Systemic volume overload and congestive heart failure during transurethral resection of the prostate treated with high-dose nitroglycerin: a case report

Case presentationA 72-year-old man (171 cm, 69 kg) with a history of benign prostatic hyperplasia (prostate volume: 5.2 × 6.1 × 4.9 cm 3 , 81 mL) and bladder outlet obstruction (maximum urinary flow rate <5 mL/s) underwent elective transurethral resection of the prostate (TURP) at our institution in December 2024.Preoperative transthoracic echocardiography demonstrated normal left ventricular function (ejection fraction: 58%, shortening fraction: 36%).Chest radiography, electrocardiography and laboratory investigations were unremarkable.The patient had no significant family history of chronic cardiovascular or pulmonary disease.The TURP procedure was performed using a bipolar plasmakinetic resection system (SurgMaster Electrosurgical Unit UES-40; Olympus Corp, Tokyo, Japan) under spinal anaesthesia (0.5% bupivacaine, 2 mL; sensory block at T10 level).Continuous bladder irrigation with 0.9% saline was maintained intraoperatively.The Endoscopic Surgical Monitoring System (ESMS; Aokai Medical Equipment Corp, Gansu, China) provided real-time measurement of irrigation fluid absorption and blood loss. 1 At the start of surgery, haemodynamic parameters of the patient were stable (heart rate [HR]: 73 bpm, blood pressure [BP]: 121/70 mm Hg, peripheral oxygen saturation [SpO 2 ]: 99%) and the procedure was initially uneventful.However, after 30 minutes the patient developed acute dyspnoea, chest tightness and a systemic swelling sensation.The HR gradually increased to 97 bpm, BP fell to 91/62 mmHg, and SpO 2 decreased to 95%.The electrocardiogram showed significant T-wave inversion and ST-T segment depression.At this point, it was noted that the volume of absorbed irrigation fluid had rapidly increased to 4000 mL, with only 100 mL of blood loss and 300 mL of intravenous lactated Ringer's solution administered.Point-of-care arterial blood gas analysis revealed pH value of 7.17, sodium level of 144 mmol/L, chloride