“THE PROSPECTIVE OBSERVATIONAL STUDY OF CORRELATION BETWEEN TOTAL BODY WATER AND SERUM

OSMOLARITY USING NON- INSAVIVE CARDIAC OUTPUT MONITORING in TURP” Presenter: Mr.Lokesh kumar.D

Guide: Dr.B. Gayathri ( HOD anesthesiology)Coguide: Dr. Vishak Manoj Bhaskar

 INTRODUCTION

TURP (Transurethral Resection of the Prostate) is

done for benign prostatic hyperplasia commonly
seen in males in geriatric age group.
There is a large amount of fluid irrigation being
used TURP surgery.
This can cause fluid overload and electrolyte
imbalance in patients.
This can be detrimental, especially the patients
with geriatric age group.
 TURP
syndrome
TURP syndrome can cause a wide variety of
symptoms that include fatigue, vomiting,
confusion, visual loss, coma and death.
These symptoms are due to absorption of
irrigation fluid via the ruptured capillaries
during resection of the prostrate gland.
Absorption of excessive irrigation fluids can
lead to which cardiac fluid overload and
neurological effects due to toxic effects of
glycine and dilution of electrolytes.
Impedance cardiography has been proposed as a simple and
readily reproducible noninvasive technique for the
determination of cardiac output, systemic vascular resistance
and total body water.
Non-invasive cardiac monitoring can be used to monitor the
fluid status of the patient and titrate the irrigation fluid, so as
to prevent the untoward incidents associated with TURP
syndrome.
 NICAS
monitor
The NICOM system and its connection to the body.

Four double electrode stickers are placed around the thorax. A

high-frequency current is passed between the 2 outer electrodes,
and the resulting voltages are recorded between the 2 inner
electrodes. The relative phase shift (Φ) and rate of change of
phase (dΦ/dt) between these signals are determined and used in
the calculations of SV. RF, radio frequency.
 Justification of
study

NICAS monitoring is a non invasive method to monitor

the total body water and heamodynamics of the patient
which can help prevent fluid overload and electrolyte
imbalance in patients undergoing TURP
 AIM

To evaluate Haemodynamic monitoring of

patients undergoing TURP under Spinal
anesthesia using bioimpedance method.
To develop the algorithm which denotes the
correlation between serum osmolarity and TBW
by REGRESSION ANALYSIS
 OBJECTIVE

SECONDARY OBJECTIVE
PRIMARY OBJECTIVE
The prospective Change in the cardiac
observation of power index, Grenor Gor
Correlation between Index (GGI), stroke
Total Body Water and volume index with the
Osmolarity in patients volume of irrigation fluid
undergoing TURP used.
To check the immediate
pre and post of
haemoglobin using
haemoglobinometer.
 Hypothesi
s

There is a Correlation between increase in TBW and

decrease serum osmolarity in patient undergoing
TURP.
NICAS monitoring of hemodynamic changes will help
in the prediction of TURP syndrome.
MATERIALS AND METHODOLOGY

SAMPLE SIZE (30)

STUDY DESIGN PROSPECTIVE OBSERVATIONAL
STUDY
PERIOD OF STUDY 18 months
STUDY POPULATION
To account for 10 percent drop out .. sample size
taken as 30 per group
Population will be 30+30 total 60
Sample size calculated based on Bioimpedance
Estimation Of Volume And Hemodynamic Changes
During Transurethral Resection Of Prostate (TURP) (A
Sherman, Y Frinerman, D Zabeeda, S Ezra, A Sidi, R
Zimlichman, T Ezri)
All consenting patients posted for TURP surgery
under spinal anaesthesia.
Sample size
n = z²α/2 p2
d²
= (1.96)² 93.5×6.5
(9.35)²
= 3.84×607.75
(9.35)²
= 2333.76
87.4225
= 26.69
n≈27
INCLUSION
CRITERIA
Patients posted for TURP
50-70 years

EXCLUSION CRITERIA
Valvular heart disease, Ischemic heart disease.
Patients on pacemakers
Ejection fraction of less than 50%
Renal failure
Peripheral edema
Where Spinal anesthesia is contraindicated Failure of
spinal anesthesia case connected to GA
Spinal Failure
REVIEW OF LITERATURE
1. Gad Cotter Et al. examined the use of non-invasive cardiac
monitoring for measuring Cardiac output in cardiac patients to
compare its validity with invasive cardiac monitoring. They
enrolled 122 patients in 3 groups, during cardiac catheterisation,
before,during and after bypass surgery in patients undergoing
coronary catheterisation and also before and during vasodilator
treatment in patients treated for acute heart failure. They found an
overall correlation between non invasive cardiac monitoring
Cardiac Index(CI) and Thermodilution CI was r=0.886 with small
bias.
2. Bhavya G et al. conducted a study on 23 postoperative cardiac
surgical patients to validate the correlation between NiCas and
thermodilution method to find cardiac index and cardiac output.
They found good correlation between the two with an r=0.75.
Percentage error for cardiac index and cardiac output was 64.78%
and 64% respectively. They found that NiCas had a good trending
ability for CI and CO, however the values were not
interchangeable with the thermodilution method.
3. A Sherman et al. did an observational study on 36 patients
undergoing TURP surgery to see the hemodynamics , total body
water and serum electrolyte changes during TURP surgery using
NiCas monitoring. They found that there was decrease in Cardiac
Index and Heart rate following TURO and serum sodium levels was
lower post operatively.
 Methodol
ogy
Patients posted for TURP surgery will be shifted to Anesthesia ICU on the
night before surgery

Premeditated as per hospital protocol on the night before surgery and on

the morning of surgery before shifting to OT.

Blood glucose level, Serum haemoglobin,Serum electrolyte, serum

Osmolarity and body weight of the patient will be measured on the
morning of surgery before shifting to OT.

In the OT routine monitors(Pulse Oximeter, ECG, NIBP, Temperature

monitor) and NiCas monitors will be connected to the patient.

One upper limb veins will be cannulated with a wide bore cannula and 10
ml/kg of ringer lactate solution will be given over 20 mins.

Haemodynamic parameters from NiCas monitor, Cardiac index,Cardiac

Power index, Stroke volume index, Grenor Gor Index,Total body water and
Systemic vascular resistance are noted. These will be again measured 30
mins after irrigation has been started, immediately postoperatively and
every 4 hourly postoperatively for 24 hours .
Patients will undergo spinal anaesthesia as per the discretion of
the anesthesiologist. No sedatives will be given during surgery.

Level of spinal blockade is noted after the drug is allowed to fix.

If the spinal anaesthesia fails or is inadequate, general

anaesthesia will be given and the patient will be excluded from
the study.

Intraoperatively, heart rate, BP, Spo2 and temperature will be

noted every 5 minutes.

Intraoperative urine output will be estimated from the drain

bucket and the volume of irrigation fluid used.

Immediate postoperative serum electrolyte, serum osmolarity

and haemoglobin levels and the residual spinal blockade level
will be seen.

Postoperative irrigation fluid and urine output will be noted.

 OUT COMES

Primary outcome:
To estimate the change in serum osmolarity using
changes in TBW using Nicas monitoring in turp.
Secondary outcome:
Early detection of turp syndrome using changes in
hemodynamic parameters of Nicas monitor.
 PROFORMA
PATIENT NAME :
AGE :
SEX :
IP NO :
DIAGNOSIS :
WEIGHT :
HEIGHT :
BMI :
1. Pre operative:
PARAMETERS PRE OP
HR
BP
SPO2
TEMP
S.ELECT
S.OSMOL
HB
2.Inter operative:

PARAME 5 10 15 20 25 30 35 40 45 50 55 60
TERS
HR
BP
SPO2
TEMP
S.ELECT
S.OSMO
L
3. Post operative:

PARAMETERS 4 hrs 8hrs 12 hrs 16hrs 20 hrs 24hrs

HR

BP

SPO2

TEMP

S.ELECT

S.OSMOL

HB
1. Pre operative:

Nicas PRE OP
parameter
systemic
vascular
resistance
Total body
water
cardiac
output
2. Inter operative:

Nicas 5 10 15 20 25 30 35 40 45 50 55 60
parameter
systemic
vascular
resistance
Total body
water
cardiac
output
3. Post operative:

Nicas 4 hrs 8hrs 12 hrs 16hrs 20 hrs 24hrs

parameter

systemic
vascular
resistance

Total body
water
cardiac output
PATIENT INFORMATION SHEET:

You are being asked to take part in research- “THE PROSPECTIVE

OBSERVATIONAL STUDY OF CORRELATION BETWEEN TOTAL BODY
WATER AND SERUM OSMOLARITY USING NON- INSAVIVE
CARDIAC OUTPUT MONITORING in TURP”
Financial expenses: You will not incur any expenses as a participant in
this study. You will not get any financial benefit from this study, but your
participation may help the future generations as it will help to to assess
the delirium in intensive care unit for the patients whose ICU stay is
prolonged.

Confidentiality: Confidentiality is guaranteed. You will have to sign an

informed consent form.

Voluntary participation and Withdrawal from the study: Your

participation is completely voluntary. You may refuse to participate in the
study or end your participation in the study at any time without penalty
or loss of benefits to which you are otherwise entitled. You are free to
ask any question during any time of the study. We will try to answer any
query that you may have.
நோயாளியின் தகவல் தாள்:

“தீவிர சிகிச்சைப் பிரிவில் உள்ள நோயாளிகளிடையே மனச்சோர்வு ஏற்படுவதைப் பற்றிய ஒரு

முன்னோக்கு கண்காணிப்பு ஆய்வு " என்ற ஆராய்ச்சியில் பங்கேற்கும்படி
கேட்கப்படுகிறீர்கள்.

நிதி செலவுகள்:

இந்த ஆய்வில் பங்கேற்பவராக நீங்கள் எந்தச் செலவும் செய்ய மாட்டீர்கள். இந்த

ஆய்வின் மூலம் நீங்கள் எந்த நிதிப் பயனையும் பெற மாட்டீர்கள், உங்கள்
பங்கேற்பு எதிர்கால சந்ததியினருக்கு உதவக்கூடும்.

இரகசியத்தன்மை:

இரகசியத்தன்மை உத்தரவாதம். தகவலறிந்த ஒப்புதல் படிவத்தில் நீங்கள்

கையொப்பமிட வேண்டும்.

தன்னார்வ பங்கேற்பு மற்றும் ஆய்வில் இருந்து விலகுதல்:

உங்கள் பங்கேற்பு முற்றிலும் தன்னார்வமானது. நீங்கள் எந்த நேரத்திலும்

ஆய்வில் பங்கேற்க மறுக்கலாம் அல்லது உங்களுக்கு உரிமையுள்ள நன்மைகளை
அபராதம் அல்லது இழப்பு இல்லாமல் எந்த நேரத்திலும் ஆய்வில் பங்கேற்பதை
முடிக்கலாம். படிப்பின் எந்த நேரத்திலும் நீங்கள் எந்த கேள்வியையும்
கேட்கலாம். உங்களிடம் உள்ள எந்த கேள்விக்கும் நாங்கள் பதிலளிக்க
முயற்சிப்போம்
WRITTEN INFORMED CONSENT FORM

Date:
Place:
Name of volunteer:
Age:
MR number:
This is to declare that I have learnt the details of the research: “THE PROSPECTIVE OBSERVATIONAL
STUDY OF CORRELATION BETWEEN TOTAL BODY WATER AND SERUM OSMOLARITY USING
NON- INSAVIVE CARDIAC OUTPUT MONITORING in TURP” from MR D.LOKESH KUMAR and the
outcome, problems and risks of the study. It has been described to me in simple language that I can
understand to my satisfaction. I have received a copy of the study documents and relevant papers. I
have read this completely and I am sure that the data generated will be kept in utmost confidentiality. I
agree to comply with all medical directions given to me. By my own decision and self-interest, I give my
consent to take part in the study. I retain my option to opt out of the study at any point of time should I
so desire. I understand that I am allowed to ask any questions regarding the study. Herewith, I legally
agree to take part in this study.

Signature of Volunteer
Signature of Witness
Signature of Investigator
 அறிவிக்கப்பட்டமுடிவு
நான் D.LOKESH KUMAR, கீழே கையொப்பமிட்டவர்கள் குறிப்பிடப்பட்ட ஆய்வில்
பங்கேற்பதற்கு ஒப்புதல் அளிக்கிறார்கள். கீழே எனது சொந்த மொழியில்
படிப்பைப்பற்றி விரிவாக விளக்கியிருந்தேன் என்ற தலைப்பில்
ஆய்வுத்திட்டத்திற்குப் பயன்படுத்தப்படும் எனது மருத்துவ வழக்குத்தாளில்
உள்ள தரவு மற்றும் விசாரணை அறிக்கை “THE PROSPECTIVE OBSERVATIONAL
STUDY OF CORRELATION BETWEEN TOTAL BODY WATER AND SERUM
OSMOLARITY USING NON- INSAVIVE CARDIAC OUTPUT MONITORING in
TURP” தனிப்பட்ட அடையாளங்காட்டிகள் மூலம் அறிவியல் கட்டுரை அல்லது
பிறவகையான பயன்பாடுகளை எழுதுவதற்கு இது பயன்படுத்தப் படலாம், மேலும் எந்த
நேரத்திலும் நான் ஆய்வில் இருந்து விலகினால், காட்டாங்குளத்தூரில் உள்ள SRM
MCH&RC இல் சிகிச்சைபெறுவதைத்தடுக்காது.
மேற்கூறிய விஷயங்கள் அனைத்தும் எனது வட்டாரமொழியில் எட்டோமே என்று
விளக்கப்பட்டுள்ளது.
. சாட்சி :
• பெயர் :
• கையெழுத்து :
• தேதி :
• நோயாளியின்விவரங்கள்:
• பெயர் :
• OP/IP எண் :
 Referenc
e
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resection of the prostate syndrome: almost gone but not
forgotten. Journal of endourology. 2009 Dec
1;23(12):2013-20.
2. Demirel I, Ozer AB, Bayar MK, Erhan OL. TURP syndrome
and severe hyponatremia under general anaesthesia. Case
Reports. 2012 Nov 19;2012:bcr-2012.
3. Jensen V. The TURP syndrome. Canadian journal of
anaesthesia. 1991 Jan;38(1):90-7.
4. Gravenstein D. Transurethral resection of the prostate
(TURP) syndrome: a review of the path physiology and
management. Anesthesia & Analgesia. 1997 Feb
1;84(2):438-46.
5. Vijayan S. TURP syndrome. Trends in Anaesthesia and
Critical Care. 2011 Feb 1;1(1):46-50.