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Challenges in trauma and acute care surgery
Acute severe iatrogenic hyponatremia
  1. Ioana Baiu1,
  2. Michael Kang2,
  3. Thomas G Weiser3
  1. 1General Surgery, Stanford University, Stanford, California, USA
  2. 2Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
  3. 3Department of Surgery, Stanford University, Stanford, California, USA
  1. Correspondence to Dr Ioana Baiu, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA; ibaiu{at}stanford.edu

https://doi.org/10.1136/tsaco-2019-000388

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    Case description

    The patient is a 68-year-old man with a history of prostate cancer metastatic to the testicles and obstructive lower urinary tract symptoms who failed medical management and multiple partial transurethral resections of the prostate (TURP). Prior to the operation, his plasma sodium was measured at 141 mmol/L. He underwent a repeat TURP with a plan for definitive radiotherapy to follow. The operation lasted approximately 90 minutes. Early in the case, several small blood vessels were transected and cauterized, resulting in minor bleeding with an estimated blood loss of 50 mL. During the procedure, the patient underwent continuous bladder irrigation with approximately 15 L of sorbitol. Immediately postoperatively, his plasma sodium was measured to be 95 mmol/L (normal 135–145 mmol/L). Measured serum osmolality was 268 mOsm/kg and calculated osmolality was 303 mOsm/kg (osmolal gap 68). His anion gap was 14 mmol/L. His arterial blood gases were acidotic with pH 7.2. His glucose was normal at 100 mg/dL.

    What would you do?

    1. Lasix drip.

    2. Dialysis.

    3. Rapid correction of sodium with hypertonic saline.

    What we did and why

    C. Rapid correction of sodium with hypertonic saline.

    TURP syndrome is a type of severe iatrogenic hyponatremia (serum sodium <120 mmol/L) that can occur during endoscopic urologic or gynecologic procedures requiring continuous irrigation. Hypotonic solutions (1.5% glycine, 3% sorbitol, or 5% mannitol) are required for the use of unipolar …

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