Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia

The transurethral prostatectomy syndrome (TURS) is defined as severe vascular hypotension reaction that complicates endoscopic surgery as a result of massive irrigating fluid absorption causing severe acute dilution hyponatraemia (HN) of <120 mmol/l. The vascular shock is usually mistaken for one of the recognized shocks and Volumetric Overload Shock type 1 (VOS1) is overlooked making Volumetric Overload Shock Type 2 (VOS2) unrecognizable. VOS1 is induced by the infusion of 3.5-5 liters of sodium-free fluids and is known as TURS or HN shock. VOS2 is induced by 12-14 liters of sodium-based fluids and is known as the adult respiratory distress syndrome. The most effective treatment for VOS1 and VOS2 is hypertonic sodium of 5% NaCl or 8.4% Sodium Bicarbonate. The literature is reviewed and the underlying patho-etiology is discussed. As Starling’s law for the capillary-interstitial fluid transfer proved wrong an alternative mechanism was found by studying the hydrodynamics of the porous orifice (G) tube. Incorporating the G tube in a chamber (C), representing the interstitial space surrounding a capillary, demonstrated a rapid dynamic magnetic field-like fluid circulation between the C and G tube lumen. The G-C phenomenon is autonomous having both filtration and absorption forces making a true replacement for Starling’s law. Abbreviations: VOS: Volumetric overload shocks, VOS1: Volumetric overload shock, Type 1, VOS2: Volumetric overload shock, Type2, TURP: The transurethral prostatectomy, TURS: The transurethral prostatectomy syndrome, ARDS: The adult respiratory distress syndrome, MVOD: The multiple vital organ dysfunction/ failure syndrome, HN: Hyponatraemia, HS: Hypertonic sodium, G Tube: The Porous orifice tube Definitions The transurethral prostatectomy syndrome (TURS) is a severe vascular hypotension reaction that complicates endoscopic surgery as a result of massive irrigating fluid absorption causing severe acute dilution hyponatraemia (HN) of <120 mmol/l [1]. Volumetric Overload Shock (VOS) is a condition caused by massive fluid infusions and is of two types; Type one (VOS1) and Type two (VOS2). VOS1 is induced by sodium-free fluid gain such as 1.5% Glycine used as irrigating fluid during endoscopic surgery such as the transurethral resection prostatectomy (TURP) [1]. It has been reported with other fluids such as Glucose, Mannitol and Sorbitol. It is known as TURS or HN shock [2] as HN is a marked serological marker for the condition [3]. VOS2 is induced by massive infusion of sodium-based fluids such as normal saline, Ringer, Hartmann, plasma and plasma substitutes and/or blood transfusions that may complicate the therapy of VOS1. VOS2 also complicates fluid therapy in critically ill patients suffering from other known shocks such as trauma, hypovolaemic, haemorrhagic and septicaemic shocks and presents with the multiple vital organs dysfunction (MVOD) or failure syndrome. The adult respiratory distress syndrome (ARDS) is another name under which VOS2 is reported. Both VOS1 and VOS2 are complications of fluid therapy [4].