Does an electronic cognitive aid have an effect on the management of severe gynaecological TURP syndrome? A prospective, randomised simulation study

Background

Lack of familiarity with the content of current guidelines is a major factor associated with non-compliance by clinicians. It is conceivable that cognitive aids with regularly updated medical content can guide clinicians’ task performance by evidence-based practices, even if they are unfamiliar with the actual guideline. Acute hyponatraemia as a consequence of TURP syndrome is a rare intraoperative event, and current practice guidelines have changed from slow correction to rapid correction of serum sodium levels. The primary objective of this study was to compare the management of a simulated severe gynaecological transurethral resection of the prostate (TURP) syndrome under spinal anaesthesia with either: an electronic cognitive aid, or with management from memory alone. The secondary objective was to assess the clinical relevance and participant perception of the usefulness of the cognitive aid.

Methods

Anaesthetic teams were allocated to control (no cognitive aid; n = 10) or intervention (cognitive aid provided; n = 10) groups. We identified eight evidence-based management tasks for severe TURP syndrome from current guidelines and subdivided them into acute heart failure (AHF)/pulmonary oedema tasks (5) and acute hyponatraemia tasks (3). Implementation of the treatment steps was measured by scoring task items in a binary fashion (yes/no). To assess whether or not the cognitive aid had prompted a treatment step, participants from the cognitive aid group were questioned during debriefing on every single treatment step. At the end of the simulation, session participants were asked to complete a survey.

Results

Teams in the cognitive aid group considered evidence-based treatment steps significantly more often than teams of the control group (96% vs. 50% for ‘AHF/pulmonary oedema’ p < 0.001; 79% vs. 12% for ‘acute hyponatraemia’ p < 0.001). Without the cognitive aid, performance would have been comparable across both groups. Nurses, trainees, and consultants derived equal benefit from the cognitive aid.

Conclusions

The cognitive aid improved the implementation of evidence-based practices in a simulated intraoperative scenario. Cognitive aids with current medical content could help to close the translational gap between guideline publication and implementation in acute patient care. It is important that the cognitive aid should be familiar, in a format that has been used in practice and training.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0365-8) contains supplementary material, which is available to authorized users.

Transurethral resection of prostate syndrome: report of a case

We report a case of transurethral resection of prostate (TURP) syndrome. A 78-year-old man with prostatic hypertrophy was scheduled for transurethral resection of the prostate under spinal anesthesia. 30 minutes after the end of the surgery, the patient presented signs of TURP syndrome with bradycardia, arterial hypotension, cyanosis, hypoxemia and coma. The electrolytes analysis revealed an acute hyponatremia (sodium concentration 125 mmol/L). Medical treatment consisted of hypertonic saline solution 3%, volume expansion, intubation and ventilation. The presented case describes a typical TURP syndrome, which was diagnosed and treated early. The patient was discharged from hospital without any complications.

[TURP syndrome: about a case]

Nous rapportons le cas d'un patient de 78 ans, sans antécédents pathologiques notables, qui a bénéficié d'une résection transuréterale d'une hypertrophie bénigne de prostate de 50g sous rachianesthésie. Ce patient a présenté, 90 minutes après le début de l'intervention, des nausées vomissements, brouillard visuel et bradycardie en rapport avec un TURP syndrome. L'ionogramme a objectivé une natrémie à 118meq/l, d'où sa mise sous sérum salé hypertonique à 3% avec bonne évolution. Cette observation décrit une forme typique mais modérée du TURP syndrome dont la prise en charge était facilitée par l'état d'éveil du patient permis grâce à la rachianesthésie.

Dilutional hyponatremia in a community hospital setting: case report

Transurethral resection of the prostate (TURP) syndrome describes the symptomatic absorption of hypotonic irrigation fluid used during a TURP procedure, the culmination of which could possibly lead to death. During the procedure, electrocautery is used to excise the urethral-occluding prostate tissue while an irrigation solution removes incisional debris and facilitates a clear surgical view. Through direct communication with the prostatic circulatory system, rapid absorption of irrigation solution can occur. Compared with bipolar and laser resectoscopes which allow the use of isotonic irrigation solution, monopolar resectoscopes require the use of an electrolyte-free irrigation solution to prevent electricity scatter. This presents a unique patient safety challenge for the smaller institutions around the world which continue to implement this technology. This article discusses a case report of a patient with TURP syndrome admitted to our surgical intensive care unit.

Atypical presentation of acute hyponatremia in transurethral resection of prostate surgery: A case report

We report a case of unusual presentation of transurethral resection of prostate (TURP) syndrome. A 58-year-old male patient with grade III benign hypertrophic hyperplasia was scheduled for TURP under spinal anesthesia. At 120 min of surgery, the patient presented with atypical symptoms of tightness in the chest with difficulty in breathing. The electrolyte analysis revealed an acute hyponatremia (serum Na⁺ 95 mEq/l). Patient was successfully treated with rapid infusion of 3% hypertonic saline along with furosemide.

Non-Surgical Bleeding and Transurethral Resection of the Prostate (TURP) Syndrome after TURP Surgery: A Case Report and Literature Review

Patients undergoing transurethral resection of the prostate (TURP) surgery can develop TURP syndrome and post-TURP bleeding. Post-TURP bleeding can be surgical, from arteries or venous sinuses, or non-surgical, due to coagulopathy preventing clot formation. Non-surgical post-TURP bleeding may be due to high concentrations of urokinase and tissue plasminogen activator (tPA) in the urine that cause fibrinolytic changes and increase bleeding risk. Urine urokinase and tPA may have both local and systemic fibrinolytic effects that may prevent blood clot formation locally at the site of surgery, and cause fibrinolytic changes systemically through leaking into the blood stream. Another post-TURP complication that may happen is TURP syndrome, due to absorption of hypotonic glycine fluid through the prostatic venous plexus. TURP syndrome may present with hyponatremia, bradycardia, and hypotension, which may be preceded by hypertension. In this case report, we had a patient with benign prostatic hyperplasia (BPH) who developed both TURP syndrome and non-surgical post-TURP bleeding. These complications were transient for one day after surgery. The local effect of urine urokinase and tPA explains the non-surgical bleeding after TURP by preventing clot formation and inducing bleeding. Coagulation studies showed fibrinolytic changes that may be explained by urokinase and tPA leakage into the blood stream. In conclusion, non-surgical bleeding after TURP can be explained by the presence of fibrinolytic agents in the urine, including urokinase and tPA. There is a deficiency in existing studies explaining the pathophysiology of the fibrinolytic changes and risk of bleeding after TURP. Herein, we discuss the possible pathophysiology of developing fibrinolytic changes after TURP. More research effort should be directed to explore this area to investigate the appropriate medications to treat and prevent post-TURP bleeding. We suggest monitoring patients' coagulation profiles and electrolytes after TURP because of the risk of developing severe acute hyponatremia, TURP syndrome, fibrinolytic changes, and non-surgical bleeding. In our review of the literature, we discuss current clinical trials testing the use of an antifibrinolytic agent, Tranexamic acid, locally in the irrigation fluid or systemically to prevent post-TURP bleeding by antagonizing the fibrinolytic activity of urine urokinase and tPA.