PLASMA SODIUM LEVELS AFTER TURP SURGERY IN

DIABETIC PATIENTS IN COMPARISON WITH NON

DIABETIC PATIENTS- A CROSS SECTIONAL STUDY

Principal Investigator:

Dr. Allwyn Thomas

PG Resident
Dept. of Anaesthesiology
MOSC MCH, Kolenchery
Phone: 9048007547

Guide:

Dr. Sara Korula

Professor
Dept. of Anaesthesiology
MOSC MCH, Kolenchery
Phone: 9446596066

Introduction and Background

Benign prostatic hyperplasia is common in elderly males. Transurethral resection of the
prostate (TURP) is a standard surgical procedure for the management of benign prostatic
obstructions. Transurethral resection of prostate syndrome is a rare, but potentially life
threatening complication of TURP procedure. It occurs as a consequence of the absorption of
fluids used to irrigate the bladder during the operation resulting in hyponatremia(1). TURP
syndrome may occur quickly or upto 24 hours postoperatively.
Diabetes Mellitus is a group of metabolic diseases characterised by hyperglycemia, resulting
from defects in insulin secretion, action or both. The prevalence of diabetes is increasing
rapidly in our population. Electrolyte disturbances are common in patients with diabetes.
Increase in plasma glucose concentration can lead to decrease in plasma sodium
concentration(2). So chances of hyponatremia can be higher in diabetic patients.

Review of Literature
Between 1% and 8% of TURP procedures are complicated by the TURP syndrome(3).
Significant hyponatremia has been reported following TURP in 11-41% of patients(4).
According to Hahn RG, absorption of small amount of fluid(1-2 litre) occurs in 5- 10% of
patients undergoing transurethral prostatic resection and results in an easily overlooked
mild transurethral resection syndrome(3). Even changes in serum sodium concentration
of >7 mmol/L and of >7% could predict the development of cardiovascular and
neurological manifestations (1).
The prevalence of Diabetes is increasing rapidly, and Type 2 Diabetes now accounts for
20 to 50% of cases of new-onset diabetes in young people(5). More than 62 million
people in India are diagnosed currently with Diabetes Mellitus(6). Increase in blood
glucose level significantly affect the serum sodium concentration. The null hypothesis is
that there is no significant difference between diabetic and nondiabetic group in the
incidence of hyponatremia.
Lacunae In Literature- We could not find any similar study of hyponatremia in TURP
surgery in diabetic patients.

Aim
To compare plasma sodium levels after TURP surgery in diabetic and non diabetic patients.

Objective
1) To assess the change in plasma levels of sodium after TURP surgery.
2) To compare the change in plasma levels of sodium between diabetic and nondiabetic
patients.
3) To compare the incidence of clinical manifestations of TURP syndrome in diabetic and
nondiabetic patients.

Materials and Methods

Study area- Department of Anaesthesiology, MOSC Medical College Hospital,
Kolenchery.
Study population- patients of ASA grade I and ll undergoing TURP surgery in MOSC
medical college satisfying the selection criteria.
Selection criteria
Inclusion criteria- Patients of ASA I and ll scheduled for elective TURP surgery.
Exclusion criteria-Patients withage>75years, contraindications to spinal anaesthesia, pre
existing hyponatremia with sodium levels < 135mEq/L and patients on diuretic
therapy.
Study definition
Hyponatremia- Hyponatremia is defined as a serum sodium level of less than 135 mEq/L.
TURP syndrome-TURP syndrome is a term applied to a constellation of symptoms and signs
caused primarily by excessive absorption of irrigating fluid. Neurological manifestations, such

as restlessness, agitation, confusion, altered sensorium, seizure and coma, result from water
intoxication and dilutional hyponatremia, which collectively produce cerebral edema.
Cardiovascular effects reflect volume overload and hyponatremia.
Circulatory disorders
-Chest pain, bradycardia, hypertension, hypotension , poor urine output

Neurological disorders
-blurred vision, nausea , vomiting, uneasiness, confusion, tiredness, consciousness, headache.
The presence of at least one circulatory disorder and one neurological disorder is necessary for
a diagnosis of TURP syndrome(7).
Diabetes Mellitus- Diabetes Mellitus is a group of metabolic diseases characterised by
hyperglycemia, resulting from defects in insulin secretion, action or both.
Hypotension- Hypotension is defined as >20% decrease in systolic blood pressure from the
baseline.
Sample size
The sample size was calculated by nMaster sample size calculation software using the
prevalence from the study by H Krishna Moorthy, Shobha Philip. Serum Electrolytes in TURP
Syndrome- Is the Role of Potassium underestimated? Indian J. Anaesth 2002;46(6): 441-444.It
is found out that for a precision of 10% and a confidence level of 95%, the sample size of 72
can be taken. So we decided to study on a total of around 75 consecutive patients undergoing
TURP surgery in the study period from January 2016 January2017

Study procedure
Patients are assessed one day prior to surgery and data regarding comorbidities and drugs are
collected. They are kept nil orally to solids for 6 hours prior to the surgery and pre medicated
with Tab. Ranitidine 150 mg and Tab. Ondansetron 4mg one hour before call to the operation
theatre. Preoperative fasting blood sugar and serum sodium are recorded along with other
routine investigations. Patients are shifted to the operation theatre and routine monitors such
as Noninvasive blood pressure(NIBP), Electrocardiogram(ECG), Percutaneous saturation
oxymetry(SPO2) are attached. Oxygen is administered via simple face mask (6L/min).
Balanced salt solution is used as maintenance fluid intraoperatively.
Under aseptic precautions, subarachnoid block is performed with 2.2ml 0.5% Bupivacaine
(Hyperbaric) and 20g Fentanyl to obtain a sensory block upto T10 level. Maximum sensory
level attained will be checked by pin prick method. If spinal anaesthesia is ineffective patient
will be removed from the study. The surgical procedure is done with 1.5%glycine as irrigation
fluid, keeping the irrigation fluid column at a height of 60cm, measured from the level of pubic
symphysis of the patients on the operating table. Monopolar resectoscope is used by the
surgeon.

The

parameters like heart rate, noninvasive blood pressure, percutaneous

saturation oxymetry, respiratory rate, duration of procedure, volume of irrigating fluid used,
volume of intravenous fluid and weight of resected prostate gland will be recorded. All
patients are carefully observed for early symptoms of TURP syndrome perioperatively and
severity graded with the checklist(Table 1) recommended by Hahn RG(4). Intraoperative
hypotension will be treated with IV fluids and/or Ephedrine 3-6mg IV boluses. Bradycardia
(HR<50/min) will be treated with IV Atropine 0.6mg boluses. Respiratory depression (RR <
8/min or SpO2 < 94%) will be treated with ventilatory assistance. Random blood sugar and
serum sodium will be measured one hour after the start of surgery and 4 hours
postoperatively.
Study design- Prospective observational study
Study duration-0ne year.

PROFORMA

Name:

Age:

Hospital No:

ASA physical status:

Diabetic:

Weight:

Non Diabetic:

Height:

Date of surgery:

Other comorbidities:

Maximum level of loss of pin prick sensation: T

Time:

Duration of surgery:

IV Fluid used and volume:

Irrigation fluid volume:

Weight resected:
Data collection sheet

Variables
Recorded
(mins)

Pre
Op

10

15

20

25

30

35

40

45

50

55

60

70

80

90

100

HR (/min)
SBP
(mmHg)
DBP
(mmHg)
MAP
(mmHg)
RR (/min)
SP02 (%)

Additional Drugs given

Ephedrine:

Midazolam:

Ondansetron:

Diuretics:
Pre operative

Plasma sodium
GRBS

Intra operative

Post operative

End
of
Sx

Severity scoring for TURP syndrome(table1)

Severity Score

Neurological

Circulatory

Chest pain

Duration<5 min

Duration >5 min

Repeated attacks

Bradycardia

HR decrease
10-20 bpm

HR decrease
>20 bpm

Repeated decreases

Hypertension

SAP up
10-20 mm Hg

SAP up
>30 mmHg

Score(2) for 15 min

Hypotension

SAP down
30-50 mmHg

SAP down
>50mm Hg

Repeated
drops>50mm Hg

Poor urine
output

Diuretics are
needed

Repeated use

Diuretics ineffective

Blurred vision

Duration <10 min

Duration >10 min

Transient blindness

Nausea

Duration<5 min

Duration 5-120 min

Intense or >120 min

Vomiting

Single instance

Repeatedly, <60 min

Repeatedly, >60
min

Uneasiness

slight

moderate

Intense

Confusion

Duration<5 min

Duration 5-60 min

Duration > 60 min

Tiredness

Patient says so

Objectively exhausted

Exhausted for >120

min

Consciousness

Mildly depressed

Somnolent<60 min

Needs ventilator

Headache

Mild

Severe<60 min

Severe > 60 min

Statistical Analysis
The categorical variables will be compared with Chi square test and the values expressed as
mean will be compared with students t test.
Ethical considerations
Approval from institutional ethics committee.
Written informed consent will be obtained from every participant.
Participant information will be kept confidential
References
1. Ishio J, NakahiraJ, Sawai T, Inamoto T, Fujiwara A, Minami T. Change in serum sodium
level predicts clinical manifestations of transurethral resection syndrome: a
retrospective review. BMC Anesthesiol. 2015 Apr 16;15(1):52.
2. Palmer BF, Clegg DJ. Electrolyte and Acid-Base Disturbances in Patients with Diabetes
Mellitus. N Engl J Med. 2015 Aug 6;373(6):548-59.
3. Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth. 2006 Jan;96(1):8-20
4. Goel CM, Badenoch DF, Fowler CG, Blandy JP, Tiptaft RC : Transurethral resection
syndrome- a prospective study. Eur. Urol. 1992;21(1): 15-7.
5. National diabetes statistics report:estimates of diabetes and its burden in the United
States,2014. Atlanta: Centers for Disease Control and Prevention, 2014.
6. Kumar A, Goel MK, Jain RB, Khanna P, Chaudhary V. India towards diabetic control: Key
issues. Australas Med J. 2013;6(10):524-31.
7. Nakahira J, Sawai T, Fujiwara A, Minami T. Transurethral resection syndrome in elderly
patients: a retrospective observational study. BMC Anesthesiol. 2014 Apr 23;14(1):30

Participant Information Sheet

The study that you have been requested to be a part of is titled Plasma sodium levels after TURP
surgery in diabetic patients in comparison with non diabetic patients- a cross sectional study. The
study is aimed at improving the medical care and providing valuable informations about electrolyte
changes in patients like you undergoing Transurethral Resection of Prostate under spinal anaesthesia.
This is an observational study to compare the incidence of hyponatremia in diabetic and non diabetic
patients undergoing this surgery. In diabetic patients, increase in blood glucose level can lead to
change in the blood level of sodium. The use of irrigating fluid can lead to many neurological and
circulatory disturbances. By assessing blood level of sodium and glucose, we will be able to detect the
changes early and provide you the best possible care.
All patients enrolled in this study will be evaluated for glucometer random blood sugar and sodium
levels preoperatively, intraoperatively and postoperatively along with other routine preoperative
investigations. All patients will receive the standard care. All the data collected including your
personal information will be kept strictly confidential and may only be examined by the Principal
Investigator/Guide/Study Regulatory Authority of the institution.The cost of extra investigation shall
be borne by the primary investigator.
Your participation in this study would provide important knowledge whereby we could improve
patient care.If you still have any queries regarding this study, you may please contact us at the details
provided below.
Principal Investigator: Dr. Allwyn Thomas
Post Graduate Student
Dept. of Anaesthesiology
Ph: 9048007547
Guide:

Dr.Sara Korula
Professor
Dept. of Anaesthesiology
Ph:9446596066

MOSC MEDICAL COLLEGE, KOLENCHERY

DEPARTMENT OF ANAESTHESIOLOGY

INFORMED CONSENT

I hereby give consent to participate in the research study Plasma sodium levels after TURP
surgery in diabetic patients in comparison with non diabetic patients- a cross sectional study to be
conducted in MOSC Medical College Hospital, Kolenchery.

I have been briefed on the foregoing research conducted by Dr.Allwyn Thomas and Dr. Sara
Korula in my own language. I have had the opportunity to clarify my concerns to my
satisfaction regarding the research. I consent voluntarily to participate in this research,
knowing that I have the right to withdraw from it at any time without affecting my medical
care.

Name of participant:
Signature of participant:
Date (dd/mm/yy): ..