The impact of irrigating fluid absorption on blood coagulation in patients undergoing transurethral resection of the prostate: A prospective observational study using rotational thromboelastometry

Hyun-Jung Shin, Hyo-Seok Na, Young-Tae Jeon, Hee-Pyoung Park, Sun-Woo Nam, Jung-Won Hwang, Hyun-Jung Shin, Hyo-Seok Na, Young-Tae Jeon, Hee-Pyoung Park, Sun-Woo Nam, Jung-Won Hwang

Abstract

Although endoscopic transurethral resection of the prostate (TURP) is a well-established procedure as a treatment for benign prostatic hyperplasia, its complications remain a concern. Among these, coagulopathy may be caused by the absorption of irrigating fluid. This study aimed to evaluate such phenomenon using a rotational thromboelastometry (ROTEM).A total of 20 patients undergoing TURP participated in this study. A mixture of 2.7% sorbitol-0.54% mannitol solution and 1% ethanol was used as an irrigating fluid, and fluid absorption was measured via the ethanol concentration in expired breath. The effects on coagulation were assessed by pre- and postoperative laboratory blood tests, including hemoglobin, hematocrit, platelet count, international normalized ratio of prothrombin time (PT-INR), activated partial thromboplastin time, electrolyte, and ROTEM.INTEM-clotting time (INTEM-CT) was significantly lengthened by 14% (P = 0.001). INTEM-α-angle was significantly decreased by 3% (P = 0.011). EXTEM-clot formation time was significantly prolonged by 18% (P = 0.008), and EXTEM-maximum clot firmness (EXTEM-MCF) was significantly decreased by 4% (P = 0.010). FIBTEM-MCF was also significantly decreased by 13% (P = 0.015). Moreover, hemoglobin (P < 0.001), hematocrit (P < 0.001), platelet counts (P < 0.001), potassium (P = 0.024), and ionized calcium (P = 0.004) were significantly decreased, while PT-INR (P = 0.001) was significantly increased after surgery. The amount of irrigating fluid absorbed was significantly associated with the weight of resected prostatic tissue (P = 0.001) and change of INTEM-CT (P < 0.001).As shown by the ROTEM analysis, the irrigating fluid absorbed during TURP impaired the blood coagulation cascade by creating a disruption in the coagulation factor activity or by lowering the coagulation factor concentration via dilution.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Flowchart.

References

    1. Crowley AR, Horowitz M, Chan E, et al. Transurethral resection of the prostate versus open prostatectomy: long-term mortality comparison. J Urol 1995;153:695–7.
    1. Neal DE. Transurethral prostatectomy. Br J Surg 1994;81:484–5.
    1. Ran L, He W, Zhu X, et al. Comparison of fluid absorption between transurethral enucleation and transurethral resection for benign prostate hyperplasia. Urol Int 2013;91:26–30.
    1. Gravenstein D. Transurethral resection of the prostate (TURP) syndrome: a review of the pathophysiology and management. Anesth Analg 1997;84:438–46.
    1. Lira-Dale A, Maldonado-Avila M, Gil-Garcia JF, et al. Effect of intraprostatic epinephrine on intraoperative blood loss reduction during transurethral resection of the prostate. Int Urol Nephrol 2012;44:365–9.
    1. Charlton AJ. Cardiac arrest during transurethral prostatectomy after absorption of 1.5% glycine. A case report and review of the literature. Anaesthesia 1980;35:804–6.
    1. Friedman NJ, Hoag MS, Robinson AJ, et al. Hemorrhagic syndrome following transurethral prostatic resection for benign adenoma. Arch Intern Med 1969;124:341–9.
    1. Doll HA, Black NA, McPherson K, et al. Mortality, morbidity and complications following transurethral resection of the prostate for benign prostatic hypertrophy. J Urol 1992;147:1566–73.
    1. Mebust WK, Holtgrewe HL, Cockett AT, et al. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141:243–7.
    1. Ruttmann TG, James MF, Aronson I. In vivo investigation into the effects of haemodilution with hydroxyethyl starch (200/0.5) and normal saline on coagulation. Br J Anaesth 1998;80:612–6.
    1. Mittermayr M, Streif W, Haas T, et al. Hemostatic changes after crystalloid or colloid fluid administration during major orthopedic surgery: the role of fibrinogen administration. Anesth Analg 2007;105:905–17. table of contents.
    1. Shin HJ, Na HS, Do SH. The effects of acute normovolaemic haemodilution on peri-operative coagulation in total hip arthroplasty. Anaesthesia 2015;70:304–9.
    1. Theusinger OM, Nurnberg J, Asmis LM, et al. Rotation thromboelastometry (ROTEM) stability and reproducibility over time. Eur J Cardiothorac Surg 2010;37:677–83.
    1. Hahn RG, Ekengren J. Absorption of irrigating fluid and height of fluid bag during transurethral resection of the prostate. Br J Urol 1993;72:80–3.
    1. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003;43:459–69.
    1. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013;30:270–382.
    1. Lier H, Vorweg M, Hanke A, et al. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013;33:51–61.
    1. Schochl H, Frietsch T, Pavelka M, et al. Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry. J Trauma 2009;67:125–31.
    1. Bell CR, Cox DJ, Murdock PJ, et al. Thrombelastographic evaluation of coagulation in transurethral prostatectomy. Br J Urol 1996;78:737–41.
    1. Nielsen JD, Gram J, Fabrin K, et al. Lack of correlation between blood fibrinolysis and the immediate or post-operative blood loss in transurethral resection of the prostate. Br J Urol 1997;80:105–10.
    1. Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection syndrome using glycine as the irrigant. J Urol 1995;154:123–8.
    1. Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth 2006;96:8–20.
    1. Ahsan Z, Cartner R, English PJ. Coagulation tests in predicting haemorrhage after prostatic resection. Br J Urol 1993;72:201–6.
    1. Ozmen S, Kosar A, Sayin A, et al. Effect of transurethral resection of the prostate on blood coagulation test results. Urol Int 2003;70:27–30.
    1. Levi M, Meijers JC. DIC: which laboratory tests are most useful. Blood Rev 2011;25:33–7.
    1. Muller MC, Meijers JC, Vroom MB, et al. Utility of thromboelastography and/or thromboelastometry in adults with sepsis: a systematic review. Crit Care 2014;18:R30.
    1. Engstrom M, Rundgren M, Schott U. An evaluation of monitoring possibilities of argatroban using rotational thromboelastometry and activated partial thromboplastin time. Acta Anaesthesiol Scand 2010;54:86–91.
    1. Casutt M, Konrad C, Schuepfer G. Effect of rivaroxaban on blood coagulation using the viscoelastic coagulation test ROTEM. Anaesthesist 2012;61:948–53.
    1. Haas T, Spielmann N, Mauch J, et al. Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth 2012;108:36–41.
    1. Rugeri L, Levrat A, David JS, et al. Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography. J Thromb Haemost 2007;5:289–95.
    1. Koami H, Sakamoto Y, Ohta M, et al. Can rotational thromboelastometry predict septic disseminated intravascular coagulation? Blood Coagul Fibrinolysis 2015;26:778–83.
    1. Wettstein MS, Poyet C, Grossmann NC, et al. Absorption of irrigation fluid during XPS GreenLight laser vaporization of the prostate: results from a prospective breath ethanol monitoring study. World J Urol 2016;34:1261–7.
    1. Hermanns T, Grossmann NC, Wettstein MS, et al. Absorption of irrigation fluid occurs frequently during high power 532 nm laser vaporization of the prostate. J Urol 2015;193:211–6.
    1. Mann KG. Biochemistry and physiology of blood coagulation. Thromb Haemost 1999;82:165–74.
    1. James MF, Roche AM. Dose-response relationship between plasma ionized calcium concentration and thrombelastography. J Cardiothorac Vasc Anesth 2004;18:581–6.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner