Fluid extravasation caused by bladder perforation during bipolar transurethral resection using saline solution -a case report-
An 84-year-old male patient, 165 cm in height and 84 kg in weight, visited the hospital to have TURP for hyperplasia of prostate with obstruction. The patient had no specific medical history. The preoperative chest X-ray and electrocardiogram (ECG) were within normal range. The hemoglobin level (Hb) was 14.2 g/dl, and the hematocrit level was 41.1%, which were within normal limits.\nAfter arriving in the operating room, noninvasive blood pressure (NIBP), ECG, and pulse oximetry were attached. After a few minutes of rest, blood pressure was 150/95 mmHg, heart rate was 85 beats/min, respiratory rate was 15 breaths/min, and oxygen saturation (SaO2) was 94.0%. The patient's position was maintained at the right lateral decubitus position. After identifying the L4-5 intervertebral space, a 25 G Quincke spinal needle was inserted into the space. After the stylet was removed and cerebrospinal fluid was confirmed to be draining well, 11 mg of 0.5% bupivacaine (Marcaine®, AstraZeneca AB, Södertälje, Sweden) with 100 ug of epinephrine was injected. Ten minutes after he was placed in the supine position, the height of sensory block was increased to the T12 and checked by pin-prick test. The patient was placed in a lithotomy position. When bipolar TURP began, the irrigation fluid with 0.9% saline solution was injected from a height of about 150 cm without pressure. The patient had a severely enlarged right lobe of the prostate. At 120 minutes after anesthesia, 4 mg of ondansetron was injected because the patient vomited. At that time vital signs were stable (HR: 71 beats/min, NIBP: 150/85 mmHg). At 135 minutes after anesthesia, the patient complained of pain on operative site, considered to be caused by a low level of anesthesia. Therefore, with the consent of the patient, spinal anesthesia was switched to general anesthesia. Pre-oxygenation with 100% oxygen was conducted. After intravenous injection of 250 mg of thiopental and 40 mg of rocuronium, endotracheal intubation with a tube of internal diameter 7.5 mm was performed. Anesthesia was maintained with 2 L/min of oxygen, 2 L/min of air, and 2 vol% of sevoflurane. Tidal volume was 500 ml and respiratory rate was 10 breaths/min, so mechanical ventilation was initiated, when PIP was 24 cmH2O.\nForty minutes after switching to general anesthesia, the surgeon inserted a Foley catheter and finished the surgery. Glycopyrrolate 0.4 mg and neostigmine 1.5 mg were injected for reversal of muscle relaxation, the patient's spontaneous respiration and muscular strength recovered, and the endotracheal tube was removed. His blood pressure was well maintained at 140-100/100-70 mmHg throughout surgery, and the body temperature was around 36.2℃. However during emergence 10 mg of labetalol was injected twice due to high blood pressure (180/110 mmHg). The total anesthetic time was 3 hours and 15 minutes, and the total surgical time was 2 hours and 30 minutes. Seven hundred fifty ml of Ringer's lactate were injected, and 5 L of 0.9% saline solution was used as an irrigation fluid. When the patient was transferred to the PACU, SaO2 was measured as 80%. Although 10 L of O2 was provided with nonrebreathing reservoir facial mask, the SaO2 was not maintained at more than 90.0% (HR 77 beats/min, NIBP 190/110 mmHg). Arterial blood gas analysis showed a pH 7.159, PaCO2 53.5 mmHg, PaO2 58.9 mmHg, HCO3- 15.9 mmol/L, base excess -9.0 mmol/L, Na+ 139 mmol/L, K+ 3.5 mmol/L, Hb 14.2 g/dl and SaO2 81.8%. The patient complained of severe respiratory difficulties and abdominal pain. On physical examination, abdominal distension was founded. The surgeon suggested conducting an abdominal CT scan, but oxygen saturation was not maintained at more than 90% despite an Ambu-bagging with 10 L of 100% O2. The anesthesiologist decided to perform the endotracheal intubation again. Two hundred fifty mg of thiopental and 50 mg of rocuronium were injected, and endotracheal intubation with a tube of ID 7.5 mm was performed. A chest X-ray was taken and an intravenous injection of 10 mg of furosemide was conducted. In PACU NIBP was 180-140/110-85 mmHg and HR was 80-70 beats/min.\nA chest X-ray was normal. After the abdominal CT scan, the patient was transferred to the intensive care unit (ICU). Findings of the abdominal CT scan are seen . In the ICU, pressure support 11 cmH2O, FIO2 0.45, and PEEP 6 cmH2O were maintained as a PSV mode. Arterial blood gas analysis showed a pH 7.380, PaCO2 26.1 mmHg, PaO2 73.9 mmHg, HCO3- 15.6 mmol/L, base excess -7.3 mmol/L, and SaO2 94.7%. After the test, intravenous injections of 10 mg of furosemide were injected twice. The total volume of urine on the day of the surgery was 1100 cc.\nOn the first day after surgery the endotracheal tube was removed and checked ABGA. Three hours later ultrasonography was conducted and showed that a great volume of fluid had accumulated around the liver. A percutaneous catheter drainage (PCD) was done into the right upper abdomen, and about 650 cc of clear yellowish fluid was drawn. The patient was transferred to a general ward on that day. The PCD catheter was removed on the fourth day after the surgery. The patient was discharged from the hospital on the tenth day after the surgery.