SURESH LAMICHHANE ,MD

ANESTHESIA SEPARTMENT ,
QMMC
To discuss the age-related anatomic & physiological changes, &
age related pharmacological changes in the elderly.

To discuss the preoperative evaluation and preparation in Cysto-

TURP.

To discuss the intraoperative management in Cysto-TURP.

To discuss the postoperative management in Cysto-TURP.

 D.G
 72 years old
 Gentleman
 Married
 Roman Catholic
 Filipino
 Address: E. Rodriguez, Quezon City
 admitted for the first time in our institution December 18,2013
 Difficulty in passing urine
1year sought to consult for difficulty of passing urine ,then treated with
PTA medical therapy
 2mth
PTA

Persistence of the above symptom

associted with frequent desire to urinate,
frequent sensation of bladder fullness,
then patient was adviced to undergo
operation (cysto TURP).
 1 day prior
to
operation

Patient was admitted with full preparation for the operation

 (-) Hypertension
 (-) Diabetes Mellitus
 (-) Heart disease
 (-) Asthma
 (-) Hyper/Hypothyroidism
 (-) Hypertension
 (-) Diabetes Mellitus
 (-) Heart disease
 (-) Asthma
 (-) Hyper/Hypothyroidism
 (-)prostatic hyperplasia
 (-) cancer
 High school graduate
 Non-smoker
 Occasional alcohol beverage drinker
 General Survey: Conscious, coherent, NICRD
 VITAL SIGNS
 BP-150/90 mmhg
 CR-68 bpm
 RR-18/MIN
 SP02-98%W/OUT O2
 Wt-72kg
 Height-170cm
 HEENT: Anicteric sclerae, pink palpebral conjunctivae
 Chest: Bilateral Equal chest expansion, clear breath sounds,
no intercostals retraction
 Heart: Adynamic precordium, no murmurs
 Abdomen: Flabby, NABS, soft, non tender
 Extremities: Pulses full and equal on all
extremities,nocyanosis
 Neurologic Exam: Essentially normal (all cranial nerves)

 Sensory: 100% (Upper & lower extremities)

 Motor: 5/5 (Upper & lower extremities)

 DTR: ++
 Assessment:
ASA 2
MAL 1
 Surgical Plan:
Cysto-TURP
 Anesthetic Plan:
SAB
 Dec 4
dec 4 dec 4
hb 122
hct 0.39 Na 145.0
BUN 2.64
wbc 8.5 K 3.23
Cl 110.4 creatinine 41.42
ptl Adeq.
 CXR-clear lungs field,atheromatous aorta
 ECG-normal sinus rhythm,normal axis,non specific ST-wave
changes
Venoclysis: D5LRS 1l x 8 hrs once on NPO
Meds: nalbuphine 5mg IM 1 hr PTOR

diphenhydramine 25 mg IM 1 hr PTOR
omeprazole 40 mg IV 2 hrs PTOR
Upon arrival at OR

General Survey: awake, conscious, coherent

Vital Sign: BP 160/90 PR 75 RR 18 Temp 37
standard Monitors used: Pulse oximeter
cardiac monitor
NIBP monitor
temperature
IVF: D5NSS 1L x 8hrs
02 inhalation via nasal cannula 2-3 lpm

SAB: LLDP,asepsis/antisepsis, local infiltration with lidocaine 2%, 1cc.

Tapped between L3-L4, using SNG 25,midline,CSF clear free flowing,

(-) blood, (-)paresthesia SBL at T10 after 5 minutes.

Agent: Bupivacaine 16mg (heavy)

VITAL SIGNS INTRAOP

ranged from: BP= 160-120/90-60mmHg

HR=70-85bpm
RR=17 bpm
SaO2=100 %.
Estimated Blood Loss 120cc
Total Urine Output 500cc w/ cystoclysis
Total infused crystalloids 450cc
PX General status and vital
signs were unremarkable
,transfer to ward after 2hrs of
PACU stay.
 Patient was discharge on 2nd
day of operation with full
satisfaction from surgery and
anesthesia.
 SAILENT FEATURES
-72 y/o male
-BPH
-Cysto-TURP
-SAB
 BPH affects 50% of males at
60 years and 90% of 85-
year-olds, is most commonly
performed on elderly
patients. a population group
with a high incidence of
cardiac, respiratory and
renal disease
 TURP is a cystoscopic
procedure used to alleviate
the symptoms of bladder
outflow obstruction, caused
by benign prostatic
hypertrophy (BPH).
The mortality rate associated with TURP is 0.2 -6%, with the
commonest cause of death being myocardial infarction.

Safe anaesthesia depends on the detection and optimisation

of co-existing diseases, and on weighing up the relative risks
and benefits of regional and general anaesthesia for each
patient.
 The terms “elderly” and “geriatric” are
about 65 years of age or older.

 While the term “aged” individuals older

than 80 years.

 Miller:
65-74 y/o –elderly
75-84 y/o- aged
85 y/0 and above- very old
 CARDIOVASCULAR CHANGES
↓ β receptor stimulation
↓ baroreceptor reflex = impaired regulation of BP
Stiffening of myocardium, arteries and veins
Systolic hypertension
Conduction system changes
Conduction blocks
 RESPIRATORY CHANGES

Stiffening of chest wall

↑ work of breathing
↓ pulmonary elasticity
↓ ventilatory response to hypercapnia and hypoxia
↓ paO2 0.35 mmHg/yr
 RENAL FUNCTION
↓ renal cortical mass

↓ GFR

↓ drug excretion

↓ tubular function

Impaired Na handling

↓ concentrating and diluting ability

 • METABOLIC AND ENDOCRINE FUNCTION

• Basal & maximal oxygen consumption declines with age.

• Most elderly men & women begin losing weight after reaching peak weight at about age 60.

• Heat production,heat loss,hypothalamic temperature-regulating centers may reset at a lower level.

 Increasing
insulin
resistance leads
to a progressive
decrease in the
ability to handle
glucose load.

Circulating
norepinephrine Neuroendocrin
levels are e response to
reported to be stress appears
elevated in to be preserved
elderly patients. or slightly
decreased.

Aging is
associated with
a decreasing
response to B-
adrenergic
agents
(“endogenous
B-blockade”).
NERVOUS SYSTEM
↓ nervous tissue mass

↓ neuronal density

↓ neurotransmitter
GASTROINTESTINAL FUNCTION

Gastric ph Hepatic fxn

decrease while decline in
gastric emptying proportion to the
is prolonged liver mass

Rate of
Plasma
biotransformatio
cholinesterage
n and albumin
level are reduce
production
in elderly
decrease
 MUSCULOSKELETAL
SYSTEM

Skin atropies w/age and Veins are often frail and Arthritic joints may Degenarative cervical spine
Muscle mass is prone to trauma w/adhesive disease can limit neck
tape,electrocautery,ECG
easily ruptured by IV interfere w/position or extension potentially
reduced infusion regional anesthesia
leads making intubation dificcult
Tissue/system Anatomic changes Functional changes

Body composition Loss of skeletal muscle and lean tissue components, Prolonged drug effects, decreased metabolism and
increased lipid heat production, decreased resting cardiac output
Fraction

Nervous system Loss of neuronal tissue mass, deafferentation, Decreased neural plasticity, decreased anesthetic
reduced central neurotransmitter activity requirement, impaired autonomic homeostasis

Cardiovascular system Decreased elasticity, reduced B-adrenergic Decreased cardiac & arterial
responsiveness Compliance, decreased maximal HR & CO

Pulmonary system Increased thoracic stiffness,decreased lung recoil, Reduced vital capacity, increased work of breathing,
reduced alveolar surface area impaired efficiency of gas exchange

Renal/hepatic system Decreased vascularity and perfusion, loss of tissue Decreased drug clearance, inability
mass To withstand salt & water loads

Blood & Immune system Thymic involution, resorption of bone marrow Decrease immune competence
Loss of hematopoietic reserve
 Progressive in
muscle mass
and in body fat
results in total
body water.

reduced
Renal and
volume of
hepatic fxn
distribution for
decline with
water-soluble
age , prolong
drugs lead to
the duration of
higher plasma
action for
concentrations
many drugs
.

volume of
Changes in
distribution for
volume of
lipid-soluble
distribution
drugs can
may also affect
lower their
elimination
plasma
half life
concentration.
 Short-acting agents:
propofol, desflurane,
A reduced anesthetic remifentanil and
requirement, represented by a succinylcholine is useful in
lower MAC. elderly patients.

Careful titration of anesthetic Drugs that are not significantly

agenst. dependent on hepatic or renal
function or blood
flow;mivacurium, atracurium &
cisacurium are useful.
 lower dose requirement for propofol, etomidate,
barbiturates, opioids, and benzodiazepines.

administration of midazolam, opioids, or ketamine further

decreases propofol requirements.

40–50% reduction in induction dose may be the result of

peak levels not decreasing as rapidly in geriatric.

Enhanced sensitivity to fentanyl, alfentanil, and sufentanil

is primarily pharmacodynamic.

Aging increases the volume of distribution for all

benzodiazepines, which effectively prolongs their
elimination half-lives.
 The MAC for inhalational agents is
reduced by 4% per decade of age over
40 years.

myocardial depressant effects of

volatile anesthetics are exaggerated in
elderly patients, tachycardiac
tendencies of isoflurane and
desflurane are attenuated.

isoflurane reduces cardiac output and

heart rate in elderly patients.
Response to succinylcholine and other neuromuscular blocker are unaltered by
ageing

Decrease cardiac output and slow muscular blood flow may cause up to 2 fold
prolongation of onset

Recovery from muscle relaxant depends on renal excretion and hepatic clearance
,may be delayed due to decrease drug clearance
 PHYSIOLOGY PHARMACOLOGY

Induction agents Decreased volume Reduced requirement

Thiopental CNS changes Prolonged drug effect
Etomidate
Propofol

Opiates Decreased volume High initial plasma

Morphine Decrease hepatic flow Prolonged drug effect
Fentanyl CNS changes Reduced dose requirement
alfentanil

Benzodiazepines Decreased liver mass & blood flow, CNS change Prolonged drug effect
Chlordiazepoxide Reduced dose requirement
Diazepam
Alprazolam

Neuromuscular blocking drugs Disseminated neurogenic atrophy Same or increased dose requirement
(non depolarizers) Decreased hepatic & renal function Prolonged drug effect
Decreased plasma levels of cholinesterase in men
(succinylcholine) Reduced dose requirement in men

Inhaled anesthetic CNS changes Reduced dose requirement

Transurethral resection of the prostate (TURP) is performed by
inserting a resectoscope through the urethra and resecting prostatic
tissue with an electrically powered cutting-coagulating metal loop.

prostatic capsule is usually preserved.

If the capsule is violated, large amounts of irrigation solution are

absorbed into the circulation and the periprostatic and
retroperitoneal spaces.
 cardiac

Common
endocrinol
ogy
chronic pulmonary
disorders medical
conditions:

vascular
 Pre- Premedication Preoperative Optimization of
may be reduced correction of fluid cardiac
operative or omitted in the and electrolyte medications and
Preparation elderly imbalance function
 Blood for anemic
Warming blanket Use of normal
Extra padding and patients and
and IV fluid saline as
careful positioning patients with large
warmer intravenous fluid
glands (> 40 g)
 ANESTHETIC Sensory supply to
TECHNIQUE OF Sensory supply to
the RECOMMENDED
CHOICE the bladder is from-
urethra,prostateand BLOCK T10
T10-T12
REGIONAL bladder neck-S2-S4
 less
haemodynamically
ADVANTAGE:unco- challenging than
operative patients or DISADVANTAGE:inab
SAB in patients
GETA to whom required ility to monitor
hemodynamic or patients mentation with cardiac
ventilatory support problems such as
aortic stenosis and
IHD
 Intravenous
fluid of choice: normal saline
(sodium, 154 mEq
per L)
 isotonic

inexpensiv nonhemolytic
e

rapidly Irrigating
excreted
Solutions nonelectrolytic

for TURP:

nontoxic transparen
t

nonmetab
olized
 Distilled water
low tonicity; caused
massive
Absorption of large
nonconductive and intravascular it is no longer used
amounts; resulted
interfered least with hemolysis, for TURP
in dilutional
surgical visibility. hemoglobinemia, procedures.
hyponatremia..
and (rarely)
renal failure.
variety of • hypo-osmolar (normal
irrigating serum osmolality is
280–300 mOsm/l)
• acidic (pH of 4.5–6.5).
solutions
 Urea
no longer used, it freely passes
into both the intracellular and
extracellular spaces and
results in elevated blood urea
concentrations.
Electrolyte solutions (Ringer's
lactate or normal saline )
cannot be used in
conjunction with an
electrocautery device,they are
ionized and are able to
conduct electrical currents.
 Glucose
Sorbitol
metabolized to fructose, can produce rarely used because
hyperglycemia.
converted to lactate, causes systemic acidosis. they are sticky and not
induce an osmotic diuresis leading to dehydration
and a hyperosmolar state.
easily handled in the
urology suite.
 Glycine
associated with
a nonessential cause depressed
hyperoxaluria (
amino acid that is mental status and
visual disturbances,
normally present in coma secondary to
blurred vision and
the circulation. hyperaminonemia.
transient blindness).
 Manitol
an osmotic diuretic.
can cause dehydration and hyperosmolality ,if absorbed into
circulation in large quantities.
marked intravascular volume expansion.
 Amount of
irrigation
fluid
number and size hydrostatic venous pressure
absorbed duration of the
of venous pressure of the at the irrigant-
during the resection
procedure is sinuses opened irrigating fluid blood interface
directly
related to ff.
recommendation for TURP:
•resection time be limited to <1 hour
• bag of irrigating fluid be suspended no
more than 30 cm above the operating
table at the beginning of the resection
and 15 cm in the final stages of resection
Several liters of irrigation solution pass
through the bladder during TURP, which can
reduce body temperature at the rate of 1OC per
hour. Approximately half the number of
patients undergoing TURP become
hypothermic and shiver at the conclusion of
surgery.
Rapid absorption of a large
volume irrigation solution
during TURP can lead to
TURP wide range of neurologic and
syndrome.(Transurethral cardiopulmonary symptoms that
Resection Syndrome) occur when irrigating fluid is
absorbed during TUR procedures,
especially TURP.
 The principal components:
respiratory distress
dilution of
secondary to volume
electrolytes and symptoms related to
expansion from rapid
proteins by the the type of irrigating
intravascular
electrolyte-free solution used.
absorption of the
irrigating fluid
irrigating fluid
 Cardiopulmonary Hematologic and Renal Central Nervous System

HYPERTENSION Hyperglycinemia Nausea/ vomiting

Bradycardia Hyperammonemia Confusion/ RESTLESSNESS
DYSRHYTHMIA HYPONATREMIA Blindness
RESPIRATORY DISTRESS Hemolysis/ Anemia Seizures
Cyanosis Acute renal failure Lethargy/ Paralysis
Hypotension Death Dilated/ nonreactive pupils
Shock Coma
Death Death
 Mild symtoms: Na > Severe
120 mEq/L ,Fluid symptoms:Na< 120
Recommendation
restriction and loop mEq/L, 3% NaCl IV at
diuretic (Furosemide) a rate of <100ml/hr
Rate of Na increase should not exceed 12 mEq/L in
24 hr period ,rapid administration of hypertonic
saline has been associated with central pontine
myelinolysis(a fatal neurological complication)
 severe (seizures, coma,
mild (restlessness, nausea,
hypertension,
Clinical manifestations shortness of breath, or
bradycardia,cardiovascular
dizziness)
collapse).
 increase in both
systolic and
diastolic
classic triad of mental status
pressures bradycardia
symptoms: changes
associated with
an increase in
pulse pressure
The irrigation solution enters the bloodstream directly through open prostatic venous sinuses and accumulates in the periprostatic and
retroperitoneal spaces.

The latter occurs primarily when the prostatic capsule is violated during surgery.

Reports in the literature suggest that as many as 8L of irrigation solution can be absorbed by the patient during TURP.

The average rate of absorption is 20ml per minute and may reach 200ml per minute; the average weight gain by the end of
surgery is 2 kg.
TURP syndrome is more likely to occur if the prostatic gland is
particularly large, the prostatic capsule is violated during
surgery, or the hydrostatic pressure of the irrigation solution is
excessively high.

Large prostatic glands have rich venous networks that promote

intravascular absorption of irrigation solution.
The Hydrostatic pressure of the irrigation solution is an important
determinant of the solution absorption rate of the patient

This pressure depends primarily on the height of the irrigation solution pole.
When the height of the pole exceeds 60 cm, the absorption of the irrigation
solution is greatly enhanced

excessively distended bladder during surgery,Facilitates absorption

TURP syndrome exhibit neurologic signs resulting from water intoxication

They assume decerebrate posture, exhibit clonus and positive babinski reflex and eventually
convulse and lapse into coma,may remain for few hrs to days

EEG shows low-voltage bilaterally.

Examination of the eye reveals papilloedema and dilated and sluggishly reacting pupils.
The crucial physiologic derangement of CNS function is not hyponatremia per
se, but acute hypoosmolality

This is predictable because the blood btrain barrier is essentially impermeable

to sodium but freely permeable to water

Cerebral edema caused by acute hypoosmolality can increase ICP which

results in bradycardia and hypertension by the cushing reflex
Sodium is a ubiquitous electrolytes that is
essential for proper function of excitatory cells,
particularly those of the heart and brain

Extreme reduction in serum sodium level alters

brain function, as well as cardiac and renal
function
The neurologic signs may be accompanied
by EEG abnormalities such as loss of alpha
wave activity and irregular discharge of
high amplitude slow wave activity.
The determining factor is the rate at which the
serum sodium level falls rather than the total fall.

The faster the fall in serum sodium level the

greater the incidence of neurologic symptoms.

A slow fall in serum sodium level apparently

allows the CNS to adapt to the hyponatremia.
 less than 115 mEq/L
serum sodium levels causes bradycardia,
less than 110mEq/L
fallls to less than 120 widening of the QRS
can develop
mEq/L, signs of complex, ST-segment
respiratory and
cardiovascular elevation, ventricular
cardiac arrest.
depression can occur. ectopic beats and
T-wave inversion.
Fluid and electrolyte
Patients with
imbalance should be preoperative Limiting the
corrected CHF should be Preservation of
height of the
preoperatively,speci treated the prostatic
al attention to the irrigation pole
vigorously with capsule.
sodium level during diuretics and to 60 cm H2O.
surgery.
fluid restriction.

micro-drips is
recommended particularly
in patients with cardiac or
renal disease.
If regional anesthesia
causes hypotension, a small
dose of a vasoconstrictor is
recommended to raise the
blood pressure, rather than
rapid infusion of IV fluids.
 Once symptoms of TURP syndrome appear,

Ensure oxygenation and circulatory support

Notify surgeon and terminate procedure

Consider insertion of invasive monitors if cardiovascular instability occurs

Send blood to lab for electrolytes and ABG

Obtain 12 lead ECG

 Rapid
administration of Unless the patient
administration of
hypertonic saline to develops clinical
hypertonic solution
correct is not always signs of
associated with
necessary and can hyponatremia,saline
CPM (causes
sometimes be administration is not
irreversible brain
detrimental. recommended.
damage).
 To reduce the hazard of
saline administration, serum Initial management of fluid
osmolality should be overload and hyponatraemia
monitored and corrected involves stopping IV fluids Give frusemide 40mg IV to
aggresively only until and commencing a fluid promote a diuresis.
symptoms substantially restriction
resolve; then hyponatremia
should be corrected at a rate
no faster than 1.5 mEq/L/hr.
most common intraoperative problems:
bleeding
TURP cardiac
requiring extravasation
syndrome in dysrhythmias
transfusion in of irrigating
2% of in 1% of
2.5% of fluid in 0.9%
patients patients
patients of patients
 common
postoperative bleeding
problems:

clot retention infection.

Bleeding Perforation fever hypothermia
Pain Conduction Pathways and Spinal Segment Projection of Pain of the Genitourinary System

Spinal Levels of Pain

Organ Sympathetics, Spinal Segments Parasympathetics
Conduction

Kidney T8-L1 CN X (vagus) T10-L1

Ureter T10-L2 S2-4 T10-L2

Bladder T11-L2 S2-4 T11-L2 (dome), S2-4 (neck)

Prostate T11-L2 S2-4 T11-L2, S2-4

Penis L1 and L2 S2-4 S2-4

Scrotum NS NS S2-4

Testes T10-L2 NS T10-L1