During transurethral prostatectomy 1-5% glycine in water is commonly used to irrigate the bladder. Absorption of small quantities of this solution is inconsequential. Occasionally, however, large amounts may be absorbed, leading to severe hyponatraemia. Such severe sodium depletion is associated with electrocardiogram (ECG) changes that include a widened and increased amplitude of QRS complex, T wave inversion," and bradycardia. We report on three patients in whom absorption of irrigation fluid during transurethral resection of the prostate led to the death of one and cardiovascular collapse in the other two. Case reportsThree patients aged 76, 62, and 75 admitted with acute retention of urine were treated initially by urethral catheterisation. They were otherwise fit patients, but in one (case 3) the ECG showed ST depression in V4-6 compatible with myocardial ischaemia. All underwent transurethral resection of benign prostate with the Travenol Intermittent Irrigation System using 1-5% glycine solution.Case 1-After roughly 30 minutes of resection under general anaesthesia, during which 18 g of prostatic tissue was removed, the patient's pulse rate fell to 35/min and systolic blood pressure to 60 mm Hg. Myocardial infarction was diagnosed and 1 mg intravenous atropine and 2 units of blood were given without effect, and asystole followed. Cardiac resuscitation failed. Necropsy examination did not show the cause of death. A venous blood sample taken during bradycardia had a sodium concentration of 86 mmol(mEq)/l (normal range 132-144 mmol/l(mEq)/l). Plasma glycine concentration was 80 mmol/l (600 mg/100 ml) (normal range 0-162-0-335 mmol/l; 1-22-2-52 mg/100 ml).Case 2-Under spinal anaesthesia 60 g of prostatic tissue was resected in one hour, and during this the patient became confused and disorientated. The pulse fell to 50/min, and systolic blood pressure fell to 80 mm Hg. A clinical diagnosis of hyponatraemia was made and a blood sample taken for immediate electrolyte analysis. A total of 300 ml of 8-4% sodium bicarbonate was given followed by 1 5 litres of Hartmann's solution. Frusemide 40 mg was given intravenously when the systolic blood pressure had risen to 100 mm Hg. The patient's mental state improved rapidly with this treatment. Blood taken at the time of the diagnosis of hyponatraemia and three hours later showed sodium concentration of 107 and 130 mmol(mEq)/l respectively.The plasma glycine concentration was 50 mmol/l (375 mg/ 100 ml) in the initial blood sample. The total bicarbonate concentration was 32 mmol(mEq)/l (normal range 23-32 mmol (mEq)/l) in the second sample.Case 3-Under general anaesthesia a total of 35 g of prostatic tissue was resected in one hour. The patient was then sent to the recovery room and roughly 10 minutes later had a respiratory arrest, with a bradycardia of 50/min. He was intubated and resuscitated with 200 ml of 8-4% sodium bicarbonate and 2 units of blood. An ECG tracing at this time showed ventricular ectopics, right bundle-branch block, and deep T wave inversion in V4-6...
Death during prostatectomyIn a recent report from this hospital,' three cases, one fatal, were described, of cardiovascular collapse due to absorption of irrigation fluid, occurring during transurethral resection of the prostate. However, the implications for pathologists conducting necropsies in such cases were not emphasised. Since then a further possible fatal case has occurred, as well as several "near misses" that were successfully treated. We now report the necropsy findings in these two fatal cases and stress the role of the pathologist in identifying the cause of death in such cases.The first case, as described in the original paper, was a man aged 76 who collapsed and died 30 minutes after the start of a routine transurethral resection of prostate (TUR). The anaesthetist, who had diagnosed and successfully treated other cases, suspected the diagnosis and took a blood sample for estimation of the serum NA+, during attempted resuscitation. This revealed a concentration of 86 mmol/l. At necropsy, there was evidence of pulmonary oedema and congestion and small effusions in all the body cavities. There was no evidence of significant cardiac disease, and the remainder of the necropsy was essentially negative. Further confirmation of absorption of irrigating fluid was obtained by estimation of the glycine concentration in the same blood sample as was used for the Na+ estimation. A level of 80 mmol/l (600 mg/100 ml) was reported. The concentration of glycine in the irrigating fluid is 1 5 g/100 ml of water. Glycine, a low molecular weight amino acid, is presumably distributed throughout the extracellular fluid, given time. However since death can occur rapidly, the degree of equilibration at the time of collapse or death is difficult to assess. Despite these limitations, one can calculate that at least three litres and probably more, was absorbed.The second patient was a man aged 77 who was admitted to a medical ward for investigation of drop attacks. Two days after admission he developed acute retention. Cardiological studies revealed evidence of ischaemic heart disease, and a systolic murmur was also apparent. A prostatectomy three years earlier had been uneventful. Two The interpretation of the results in this second case is much more difficult due to two factors. The necropsy was performed 65 hours after death, and there is evidence that Na+ concentrations fall after death, although there is considerable individual variation in the rate of fall.2 In addition, the patient was given 200 ml of 8-4% bicarbonate during resuscitation. In retrospect, we should have estimated the Na+ level in vitreous humour, since the concentrations at this site are much more stable post mortem,3 and estimated the blood glycine. Only then would we have been able to assess the degree of absorption. The amount of fluid absorbed and the degree of hyponatraemia was undoubtedly much less than in the first case, but with significant cardiac disease, it seems reasonable that lesser degrees may be fatal.In conclusion, the message seems ...
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