Roberthahn.seBritish Journal of Anaesthesia 96 (1): 8–20 (2006) Advance Access publication November 29, 2005 Fluid absorption in endoscopic surgery Department of Anaesthesia, Karolinska Institute, South Hospital, SE-118 83, Stockholm, Sweden Fluid absorption is an unpredictable complication of endoscopic surgery. Absorption of smallamounts of fluid (1–2 litre) occurs in 5–10% of patients undergoing transurethral prostaticresection and results in an easily overlooked mild transurethral resection (TUR) syndrome.
Large-scale fluid absorption is rare but leads to symptoms severe enough to require intensivecare. Pathophysiological mechanisms consist of pharmacological effects of the irrigant solutes, thevolume effect of the irrigant water, dilutional hyponatraemia and brain oedema. Other less widelyknown factors include absolute losses of sodium by urinary excretion and morphological changesin the heart muscle, both of which promote a hypokinetic circulation. Studies in animals, volun-teers and patients show that irrigation with glycine solution should be avoided. Preventivemeasures, such as low-pressure irrigation, might reduce the extent of fluid absorption butdoes not eliminate this complication. Monitoring the extent of absorption during surgery allowscontrol of the fluid balance in the individual patient, but such monitoring is not used widely.
However, the anaesthetist must be aware of the symptoms and be able to diagnose this com-plication. Treatment should be based on administration of hypertonic saline rather than ondiuretics. New techniques, such as bipolar resectoscopes and vaporizing instead of resectingtissue, result in a continuous change of the prerequisites for fluid absorption and its consequences.
Br J Anaesth 2006; 96: 8–20 Keywords: complications, hyponatraemia; complications, irrigation; complications, surgery;kidney, diuretics, mannitol; metabolism, sorbitol; pharmacokinetcs, glycine Many endoscopic surgical procedures require the use of have been reported. Severe events are associated with an irrigating fluid to dilate the operating field and to absorption of >3 litre of fluid.
wash away debris and blood. A potential complication of The TUR syndrome can occur with other operations such irrigation is systemic absorption of the fluid to including transcervical resection of the endometrium the extent that overt symptoms are produced. The conse- quences depend on the rate, volume and nature of the fluid cystoscopy,109 127 arthroscopy,69 rectal tumour surgery, vesical ultrasonic lithotripsy and percutaneus nephrolitho-tripsy.19 24 115 Fluid absorption was described, in 1947, as the cause of renal damage after transurethral resection of the prostate (TURP).
Irrigating fluid is most frequently absorbed directly into the The sterile water used for irrigation apparently caused vascular system when a vein has been severed by electro- intravascular haemolysis when absorbed. Within a few surgery. The driving force is the fluid pressure, which needs years, the modern non-electrolyte solutions containing gly- to exceed the venous pressure of 1.5 kPa.66 The period of cine, mannitol or sorbitol were introduced to prevent time that the fluid pressure exceeds 2 kPa (15 mm Hg) haemolysis, without dispersing the electric current used increases significantly with the absorbed volume.41 77 for cutting with the resectoscope. However, other adverse Major fluid absorption rarely stops once initiated and effects due to fluid absorption soon became apparent. They often coincides with a decrease in arterial pressure.48 arose in both the cardiovascular and nervous systems and, in Extravasation occurs after instrumental perforation of the the late 1950s, became known as the ‘transurethral resec- prostatic capsule during TURP, the uterine wall in TCRE,89 tion (TUR) syndrome'. Since then, several hundred life- or the bladder wall during cystoscopy127 and TUR of bladder threatening32 60 96 and even fatal5 12 69 87 100 TUR syndromes tumours.20 38 Several litres of irrigating fluid are rapidly The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved. For Permissions, please e-mail: [email protected] Fluid absorption during endoscopy deposited in the periprostatic, retroperitoneal or intraperi- An alternative approach is to measure the amount of toneal spaces. The fluid pressure only needs to exceed the absorbed fluid and the number of patients who develop intra-abdominal pressure of 0.5 kPa for extravasation to symptoms. The likelihood of symptoms developing can then be described in terms of ‘risk' for increasing volumes Extravasation is more common during renal stone sur- of absorbed fluid (Figs 2 and 3). Such data allows valid gery,24 115 while direct intravascular absorption is the comparison of the incidence of symptoms with various more common during TURP31 34 45 48 and TCRE.89 irrigating fluids.
Absorption in excess of 1 litre of glycine solution, which is associated with a statistically increased risk of symp- toms,92 has been reported in 5–20% of the TURPs performed(Fig. 1). Extravasation is the cause in 20% of these Smoking is the only patient factor known to be associated patients.54 55 92 with large-scale fluid absorption during TURP.43 Patients Fluid absorption is slightly more common during TCRE with prostate cancer who undergo TURP have the same than during TURP,15 28 72 the average being 400–700 ml.
incidence of fluid absorption as those with benign tissue.48 Istre71 reported absorption to be in excess of 1.5 litre in Fluid absorption increases with the extent of the resection 9% of patients, but there also appears to be a learning as the exposure is prolonged.48 Visual indications of fluid curve. In larger case series, the incidence of the TUR syn- absorption to the surgeon are usually lacking, although cap- drome may be <1%.73 sular perforation,103 which occurs in at least 10% of the In one study, fluid absorption exceeded 1 litre in 7% of TURPs, or apparent damage to a venous sinus increases patients undergoing percutaneous renal stone surgery.19 the likelihood of its occurrence.
Gehring and co-workers detected fluid absorption in all During TCRE, fluid absorption occurs more often during 31 patients who underwent this operation, and those with resection of fibroids.71 113 Variable amounts of fluid are extravasation required more opioids and had a longer hos- extravasated via the Fallopian tubes88 but previous steril- pital stay.24 Four of them remained in the ICU for more ization does not alter total absorption.15 89 Symptoms of glycine absorption Mild to moderately severe TUR syndrome occurs in between The incidence and severity of symptoms for increasing 1 and 8% of TURPs performed.25 31 34 111 121 Certain smaller amounts of absorbed fluid have been best established for patient series have a higher incidence,4 7 99 while others do glycine solution. In one retrospective analysis,92 patients not report any cases.26 One problem is that few studies use a who absorbed 0–300 ml of glycine solution had an average clear definition of the TUR syndrome. High variability in of more than one symptom. This increased to more than two fluid absorption and patient's responses makes it necessary when 1–2 litre had been absorbed, to more than three when to include up to 400 patients in any meaningful examination 2–3 litre had been absorbed, and to more than five for vol- of the incidence of the syndrome. The use of a checklist to umes >3 litre. The odds ratio for symptoms to develop was grade symptoms is recommended (Table 1).54 55 92 7 for TURPs during which 1–2 litre of glycine had been Table 1 A checklist used to define and score symptoms included in the TUR syndrome. In three studies,54 55 92 the number and severity of symptoms showed astatistically significant increase as more irrigating fluid was absorbed. HR, heart rate; SAP, systolic arterial pressure Duration <5 min Duration >5 min HR decrease 10–20 bpm HR decrease >20 bpm Repeated decrease SAP up 10–20 mm Hg SAP up >30 mm Hg Score (2) for 15 min SAP down 30–50 mm Hg SAP down >50 mm Hg Repeated drops >50 mm Hg Poor urine output Diuretics are needed Diuretics ineffective Duration <10 min Duration >10 min Transient blindness Duration <5 min Duration 5–120 min Intense or >120 min Repeatedly, <60 min Repeatedly, >60 min Duration <5 min Duration 5–60 min Duration >60 min Objectively exhausted Exhausted for >120 min Somnolent <60 min Severe <60 min Severe >60 min Incidence of fluid absorption (n =817) Prickling sensations Arterial hypotension Fluid absorption (ml) Incidence of symptom (%) Operating time (ml) <500 500– 1000– 1500– 2000– >3000 Fluid absorption (ml) Range of fluid absorption (ml) Fig 2 The incidence of prickling sensations, arterial hypotension, feelings of uneasiness and chest pain with increasing amounts of absorption ofglycine 1.5% during TURP. The absorption was measured by ethanol Fig 1 The incidence of fluid absorption during transurethral prostatic resec- 1%. Data are summarized from three studies54 55 92 using the checklist tion as measured by the ethanol method in 817 consecutive patients, sum- shown in Table 1.
marized from two studies.54 55 The uptake exceeded 500 ml in 16% of theoperations performed (A). The amount of absorbed fluid is difficult to pre-dict from the extent of surgery, although it does become more common and complains of headache. The most consistent signs are brady- more pronounced in prolonged (B) and bloody operations (C). The x–y plotsshow data on 375 patients from three studies,54 55 92 all of those who had cardia and arterial hypotension (Fig. 2). ‘Feeling bad' is fluid absorption and a minority of the patients with zero absorption.
slightly more common than perioperative nausea, whichis reported by 5–10% of the patients. Chest pain occursin 5% of the patients who absorb >1 litre, and is more likely absorbed. Further increases mainly comprised neurological if the blood loss is small.98 Hypertension is statistically symptoms. This dose-dependent increase in the number of unrelated to fluid absorption.
symptoms arising has been corroborated in subsequentprospective studies.54 55 A pooled analysis of the incidenceof various symptoms, based on these three studies which were carried out in the same way, shows that the TUR The most common signs and symptoms are nausea and syndrome has a progressive nature.
arterial hypotension followed by vomiting and low urinaryoutput, all of which become more frequent as more irrigatingfluid is absorbed (Fig. 3). Visual disturbances are reported by 10% of the patients who absorb >500 ml of glycine solution.
The patient sometimes reports transient prickling and burn- Arterial hypertension becomes less common when more ing sensations in the face and neck, becomes restless and irrigating fluid is being absorbed. Depressed consciousness Fluid absorption during endoscopy The incidence of acute myocardial infarction during TURP is between 1 and 3%.70 Evidence of cardiac isch- aemia, using Holter ECG, was found in 25% of TURP patients, mostly in those with known cardiovascular disease.124 A marginal increase in cardiac enzymesoccurred in 7% of all TURP patients,70 but the incidence was higher in patients with glycine absorption.49 Severe TUR syndrome is rare but well described in the literature. A review of 24 severe cases (glycine 1.5%) Arterial hypotension showed that neurological symptoms occurred in 92%, car- diovascular symptoms in 54%, visual disturbances in 42%,digestive tract signs in 25% and renal failure in 21%. The mortality was 25%.100 Pharmacokinetics and pharmacodynamics Glycine is a non-essential amino acid which was introduced in 1948 as an irrigating fluid solute (usually 1.5%) with low cost and lack of allergic reactions. The plasma concentration in humans is 0.3 mmol litre 1, which is raised 25-fold on Incidence of symptom (%) administration of 1 litre of this fluid. The distribution half- life is only 6 min,51 while the terminal half-life is between 40 min and several hours.33 51 56 The half-life is dose- Poor urine output dependent36 which is probably due to intracellular accumu- lation of glycine.86 Penetration into the central nervous system is restricted,126 but may be clinically important.112 Elimination of glycine occurs primarily in the liver, yield- ing ammonia. Only 5–10% of an excess dose is excreted unchanged in the urine, promoting an osmotic diuresis.56 The plasma concentration and urinary excretion of other <500 500– 1000– 1500– 2000– >3000 non-essential amino acids are also increased.32 33 Visual disturbances correlate with a plasma glycine con- Range of fluid absorption (ml) centration of 5–8 mmol litre 1 44 82 while higher concentra-tions produce transient blindness.120 Nausea and vomiting Fig 3 The incidence of nausea, arterial hypotension, vomiting and poor develop when the plasma glycine concentration exceeds urinary output with increasing amounts of absorption of glycine 1.5% after 10 mmol litre 1.25 33 Concentrations measured in fatal TURP. The absorption was measured by ethanol 1%. Data are summarizedfrom three studies using the checklist shown in Table 1.
TUR syndromes have been 21 and 80 mmol litre 1.5 96 Mannitol is an isomer of glucose used as a 3 or 5% solu- develops in 5% of the patients after absorption of >1 litre tion. After a short distribution phase, mannitol spreads of fluid. Diarrhoea occurs in 20% of those who absorb throughout the extracellular fluid space. The elimination >3 litre.
half-life is 100 min51 but can be twice85 and even four Abdominal pain is reported by 10–20% of patients who times1 longer in TURP patients with a moderately elevated absorb >1 litre of fluid. This symptom is strongly related to serum creatinine concentration.
extravasation, which is also associated with a higher inci- Mannitol is not metabolized and is excreted unchanged in dence of arterial hypotension and poor urinary output.37 the urine,1 promoting an osmotic diuresis. This effect makes The clinician should be aware of a mild TUR syndrome, it inappropriate to combine irrigation with mannitol 5% and which is easily overlooked. This presents with nausea and postoperative diuretic therapy.75 85 However, mannitol is not often a sudden reduction in arterial pressure 30–45 min after diuretic in a 0.5–1% concentration as an irrigating fluid the operation.54 55 92 Serum sodium is lowered 5–10 mmol mixed with 2–3% sorbitol.84 87 A maximum concentration of 2 g litre 1 was measured in The ‘mini-mental' status test shows that glycine absorp- 10 volunteers who received 1.2 litre of mannitol 3%.51 tion has a strong association with transient confusion after Plasma concentrations >4 g litre 1 were associated with TURP.83 Apparent confusion may occur in response to bradycardia and hypotension after TURP75 while other absorption of 1–2 litre,114 but is more consistent with larger authors found few or no symptoms after absorption of man- absorption volumes4 25 and might proceed to depressed nitol 5%,1 a fact probably attributable to the isotonic nature consciousness33 102 115 and coma.60 100 116 of mannitol 5%.
and pulmonary oedema may develop on the operatingtable,14 21 32 particularly during operations associated witha small blood loss.35 Hypervolaemia is followed by a longer and more prob- lematic hypokinetic haemodynamic phase, which is charac-terized by low cardiac output, hypovolaemia and low arterial pressure.8 14 105 110 Factors promoting the haemodynamic Plasma dilution 0.1 changeover include natriuresis, osmotic diuresis and, with glycine and sorbitol, intracellular uptake of water. Hypona-traemia, hypocalcaemia,13 14 low serum osmolality,100 acute lowering of the body temperature23 and release of prostatic substances118 or endotoxins111 may also contribute. There-fore, bradycardia and a marked decrease in systolic arterial Fig 4 Computer simulation of the plasma dilution resulting from experi- pressure down to 50–70 mm Hg at the end of, or just after, mental infusion of 1.5 litre of three irrigating fluids for more than 20 min in10 volunteers. There are only small differences between the fluids despite the operation is often the first sign suggesting TUR syn- the differences in half-life of the solutes. Calculation is based on data from drome.4 14 110 Pulmonary oedema might also develop late, indicating that serum sodium is <100 mmol litre 1 11 102 incoexistence with severe hypo-osmolality.18 Sorbitol is metabolized to fructose and glucose in the liver and has a distribution half-life of 6 min and a terminal half-life of 33 min.51 As for glycine, 5–10% of an infused Disturbances of cardiac function due to excess water might load is excreted unchanged by the kidneys. Plasma sorbitol be an important cause of cardiovascular collapse. Depres- concentrations corresponding to 2 litre of absorbed fluid sion of the conductivity system, bradycardia, and depression have been reported after TURP without associated untoward of the ST segment and T wave is common also in humans effects. However, in five patients with TUR syndrome (of with massive fluid absorption.4 49 87 96 102 whom two died), the total serum concentration of irrigant Animal studies have shown damage to the myocardial solutes was between 5.4 and 12.0 g litre 1 when irrigation histoskeleton in association with irrigating fluids and that was performed with a mixture containing sorbitol 2.7% and glycine in particular causes hypoxic lesions in the subendo- mannitol 0.54%.87 The major portion of this solute concen- cardium50 52 57 105 (Fig. 5) and an acute increase in the tration can be attributed to sorbitol.
weight of the heart.93 105 The ECG shows a bradycardiawith prolongation of the PQ time, widening of the QRS Water in irrigation fluids complex and reduction of the QRS amplitude, all ofwhich correlate with the outcome.93 The fluid volume in which the solutes are dissolved adds tothe symptoms of fluid absorption. The volume expansion ofthe intravascular space and dilution of the plasma has been quantified in volunteers. Mannitol 3% expands the plasma Dilution of plasma proteins rarely exceeds 25%, but might more than glycine 1.5%104 while sorbitol–mannitol takes an intermediate position (Fig. 4).
(<120 mmol litre 1) may cause muscle weakness, muscular The lower osmolality of irrigating fluid compared with twitches, epileptic seizures and shock.25 99 This key finding plasma means that irrigant water enters the cells very is often accompanied by reduction of serum osmolality of quickly after absorption takes place. Glycine and sorbitol 10–25 mosmol kg 1, as most irrigating fluids are hypo- enter the cells and, by virtue of osmosis, bring water intra- osmolar (200 mosmol kg 1). Ghanem and Ward25 reported cellularly. Cellular oedema develops with a delay related a strong correlation between low serum osmolality and to the half-life of the solute and, together with urinary excre- symptoms and Desmond18 between osmolality and pul- tion and surgical haemorrhage, reduces the extracellular monary oedema. Serum potassium often increases tran- overhydration.104 105 siently by 15–25% in response to fluid absorption,particularly after absorption of glycine.56 82 The hyper-kalaemia is probably related to intracellular uptake of the General pathophysiology irrigant solute.
Absorption of a volume large enough to cause TUR syn- drome is accompanied by metabolic acidosis with pH levels Fluid absorption causes a transient hypervolaemia with an ranging from 7.10 to 7.25.63 127 Hypoxia has also been increase in central pressures, which plateaus within reported,28 but it is less consistent and is more common 15 min.32 35 Shortness of breath, uneasiness, chest pain
Fluid absorption during endoscopy Fig 5 Cardiac pathology in animals infused with irrigating fluid. Light microscopy is used with haematoxylin–eosin stain, with the permission of ProfessorJovan Rajs, Karolinska Institute. (A) Focal myocarditis in the heart of a mouse after receiving glycine 1.5%. (B) Focal necrosis of myocytes withinflammatory reaction in a rabbit from glycine 1.5%. (c) Vasodilatation and haemorrhage in the subendocardium in a mouse given mannitol 5%.
(D) Extreme interstitial dilatation in the myocardium of a rabbit sacrificed 2 h after being treated with 100 ml kg 1 of glycine 1.5%.
The incidence of urosepsis seems to be increased by i.v.
fluid absorption during TURP54 and by extravasation in Abdominal pain, which may radiate to the shoulder, is a common first sign of extravasation.37 Extracellularelectrolytes diffuse into the pool of deposited irrigating fluid6 90 and the hyponatraemia is most pronounced 2–4 h Brain oedema is a serious problem and cerebral herniation later.37 This movement of electrolytes is followed by hypo- developing a few hours postoperatively5 100 is a major cause volaemia, with bradycardia and arterial hypotension.6 38 115 of death from fluid absorption, in addition to cardiovascular Extravasation may go undetected until the next day, because or respiratory collapse.12 87 96 Signs of cerebral oedema on of the slow development.127 CT scans were found after absorption of as little as 1 litre ofglycine 1.5% during TCRE72 while this did not occur inyounger male volunteers.104 However, lowering of the serum osmolality in response to larger amounts of glycine Certain features of the pathophysiology are unique to each solutions raises the intracerebral pressure in experimental irrigating fluid.
animals105 and in TURP patients.78 Glycine is an inhibitory neurotransmitter in the retina.
The patient may become comatose after glycine absorp- An excess amount slows down the transmission of impulses tion without having cerebral oedema, but with signs of meta- from the retina to the cerebral cortex. Prolongation of visual- bolic encephalopathy with,98 or without,127 a marked evoked potentials and deterioration of vision occur after increase in blood ammonia, arising from the metabolism absorption of as little as a few hundred millilitres of glycine 1.5%.44 79 82 More pronounced absorption, corresponding toglycine concentrations of 7–8 mmol litre 1, abolishes the oscillatory potentials on the electroretinogram.120 There are Moderate amounts of irrigating fluid (up to 2.5 litre) induce clinical reports of transient blindness after absorption of osmotic diuresis, which results in absolute losses of sodium glycine during most types of endoscopic surgery. Intraocular from the body (40 mmol litre 1 urine).51 112 With larger pressure,99 fundoscopy, pupillary reflexes and brain CT scan amounts of irrigating fluid, they ultimately swell, which are normal, while the pupils may be dilated. The blindness promotes anuria.50 119 In extravasation, failure to void cor- resolves within 24 h.
relates with arterial hypotension,37 92 which causes anoxia of Prickling sensations and facial warmth are early signs of the renal tubular cells.
glycine absorption.56 Vasopressin is released as a specific response to glycine in saline compared with other irrigating solutions. Pulmonary doses exceeding 25–30 g32 112 leading to water retention and oedema is a reported consequence.29 restoration of the serum sodium after fluid absorption more Sterile water is often used for cystoscopy as it offers the surgeon a very clear view of the operating field. Warnings Hyperammonaemic encephalopathy may develop as against using sterile water for irrigation during electro- ammonia is an intermediate product in glycine metabolism.
surgery are based on both animal experiments119 and clinical Blood ammonia concentrations >100 mmol litre 1 (normal experience;80 but, more recently, several authors have rec- range 10–35) are associated with neurological symptoms, ommended the fluid for limited resections.30 68 81 Although and values up to 800 mmol litre 1 have been reported.63 there is no agreement about how much sterile water is Ammonia is released from the liver and kidneys and needed to cause renal failure, damage requiring chronic removed in the head and limbs. The blood concentration haemodialysis still occurs with accidental and unexpected correlates with the glycine dose and symptoms such as con- absorption of sterile water.20 Serum potassium might also fusion.56 Interindividual variability is great, however, and patients may show neurological symptoms after absorbing Sterile water could be expected to promote cerebral large amounts of glycine 1.5% while still having a normal oedema more vigorously than other electrolyte-free irrigat- blood ammonia concentration. Only 15–20% of volunteers show an increase in blood ammonia when challenged by aglycine overload.53 There is a vague correlation betweenhyperammonaemia and visual disturbances,44 82 while these Comparing outcomes factors are independent from cerebral oedema. Other meta- The clinician has an interest in knowing which irrigation bolic products of glycine have also been associated with fluid is associated with the least danger if fluid absorption neurological symptoms. Among them are glycolic acid occurs. This issue was studied by Hahn's group during the and glyoxilic acid, which accumulate in the cerebrospinal 1990s. A consistent finding in these studies was the poor fluid,97 98 and glutamate (glutamic acid), the elevation of performance of glycine 1.5%.
which shows a time-course similar to the symptoms.33Some of the metabolic symptoms of glycine absorptioncan be recognized in hyperglycinaemia, which is a rare dis- order of amino acid metabolism characterized by episodes of Zhang and colleagues128 studied rat cardiac myocytes and ketosis and metabolic acidosis that may proceed to coma.
found that 99% of cells were viable after being mixed with Oxalate is an end-product of glycine metabolism, but sorbitol 2% or mannitol 1%, while only 83% of them were studies in volunteers and TURP patients refute the assertion viable after glycine 1.5%.
that glycine markedly increases oxalate excretion.
In live mice, i.v. infusion of irrigating fluids was associ- Allergic reactions to mannitol are very rare. Mannitol ated with survival in 20% (glycine 1.5%), 32% (sorbitol 2% concentrations >5% are often used for purposes other with mannitol 1%) and 60% (mannitol 5%).91 Survival after than irrigation and entail the risk of acute renal failure in glycine administration was dependent on both the glycine dehydrated patients.64 dose and the accompanying fluid volume after both i.v.129 Metabolic complications of sorbitol are due to a primary and intraperitoneal95 administration. Isotonic glycine 2.2% metabolite, fructose. Rapid administration of fructose, com- was associated with the poorest outcome. Glycine 1.5%, pared with absorption of 5 litre of sorbitol 5% for more than 100 ml kg 1 for more than 60 min, was fatal in two out 30 min, causes lactic acidosis.9 Fructose might also induce of seven rabbits, while no animal died after mannitol 3% or coma in patients with liver disease.125 Infusion of sorbitol sorbitol–mannitol.50 Glycine solution induced the greatest has lead to death of patients with intolerance to fructose, increase in cardiac weight and tissue damage in the heart, because of lack of the aldolase B enzyme.106 Finally, hypo- kidneys, liver and brain. Maatman and colleagues76 reported glycaemia develops in young patients with fructose-1,6- microscopic damage to the liver and kidney of rats given diphosphatase deficiency who are given sorbitol.
glycine 1.5% by i.v. and retroperitoneal infusion, while the Normal saline is used for irrigation with the bipolar resec- histology was normal after Ringer's solution and water. The toscope. Although cerebral oedema is unlikely, infusion of water content of the mouse hearts increased markedly after 25 ml kg 1 of isotonic electrolyte solution for more than infusion of glycine 1.5%, but not after normal saline or 15 min in women caused sensations of swelling in the hands glycine 1.5% in normal saline.93 and face, slight dyspnoea, abdominal sensations and anal- In pigs, mannitol 5% increased the blood volume more gesia around the lips.46 Twice the volume infused for more than glycine 1.5%, and maintained the haemodynamic pro- than 1 h was followed by mental changes and discomfort from file better during infusion.105 The intracranial pressure dou- swelling.123 Moreover, normal saline causes hyperchlo- bled during infusion of glycine 1.5%, but was unchanged in raemic acidosis due to its excessive content of chloride.122 response to mannitol 5%. The peripheral vascular resistance Because of the greater plasma volume expansion,112 acute was increased during infusion of glycine 1.5% in sheep112 volume overload is more likely during absorption of normal and pigs.105 For both fluids, cardiac output and aortic blood Fluid absorption during endoscopy flow decreased by as much as 50% after the infusion was Absorption (ml) = –223+6440 breath ethanol (mg ml−1)/ completed.105 A similar cardiodepression has been observed irrigant ethanol conc (%)+17×time (min) in dogs given glycine 1.5%.
In studies based on infusing 1 litre of irrigating fluid for more than 20–30 min, glycine 1.5% elicits more symptomsthan mannitol 3% and 5%,56 104 while glycine 2.2%is worst.56 Glycine, but not mannitol 3% or sorbitol– mannitol solutions, reduces cardiac output by increasingperipheral resistance.84 The diastolic and mean arterial pres-sures become slightly increased.56 84 104 Ethanol, which can be added to the fluid to allow moni- toring of fluid absorption, has no effect on the fluid balance in prostatectomy patients given glycine 1.5%. Ethanol read- Fluid absorption indicated by ethanol (ml) ily enters the cells and only slightly increases the resistance to haemolysis.55 The breath ethanol concentration is prac-tically identical regardless of whether the ethanol is added Measured fluid absorption (ml) to glycine 1.0%, glycine 1.5% or mannitol 3%.56 84 104 Fig 6 Early graph, from 1989, showing the fluid absorption as indicated bycareful measurements of the volumetric fluid balance corrected for bloodloss at the end of any 10 min period of TURP vs the fluid absorption as obtained by a regression equation based on the expired breath ethanolconcentration, the ethanol concentration in the irrigating fluid and the period In a two-centre evaluation, glycine 1.0% had the same inci- of time during which ethanol has been detected. Most of the data are from dence of symptoms as glycine 1.5%,55 but mannitol 3% had refs 31 and 34.
a significantly lower incidence of symptoms, such as nausea,than glycine 1.5%.54 Cardiovascular events did not differbetween the fluids. Inman and colleagues70 found no differ- Gravimetry implies that the patient is operated on on a ence, based on 205 patients, in symptoms and cardiac bed-scale and that an increase in body weight implies fluid enzymes between glycine 1.5% and sorbitol–mannitol.
absorption. The method must take blood loss and all i.v.
infusions into account, and recordings should be madewhen the bladder is empty. Coppinger and colleagues16 108 Measuring fluid absorption have shown that the gravimetric method is quite accurate, Fluid absorption can be quantified by measuring serum when incorporating modern transducers and potential errors sodium in all cases where the solution lacks electrolytes.
The method is best applied repeatedly during surgery, but is Central venous pressure increases transiently on intravas- rarely used clinically because of practical problems and cular administration of irrigating fluid, but the method is invasiveness. As a rule, serum sodium is only measured relatively insensitive because 500 ml must be absorbed at the end of surgery. The hyponatraemia then correlates within 10 min to increase the pressure by 2 mm Hg.45 with the amount of absorbed fluid, although smaller absorp- The result is also affected by blood loss and other fluid tion events may be blurred by variability and the sodium therapy111 but it may be recommended for poor-risk content of other infusions. Serum sodium is also a poor guide to the degree of extracellular overhydration during the post- Measurement with isotopes was long considered to be operative phase.42 the most reliable method to quantify fluid absorption,77 Volumetric fluid balance is based on the calculation of the but modern safety precautions make them difficult to apply.
difference between the amount of irrigating fluid used and Isotopes are a sensitive tool for detecting low-grade the volume recovered. Positive values are regarded as absorption. The accuracy is hampered by many factors, Ethanol is based on the same principle as isotopes that a including variations in bag-to-bag content, spillage, blood tracer is added to the irrigating fluid and that the body con- loss and urinary excretion. Haemodilution during surgery centration measured is an index of fluid absorption. Mea- should be considered in the blood loss figure to accurately surements of the ethanol concentration in the exhaled breath account for the plasma loss. All these factors make volu- can be made during surgery with relatively little effort. The metric balance an unreliable tool,94 and it must be refined to first clinical trial used glycine 1.5% with ethanol 2%,31 but be accurate.31 34 45 Volumetric fluid balance is more useful later studies concluded that 1% was suitable for clinical during TCRE as the confounding influence of blood loss is use.34 The sensitivity is 75 ml per 10 min of surgery, much smaller than during TURP (Fig. 6).58 and any further elevation of the breath ethanol concentration implies that more fluid is being absorbed (Fig. 6). Ethanol Low-pressure irrigation monitoring method can be applied during both spinal and Performing TURP with a low fluid pressure, below the general anaesthesia and in patients with poor lung function.
critical pressure for intravascular absorption, would limit The method has been well evaluated worldwide. Two the risk. This can be achieved by applying a suprapubic reviews are available.39 40 evacuation instrument (Reuter's trocar)101 or a special Absorption of fluid directly into the bloodstream is channel in a resectoscope (the Iglesias technique).
accompanied by a prompt decrease in serum sodium, eleva- Several authors have found irrigation using the suprapu- tion of the central venous pressure and an increase in the bic trocar to be efficient,65 while others have not. There is serum or breath concentration of any marker present in the even more widespread scepticism about the effectiveness fluid. These elevations correlate with the volume of of the Iglesias method. Heidler59 reported development of absorbed irrigant fluid as obtained by gravimetric weighing severe hyponatraemia in 3 out of 30 patients undergoing and very careful measurements of volumetric balance.
TURP using an Iglesias resectoscope. In contrast, only Extravasation is detected immediately only by gravi- 1 patient out of 60 developed severe hyponatraemia when metric weighing and volumetric fluid balance, while serum the pressure was maintained below 2 kPa using the supra- sodium and breath ethanol become apparent 15–20 min pubic trocar. In another study, the trocar maintained a low later.37 The maximum concentrations are approximately pressure (<1.5 kPa) only in half of the operations.41 Five one-third of those indicated by intravascular absorption, mild TUR syndromes occurred in 500 patients using this and a further increase after the operation is characteristic.39 evacuation device.121 The variable effectiveness is probablybecause of outflow obstruction by blood clots, which raisesthe fluid pressure. Low-pressure irrigation is probably more efficient if combined with monitoring of the intravesical Several methods have been proposed to reduce the risk of fluid absorption and its associated dangers. None of them iscapable of eliminating the complication.
Bipolar resectoscope A bipolar technique allows the use of normal saline for irrigation, which will influence the signs of TUR syndrome.
Fluid absorption varies between surgeons and depends on The incidence of mental changes and abdominal pain will be their skill in avoiding prostatic capsule perforations and the similar to that with sorbitol–mannitol irrigation,46 122 123 and opening up of venous sinuses. However, studies do not sup- vascular overload resulting in pulmonary oedema could be port that experienced surgeons have less fluid absorption expected as a more common problem.29 during their operations61 74 but those who obtain immediatefeedback via ethanol monitoring learn how to operate with less fluid absorption.74 Alternative techniques to TURP have been developed, one Spinal anaesthesia does not reduce absorption48 but of them being vaporization of the prostate. Fluid absorption allows early detection of gross changes in mental status.
and blood loss are less pronounced during this operation, but This approach offers limited possibilities to interact with fluid absorption of up to 3 litre may still occur.
the absorption process as symptoms require the build-upof a considerable absorption volume.
Vasoconstrictor with vasopressin injected at the operating Reduction of surgical time site is claimed to reduce fluid absorption during TCRE27 and It is a common belief that dangerous fluid absorption during might possibly have the same effect during TURP.107 Dur- TURP is prevented by keeping the operating time below ing TCRE, pretreatment with hormones to reduce endome- 1 h.18 However, massive absorption has been described trial thickness affects the risk of fluid absorption in many, after as little as 15 min of surgery (Fig. 1).34 48 87 but not in all, studies.113 Lowering the fluid bag Placing the irrigating fluid bag at 60 cm above the operating table was advocated early on as a method of controlling fluid Visual disturbances resolve spontaneously within 24 h and absorption.77 However, two studies comprising nearly 600 need no treatment.32 79 Mild adverse events are treated by patients could not demonstrate any correlation between bag supportive measures, including antiemetics. Hypertension is height and fluid absorption during TURP.47 117 The reason is likely to be transient. The cardiovascular collapse can be probably that the urologist tends to operate at a certain fluid reversed if treatment is instituted promptly. Bradycardia and pressure, which might be much lower than the maximum hypotension should be treated with atropine, adrenergic possible pressure indicated by the bag height.22 drugs and i.v. calcium.110 Although fluid restriction was Fluid absorption during endoscopy recommended previously,8 plasma volume expansion is and it should be noted that most symptoms appear indicated as hypovolaemia and low cardiac output develops 30–45 min after surgery is completed. At that time, the as soon as irrigation is discontinued.32 35 105 110 119 hyponatraemia is explained by natriuresis and not by Specific treatment includes hypertonic saline, which is dilution. However, symptoms related to fluid absorption indicated when several symptoms develop or the serum develop in 3–5% of patients. Neurological symptoms sodium concentration is <120 mmol litre 1. Both experi- are prominent whem glycine 1.5% is used. Some mental10 21 and clinical3 25 60 102 studies support the use of patients develop a severe TUR syndrome which involves this treatment, although serum sodium concentrations a hypokinetic circulation and damage to the heart. Their down to 100 mmol litre 1 may be fatal.87 Patients who treatment should be based more on hypertonic saline than do not receive hypertonic saline, or with a delay of several on furosemide.
hours, more frequently suffer residual neurological damage To control fluid absorption, the surgical training should be guided by immediate feedback about fluid absorption. The Warnings about pontine myelinolysis resulting from rapid surgeon should be notified about ongoing fluid absorption correction of hyponatraemia originally pertained to chronic whenever it exceeds 1 litre. This allows steps to be taken to hyponatraemia, but recent studies question rapid correction prevent excessive absorption. Treatment can be instituted also in acute hyponatraemia. Raising the serum sodium con- early and the optimal concentration of postoperative care be centration by 1 mmol litre 1 h 1 may be taken as a safe rate.2 chosen. The most viable methods to monitor fluid absorption Hypertonic saline combats cerebral oedema, but it also are ethanol monitoring and gravimetric weighing. Little is expands the plasma volume, reduces cellular swelling and yet known about the risks associated with alternative resec- increases urinary excretion without increasing the total sol- tion techniques, such as the bipolar resectoscope.
ute excretion. In the past, there was a fear of hypertonicsaline inducing pulmonary oedema,8 87 but this has notbeen seen in clinical experience.
Supplementary data The primary indication of i.v. furosemide is to combat acute pulmonary oedema and to induce diuresis when this The complete list of 320 references is available as supple- does not occur spontaneously. In other situations, the best mentary data to the online version of this article, at www.bja.
practice is probably to withhold this until the patient is haemodynamically stable and hypertonic saline is infused.
No studies support its routine use in the treatment of fluid absorption. In fact, furosemide after TURP aggravates thehyponatraemia and hypovolaemia.17 Early treatment with 1 Allge´n LG, Norle´n H, Kolmert T, Berg K. Absorption and elim- ination of mannitol solution when used as an isotonic irrigating furosemide is based on the belief that hyponatraemia is agent in connection with transurethral resection of the prostate.
solely due to fluid overload which dilutes the extracellular Scand J Urol Nephrol 1987; 21: 177–84 fluid space.18 87 One hour after surgery, however, the 2 Ayus JC, Arieff AI. Glycine-induced hypo-osmolar hyponatremia.
hyponatraemia following moderate-sized absorption (up Arch Intern Med 1997; 157: 223–6 to 1.3 litre) is entirely because of natriuresis, while half 3 Ayus JC, Krothapalli RK, Arieff AI. Treatment of symptomatic of the hyponatraemia is explained by these factors in hyponatremia and its relation to brain damage. N Engl J Med 1987; 317: 1190–5 4 Baba T, Shibata Y, Ogata K, et al. Isotonic hyponatremia and Extravasation is treated with the similar measures. Great cerebrospinal fluid sodium during and after transurethral resec- care should be taken to counteract arterial hypotension and tion of the prostate. J Anesth 1995; 9: 135–41 oliguria.37 Morbidity and mortality can also be reduced by 5 Baggish MS, Brill AIO, Rosenweig B, Barbot JE, Indman PD. Fatal surgical drainage of the retroperitoneal fluid, but this is only acute glycine and sorbitol toxicity during operative hysteroscopy.
necessary after massive absorption.37 Such drainage also J Gynecol Surg 1993; 9: 137–43 removes extracellular electrolytes that have diffused into 6 Baillo AM, Gassol JM, Redorta JP, Castro MN, Gime´nez NM.
the fluid pool,90 which makes hypertonic saline a valuable Physiopathology and surgical treatment of extravasated peri-toneal fluid after transurethral resection. Eur Urol 1984; 10: remedy when drainage is performed.10 7 Balzarro M, Ficarra V, Bartoloni A, Tallarigo C, Malossini G.
transurethral resection of the prostate syndrome. Urol Int Fluid absorption is a complication inherent in many endo- 2001; 66: 121–6 scopic procedures that can be limited by technical means but 8 Beal JL, Freysz M, Berthelon G, D'Athis P, Briet S, Wilkening M.
never prevented. The past decade has provided better insight Consequences of fluid absorption during transurethral resectionof the prostate using distilled water or glycine 1.5 per cent. Can J into the incidence of fluid absorption, how various irrigating Anaesth 1989; 36: 278–82 fluids compare and the gradual increase in the number and 9 Bergstro¨m J, Hultman E, Roch-Norlund AE. Lactic acid accumu- type of symptoms occurring when more fluid is being lation in connection with fructose infusion. Acta Med Scand 1968; absorbed. Mild TUR syndrome should be better recognized 10 Bernstein GT, Loughlin KR, Gittes RF. The physiologic basis of the 30 Grundy PL, Budd DWG, England R. A randomized controlled trial TUR syndrome. J Surg Res 1989; 46: 135–41 evaluating the risk of sterile water as an irrigating fluid during 11 Butt AD, Wright IG, Elk RJ. Hypo-osmolar intravascular volume transurethral electrovaporization of the prostate. Br J Urol 1997; overload during anaesthesia for transurethral prostatectomy.
A report of 2 cases. S Afr Med J 1985; 67: 1059–61 31 Hahn RG. Ethanol monitoring of irrigating fluid absorption 12 Byard RW, Harrison R, Wells R, Gilbert JD. Glycine toxicity in transurethral prostatic surgery. Anesthesiology 1988; 68: and unexpected intra-operative death. J Forensic Sci 2001; 46: 13 Chassard D, Berrada, K, Tournadre JP, Boule´treau P. Calcium transurethral prostatic resection. Intensive Care Med 1988; 14: homeostasis during i.v. infusion of 1.5% glycine in anaesthetized pigs. Br J Anaesth 1996; 77: 271–3 33 Hahn RG. Serum amino acid patterns and toxicity symptoms 14 Chow MYH, Tan SSW. A case of fluid embolism from transcer- following the absorption of irrigant containing glycine in transur- vical endometrial resection. Ann Acad Med Singapore 1997; 26: ethral prostatic surgery. Acta Anaesthesiol Scand 1988; 32: 15 Chui PT, Short T, Leung AKL, Tan PE, Oh TE. Systemic absorption 34 Hahn RG. Early detection of the TUR syndrome by marking the of glycine irrigation solution during endometrial ablation by trans- irrigating fluid with 1% ethanol. Acta Anaesthesiol Scand 1989; cervical endometrial resection. Med J Aust 1992; 157: 667–9 16 Coppinger SWV, Lewis CA, Milroy EJG. A method of measuring 35 Hahn RG. Fluid and electrolyte dynamics during development of fluid balance during transurethral resection of the prostate.
the TURP syndrome. Br J Urol 1990; 66: 79–84 Br J Urol 1995; 76: 66–72 36 Hahn RG. Dose-dependent half-life of glycine. Urol Res 1993; 21: 17 Crowley K, Clarkson K, Hannon V, McShane A, Kelly DG. Diuret- ics after transurethral prostatectomy: a double-blind controlled 37 Hahn RG. Transurethral resection syndrome from extravascular trial comparing frusemide and mannitol. Br J Anaesth 1990; 65: absorption of irrigating fluid. Scand J Urol Nephrol 1993; 27: 387–94 38 Hahn RG. Transurethral resection syndrome after transurethral 18 Desmond J. Serum osmolality and plasma electrolytes in patients resection of bladder tumours. Can J Anaesth 1995; 42: 69–72 who develop dilutional hyponatremia during transurethral 39 Hahn RG. Ethanol monitoring of irrigating fluid absorption resection. Can J Surg 1970; 13: 116–21 (review). Eur J Anaesthesiol 1996; 13: 102–15 19 Dimberg M, Norle´n H, Ho¨glund N, Allge´n L-G. Absorption of 40 Hahn RG. The use of ethanol to monitor fluid absorption in irrigating fluid during percutaneous transrenal lithotripsy. Scand J transurethral resection of the prostate (review). Scand J Urol Urol Nephrol 1993; 27: 463–7 Nephrol 1999; 33: 277–83 20 Dorotta I, Basali A, Ritchey M, O‘Hara JF, Sprung J. Transurethral 41 Hahn RG. Intravesical pressure during fluid absorption in trans- resection syndrome after bladder perforation. Anesth Analg 2003; urethral resection of the prostate. Scand J Urol Nephrol 2000; 34: 21 Drinker HR, Shields T, Grayhack JT, Laughlin L. Simulated trans- 42 Hahn RG. Natriuresis and ‘‘dilutional'' hyponatremia after infusion urethral resection in the dog: early signs and optimal treatment.
of glycine 1.5%. J Clin Anesth 2001; 13: 167–74 J Urol 1963; 89: 595–602 43 Hahn RG. Smoking increases the risk of large-scale fluid absorp- 22 Ekengren J, Zhang W, Hahn RG. Effects of bladder capacity and tion during transurethral prostatic resection. J Urol 2001; 166: height of fluid bag on the intravesical pressure during transure- thral resection of the prostate. Eur Urol 1995; 27: 26–30 44 Hahn R, Andersson T, Sikk M. Eye symptoms, visual evoked 23 Evans JWH, Singer M, Coppinger SWV, Macartney N, Walker JM, potentials and EEG during intravenous infusion of glycine. Acta Milroy EJG. Cardiovascular performance and core temperature Anaesthesiol Scand 1995; 39: 214–9 during transurethral prostatectomy. J Urol 1994; 152: 2025–9 45 Hahn R, Berlin T, Lewenhaupt A. Irrigating fluid absorption and 24 Gehring H, Nahm W, Zimmermann K, Fornara P, Ocklitz E, blood loss during transurethral resection of the prostate studied Schmucker P. Irrigating fluid absorption during percutaneous by a regular interval monitoring (RIM) method. Scand J Urol nephrolithotripsy. Acta Anaesthesiol Scand 1999; 43: 316–21 Nephrol 1988; 22: 23–30 25 Ghanem AN, Ward JP. Osmotic and metabolic sequelae of volu- 46 Hahn RG, Drobin D, Sta˚hle L. Volume kinetics of Ringer's solution metric overload in relation to the TUR syndrome. Br J Urol 1990; in female volunteers. Br J Anaesth 1997; 78: 144–8 47 Hahn RG, Ekengren J. Absorption of irrigating fluid and height 26 Goel CM, Badenoch DF, Fowler CG, Blandy LP, Tiptaft RC.
of the fluid bag during transurethral resection of the prostate.
Transurethral resection syndrome. A prospective study. Eur Br J Urol 1993; 72: 80–3 Urol 1992; 21: 15–7 48 Hahn RG, Ekengren J. Patterns of irrigating fluid absorption during 27 Goldenberg M, Zolti M, Bider D, Etchin A, Ben-Ami Sela, Seidman transurethral resection of the prostate as indicated by ethanol.
DS. The effect of intracervical vasopressin on the systemic J Urol 1993; 149: 502–6 absorption of glycine during hysteroscopic endometrial ablation.
49 Hahn R, Esse´n P. ECG and cardiac enzymes after glycine absorp- Obstet Gynecol 1996; 87: 1025–9 tion in transurethral prostatic resection. Acta Anaesthesiol Scand 28 Goldenberg M, Zolti M, Seidman DS, Bider D, Mashiach S, 1994; 38: 550–6 Etchin A. Transient blood oxygenation desaturation, hypercapnia, 50 Hahn RG, Nennesmo I, Rajs J, Sundelin B, Wroblevski R, Zhang W.
and coagulopathy after operative hysteroscopy with glycine Morphological and X-ray microanalytical changes in mammalian used as the distending medium. Am J Obstet Gynecol 1994; 170: tissue after overhydration with irrigating fluids. Eur Urol 1996; 29: 29 Grove JJ, Shinaman RC, Drover DR. Noncardiogenic pulmonary 51 Hahn RG, Nilsson A, Sta˚hle L. Distribution and elimination of the edema and venous air embolus as complications of operative solute and water components of urological irrigating fluids. Scand J hysteroscopy. J Clin Anesth 2004; 16: 48–50 Urol Nephrol 1999; 33: 35–41 Fluid absorption during endoscopy 52 Hahn RG, Olsson J, So´tonyi P, Rajs J. Rupture of the myocardial 71 Istre O. Transcervical resection of the endometrium and fibroids: histoskeleton and its relation to sudden death after overhydration the outcome of 412 operations performed over 5 years. Acta with glycine 1.5% in the mouse. APMIS 2000; 108: 487–95 Obstet Gynecol Scand 1996; 75: 567–74 53 Hahn RG, Sandfeldt L. Blood ammonia levels after intravenous 72 Istre O, Bjoennes J, Naess R, Hornbaek K, Forman A. Postop- infusion of glycine with and without ethanol. Scand J Urol Nephrol erative cerebral oedema after transcervical endometrial resection 1999; 33: 222–7 and uterine irrigation with 1.5% glycine. Lancet 1994; 344: 1187–9 54 Hahn RG, Sandfeldt L, Nyman CR. Double-blind randomized 73 Jansen FW, Vredevoogd CB, Ulzen KV, Hermans J, Trimbos JB, study of symptoms associated with absorption of glycine 1.5% Trimbos-Kemper TCM. Complications of hysteroscopy: a or mannitol 3% during transurethral resection of the prostate.
prospective, multicenter study. Obstet Gynecol 2000; 96: 266–70 J Urol 1998; 160: 397–401 74 Konrad C, Gerber HR, Schuepfer G, Schmucki O. Transurethral 55 Hahn RG, Shemais H, Esse´n P. Glycine 1.0% versus glycine 1.5% as resection syndrome: effect of the introduction into clinical prac- irrigating fluid during transurethral resection of the prostate.
tice of a new method for monitoring fluid absorption. J Clin Anesth Br J Urol 1997; 79: 394–400 1998; 10: 360–5 56 Hahn RG, Stalberg HP, Gustafsson SA. Intravenous infusion of 75 Logie JRC, Keenan RA, Whiting PH, Steyn JH. Fluid absorption irrigating fluids containing glycine or mannitol with and without during transurethral prostatectomy. Br J Urol 1980; 52: 526–8 ethanol. J Urol 1989; 142: 1102–5 76 Maatman TJ, Musselman P, Kwak YS, Resnick MI. Effect of glycine 57 Hahn RG, Zhang W, Rajs J. Pathology of the heart after overhy- on retroperitoneal and intraperitoneal organs in the rat model.
dration with glycine solution in the mouse. APMIS 1996; 104: Prostate 1991; 19: 323–8 77 Madsen PO, Naber KG. The importance of the pressure in the 58 Hawe JA, Chien PFW, Martin D, Phillips AG, Garry R. The validity prostatic fossa and absorption of irrigating fluid during transur- of continuous automated fluid monitoring during endometrial ethral resection of the prostate. J Urol 1973; 109: 446–52 surgery: luxury or necessity? Br J Obstet Gynecol 1998; 105: 78 Maluf NSR, Boren JS, Brandes GE. Absorption of irrigating solu- tion and associated changes upon transurethral electroresection 59 Heidler H. Frequency and causes of fluid absorption: a compari- of the prostate. J Urol 1956; 75: 824–36 son of three techniques for resection of the prostate under con- 79 Mantha S, Rao SM, Singh AK, Mohandas S, Prakash Rao BS, tinuous pressure monitoring. Br J Urol 1999; 83: 619–22 Joshi N. Visual evoked potentials and visual acuity after transur- 60 Henderson DJ, Middleton RG. Coma from hyponatraemia follow- ethral resection of the prostate. Anaesthesia 1991; 46: 491–3 ing transurethral resection of the prostate. Urology 1980; XV: 80 Marshall V. Renal failure after prostatectomy due to intravascular haemolysis. Aust N Z J Surg 1962; 32: 123–7 61 Hjertberg H, Jorfeldt L, Schelin S. Use of ethanol as a marker 81 Memon A, Buchholz N-P, Salahuddin S. Water as an irrigant in substance to increase patient safety during transurethral prostatic transurethral resection of the prostate: a cost-effective alterna- resection. Urology 1991; 38: 423–8 tive. Arch Ital Urol Androl 1999; LXXI: 131–4 62 Hjertberg H, Pettersson B. The use of a bladder pressure warning 82 Mizutani AR, Parker J, Katz J, Schmidt J. Visual disturbances, serum device during transurethral prostatic resection decreases absorp- glycine levels and transurethral resection of the prostate. J Urol tion of irrigating fluid. Br J Urol 1992; 69: 56–60 1990; 144: 697–9 63 Hoekstra PT, Kahnoski R, McCamish MA, Bergen W, Heetderks 83 Nilsson A, Hahn RG. Mental status after transurethral resection DR. Transurethral prostatic resection syndrome—a new per- of the prostate. Eur Urol 1994; 26: 1–5 spective: encephalopathy with associated hyperammonaemia.
84 Nilsson A, Randmaa I, Hahn RG. Haemodynamic effects of irri- J Urol 1983; 130: 704–7 gating fluids studied by Doppler ultrasonography in volunteers.
64 Horgan KJ, Ottaviano YL, Watson AJ. Acute renal failure due to Br J Urol 1996; 77: 541–6 mannitol intoxication. Am J Nephrol 1989; 9: 106–9 85 Norle´n H, Allge´n LG, Wicksell B. Mannitol concentrations in 65 Hubert J, Cormier L, Gerbaud PF, Guillemin F, Pertek JP, Mangin blood plasma in connection with transurethral resection of the P. Computer-controlled monitoring of bladder pressure in the prostate using mannitol solution as an irrigating fluid. Scand J Urol prevention of ‘TUR syndrome': a randomized study of 53 cases.
Nephrol 1986; 20: 119–26 Br J Urol 1996; 78: 228–33 86 Norle´n H, Dimberg M, Allge´n L-G, Vinnars E. Water and elec- 66 Hulte´n J, Bengtsson M, Engberg A, Hjertberg H, Svedberg J. The trolytes in muscle tissue and free amino acids in muscle and pressure in the prostatic fossa and fluid absorption. Scand J Urol plasma in connection with transurethral resection of the prostate.
Nephrol 1984; 82 (Suppl): 33–43 II. Isotonic 2.2% glycine solution as an irirgating fluid. Scand J Urol Nephrol 1990; 24: 95–101 irrigating fluid during TURP. The role of transmural bladder pressure as the driving pressure gradient. Br J Urol 1990; Symptomatology, pathophysiology and treatment of the transur- ethral resection of the prostate syndrome. Br J Urol 1973; 45: 68 Hulte´n JO, Tran VT, Pettersson G. The control of haemolysis during transurethral resection of the prostate when water is used 88 Olsson J, Berglund L, Hahn RG. Irrigating fluid absorption from for irrigation: monitoring absorption by the ethanol method.
the intact uterus. Br J Obstet Gynaecol 1996; 103: 558–61 BJU Int 2000; 86: 989–92 89 Olsson J, Hahn RG. Ethanol monitoring of irrigating fluid absorp- 69 Ichai C, Cialis JF, Roussel LJ, et al. Intravascular absorption of tion in transcervical resection of the endometrium. Acta Anaes- glycine irrigating solution during shoulder arthroscopy: a case thesiol Scand 1995; 39: 252–8 report and follow-up study. Anesthesiology 1996; 85: 1481–5 90 Olsson J, Hahn RG. Simulated intraperitoneal absorption of 70 Inman RD, Hussain Z, Elves AWS, Hallworth MJ, Jones PW, irrigating fluid. Acta Obstet Gynecol Scand 1995; 74: 707–13 Coppinger SWV. A comparison of 1.5% glycine and 2.7% 91 Olsson J, Hahn RG. Survival after high-dose intravenous sorbitol–0.5% mannitol irrigants during transurethral prostate infusion of irrigating fluids in the mouse. Urology 1996; 47: resection. J Urol 2001; 166: 2216–20 92 Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral 111 Sohn MH, Vogt C, Heinen G, Erkens M, Nordmeyer N, Jakse G.
resection syndrome using glycine as the irrigant. J Urol 1995; 154: Fluid absorption and circulating endotoxins during transurethral resection of the prostate. Br J Urol 1993; 72: 605–10 93 Olsson J, Hahn RG. Glycine toxicity after high-dose intravenous 112 Stalberg HP, Hahn RG, Hjelmqvist H, Ullman J, Rundgren M.
infusion of glycine 1.5% in the mouse. Br J Anaesth 1999; 82: 250–4 Haemodynamics and fluid balance after intravenous infusion of 94 Olsson J, Rentzhog L, Hjertberg H, Hahn RG. Reliability of clinical 1.5% glycine in sheep. Acta Anaesthesiol Scand 1993; 37: 281–7 assessment of fluid absorption in transurethral prostatic resec- 113 Steffensen AJ, Hahn RG. Fluid absorption and the long-term out- tion. Eur Urol 1993; 24: 262–6 come after transcervical resection of the endometrium. Acta 95 Olsson J, Sandfeldt L, Hahn RG. Survival after high-dose intraperi- Obstet Gynaecol Scand 1998; 77: 863–8 toneal infusion of glycine solution in the mouse. Scand J Urol 114 Tuzin-Fin P, Guenard Y, Maurette P. Atypical signs of glycine Nephrol 1997; 31: 119–21 absorption following transurethral resection of the prostate: 96 Osborn DE, Rao PN, Greene MJ, Barnard RJ. Fluid absorption two case reports. Eur J Anaesthesiol 1997; 14: 471–4 during transurethral resection. Br Med J 1980; 281: 1549–50 115 Tauzin-Fin P, Krol-Houdek MC, Saumtally S, Muscagotty J-M.
97 Pe´rier C, Frey J, Auboyer C, et al. Accumulation of glycolic acid Intoxication par la glycine apre s chirurgie re´nale par voie percu- and glyoxilic acid in serum in cases of transient hyperglycinemia tane´e. Can J Anaesth 1993; 40: 866–9 after transurethral surgery. Clin Chem 1988; 34: 1471–3 116 Tauzin-Fin P, Sanz L, Houdek MC, Saumtally S, Muscagorry JM.
98 Pe´rier C, Mahul P, Molliex S, Auboyer C, Frey J. Progressive Coma lors d'une re´section endoscopique de prostata. Ann Fr changes in glycine and glycine derivatives in plasma and cere- Anesth Re´anim 1991; 10: 486–9 brospinal fluid after transurethral prostatic resection. Clin 117 van Renen RG, Reymann U. Comparison of the effect of two Chem 1990; 26: 2152–3 heights of glycine irrigation solution on serum sodium and osmo- 99 Peters KR, Muir J, Wingard DW. Intraocular pressure after trans- lality during transurethral resection of the prostate. Aust N Z J Surg urethral prostatic surgery. Anesthesiology 1981; 55: 327–9 1997; 67: 874–7 100 Radal M, Jonville Bera AP, Leisner C, Haillot O, Autret-Leca E.
118 Verilli RA, Uhlman RC, Viek NF, Hunsicker WC. The hypotensive Effets inde´sirables des solutions d'irrigation glycolle´es. The´rapie effect of a prostatic extract. J Urol 1962; 87: 184–6 1999; 54: 233–6 119 Wakim KG. The pathophysiologic basis for the clinical manifes- 101 Reuter M, Reuter HJ. Prevention of irrigant absorption during tations and complications of transurethral prostatic resection.
TURP: continuous low-pressure irrigation. Int Urol Nephrol J Urol 1971; 106: 719–28 1978; 10: 293–300 120 Wang JM-L, Creel DJ, Wong KC. Transurethral resection of the 102 Rothenberg DM, Berns AS, Ivankovich AD. Isotonic hyponatremia prostate, serum glycine levels, and ocular evoked potentials.
following transurethral prostate resection. J Clin Anesth 1990; Anesthesiology 1989; 70: 36–41 121 Weis N, Jo¨rgensen PE, Bruun E. ‘‘TUR syndrome'' after transur- 103 Salmela L, Aromaa U, Lehtonen L, Peura P, Olkkola KT. The effect ethral resection of the prostate using suprapubic drainage. Int Urol of prostatic capsule perforation on the absorption of irrigating Nephrol 1987; 19: 165–9 fluid during transurethral resection. Br J Urol 1993; 72: 599–60 122 Wilkes NJ, Woolf R, Mutch M, et al. The effects of balanced versus 104 Sandfeldt L, Hahn RG. Comparison of urological irrigating fluids saline-based hetastarch and crystalloid solutions on acid–base and containing glycine and mannitol in volunteers. Prostate 1999; 41: electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg 2001; 93: 811–16 105 Sandfeldt L, Riddez L, Rajs J, Ewaldsson C-A, Piros D, Hahn RG.
123 Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect High-dose intravenous infusion of urological irrigating fluids of intravenous lactated Ringer's solution versus 0.9% sodium containing glycine and mannitol in the pig. J Surg Res 2001; 95: chloride solution on serum osmolality in human volunteers.
Anesth Analg 1999; 88: 999–1003 106 Schulte MJ, Lenz W. Fatal sorbitol infusion in patient with 124 Windsor A, French GWG, Sear JW, Foe¨x P, Millett SV, Howell SJ.
fructose-sorbitol intolerance. Lancet 1977; 2; 188 Silent myocardial ischaemia in patients undergoing transurethral 107 Sharma D, Harvey AB. Does intraprostatic vasopressin prevent prostatectomy. Anaesthesia 1996; 51: 728–32 the transurethral resection syndrome? BJU Int 2000; 86: 223–6 125 Woods HF, Albert KGMM. Dangers of intravenous fructose.
108 Shipstone DP, Inman RD, Beacock CJM, Coppinger SWV. Valida- Lancet 1972; 2: 1354–7 tion of the ethanol breath test and on-table weighing to measure 126 Wright N, Seggie J. Glycine toxicokinetics: vitreous fluid concen- irrigating fluid absorption during transurethral prostatectomy.
tration and visual impairment. Clin Invest Med 1992; 15: 159–62 BJU Int 2002; 90: 872–5 127 Yende S, Wunderink R. An 87-year-old man with hypotension and confusion after cystoscopy. Chest 1999; 115: 1449–51 absorption syndrome following cystoscopy. Clin Nephrol 1996; 128 Zhang W, Andersson B, Hahn RG. Effect of irrigating fluids and prostatic tissue extracts on isolated cardiomyocytes. Urology 110 Singer M, Patel M, Webb A, Bullen C. Management of the trans- 1995; 46: 821–4 urethral prostate resection syndrome: time for reappraisal? Crit 129 Zhang W, Hahn RG. ‘‘Double toxicity'' of glycine solution in the Care Med 1990; 18: 1479–80 mouse. Br J Urol 1996; 77: 203–6
Valoración económica de la oportunidades y riesgos ¿Hay que poner precio a la biodiversidad para conservarla? Con la colaboración de: Conclusiones del Seminario sobre la valoración económica de la biodiversidad, oportunidades y riesgos. Madrid, 30 septiembre - 1 octubre de 2011
Chin. Phys. B Vol. 24, No. 1 (2015) 014704 TOPICAL REVIEW — Magnetism, magnetic materials, and interdisciplinary research Surface modification of magnetic nanoparticles in Chu Xin(储 鑫), Yu Jing(余 靓), and Hou Yang-Long(侯仰龙 Department of Materials Science and Engineering, College of Engineering, Peking University, Beijing 100871, China (Received 4 November 2014; published online 9 December 2014)