved wrong and the correct replacement is the hydrodynamic of the G tube.

Conclusion: Volumetric overload causes shock of two types, VOS1 and VOS2. VOS 1 is characterized with acute dilution HN and is known as the TURP syndrome. Mistaking VOS1 for a recognized shock and treating it with vascular expansion is lethal while HST is life-saving. Starling's law which dictates the faulty rules on fluid therapy proved wrong and the correct replacement is the hydrodynamic of the G tube.

Suggested References

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2.             Harrison III RH, Boren JS, Robinson JR. Dilutional hyponatraemic shock: another concept of the transurethral prostatic reaction. J Uro. 1956; 75 (1): 95-110.

3.             Arieff AI. Hyponatraemia, convulsion, respiratory arrest and permanent brain damage after elective surgery in healthy women. N Engl J Med 1986; 314 (24): 1529-34.

4.             Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet 1967; ii: 319-23.

5.             Danowski TS, Winkler AW, Elkington JR. The treatment of shock due to salt depression; comparison of isotonic, of hypertonic saline and of isotonic glucose solutions. J. Clin. Invest. 1946; 25: 130