drowsiness persisted with the patient only
opening his eyes voluntarily and not being able
to move his limbs. Since intravenous hypertonic
saline was not available, sodium replacement
was done orally with 8 hourly Ryle tube feeds of
4 gm of table salt in 50 ml distilled water.
Sodium levels returned to normal in the next
two days to 135 meq/lit. Correspondingly,
patient’s alertness improved and power in the
limbs returned to normal. Oral potassium and
table salt supplementation was continued.
Subsequent electrolyte examinations were
normal except on the sixth day, when his
potassium dropped to 2.9 meq/lit. That time, he
developed atrial fibrillation with ventricular rate
of 140 per minute. Normal sinus rhythm was
restored with intravenous adenosine. For the
next 12 days in the hospital, patient had normal
electrolyte levels. Oral supplementation of
electrolytes was tapered and omitted. Further
stay in the hospital was complicated by
development of deep vein thrombosis, which
was appropriately treated. The patient was
discharged asymptomatic on the eighteenth day
after admission.
Discussion
This case highlights two important points.
Though metabolic complications are not
uncommon after transurethral prostatic
resection, delayed manifestation of this
complication is rare. This report suggests that it
can occur even after six days of the surgery.
Manifestation of this complication depends on
the type of the irrigation fluid used, experience
of the surgeon (number of venous channels
opened), duration of surgery and peripheral
venous pressure. Use of glycine as irrigating
fluid has vastly reduced the incidence of this
complication. However, increased ammonia
levels following metabolism of glycine and high
levels of glycine per se can give rise to
neurological complications.
More importantly, there is a strong possibility
that pre-operative treatment with diuretic
(indapamide) may have contributed to this
complication in this patient. Though, the
incidence of hypokalemia with indapamide
treatment is very low, mild hypokalemia and
possibly hypomagnesemia is possible with long-
term treatment.(2) Since there is already a
propensity for metabolic changes during
prostate surgery, pre-existing electrolyte
abnormalities can further complicate the
surgery. Hence, the treating physician and
surgeon should make a conscious effort to elicit
history of diuretic treatment prior to prostate
surgery. Hypertension being a common ailment
in the age group being operated for prostate
enlargement, many of these patients may be on
diuretics. We strongly recommend that these
patients should have estimation of electrolytes
as a part of their pre-operative examination.
References:
1. Sear JW, Rosewarne F. Anesthesia for
surgeons. In Morris PJ, Malt RA,
Editors. Oxford textbook of surgery,
volume 1 . Oxford University Press,
Oxford, UK, 1994; pp 77-78.
2. Poulsen L, Friberg M, Noer I, et al.
Comparison of indapamide and
hydrochlorthiazide plus amiloride as a
third drug in the treatment of arterial
hypertension. Cardiovasc Drugs Ther
1989;3:141-144.
Reviewer's Comments:
It is a well documented fact that hypertensive
patients on diuretics are more prone to
developing acute manifestations of TUR
syndrome due to pre-existing subclinical
electrolyte abnormalities. The use of 1.5%
Glycine as irrigant solution has reduced the
complications related to hypotonicity of irrigating
fluids (sterile water), but complications relating
to volume load as well as biochemical alterations
(hyperammonemia) continue to be matter of
concern. The occurrence of clinical and
metabolic alterations after a recent TURP has
prompted the authors to presume this to be
case of delayed TUR syndrome. Tachycardia and
neutrophiic leukocytosis are pointers towards
sepsis, which by itself could cause metabolic
encephalopathy and be responsible for the
patient' s condition. Recent TURP and diuretic
therapy may be only additional factors
complicating the clinical picture. However, as the
authors state, patients on diuretic therapy pre-
operatively should be closely monitored in the
perioperative period, clinically and
biochemically, to minimize the risk of early or
delayed manifestations of a potentially life-
threatening clinical entity.