twisted after surgery: what caused torsades? copyright © 2015, all rights reserved from the...
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Twisted After Surgery:
What Caused Torsades?
COPYRIGHT © 2015, ALL RIGHTS RESERVED
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A 48 year old woman is hospitalized for clipping of a cerebral aneurysm (craniotomy) Presented with severe headache
Hypertension well controlled – diureticActive, exercises 4 X week strenuouslyHistory of post op nausea and vomiting following
cholecystectomyNo other active medical issuesUnremarkable family history
Stumper
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Stumper
Admit labs:• Lytes normal, LFTs normal,
renal function normal, CBC normal
• CXR: Nad• ECG
Stumper
CraniotomyWhat about the prior history of post op nausea
and vomiting?See Consensus Guidelines for the
Management of Postoperative Nausea and Vomiting Guideline to asses her risk and devise a plan.
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Gan TJ, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014;118:85–113
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Stumper
Undergoes craniotomy without complicationFifteen minutes after return to ICU – Nausea
Rx ondansetron (zofran)
Nausea persists IV fluid
No chest pain or dyspneaHypotension, unresponsive 15 minutes later
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Rhythm Strip
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ECG Post CardioversionQT Prolongation
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The patient is now hemodynamically stable.
At this point, what should we be doing?
Cardiac catheterization CT angiogram of chest AICD Revise medical therapy
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Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137.
Cardiac cath: Is this an acute MI?
Gupta PK, et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery. Circulation. 2011;124:381-387.
Gupta Perioperative Cardiac Risk
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Age: 48Creatinine: < 1.5 mg/dLASA Class: 1 (Healthy other than aneurysm)Functional status: Totally IndependentProcedure site: Brain
Estimated risk of perioperative myocardial infarction or cardiac arrest: 0.03%
CT Scan of Chest
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Pulmonary embolismAortic dissection
Tracy CM, et al. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. 2012;60(14):1297-1313.
Risk Factors Perioperative Torsades de Pointes
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QTc prolongationAdditional triggers:
Female Craniotomy Bradycardia (nausea – vagal) Hypokalemia
Drugs Ondansetron (Zofran)
From the French“Twisting of the Spikes”
Quiz
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Who was President of the U.S. when the first case of TdP was reported?
1. Andrew Johnson (1865-1869)
2. Grover Cleveland (1893-1897)
3. Theodore Roosevelt (1901-1909)
4. Harry Truman (1945-1953)
5. Lyndon Johnson (1963-1969)
Quiz
Copyright © 2015
Who was President of the U.S. when the first case of TdP was reported?
1. Andrew Johnson (1865-1869)
2. Grover Cleveland (1893-1897)
3. Theodore Roosevelt (1901-1909)
4. Harry Truman (1945-1953)
5. Lyndon Johnson (1963-1969)
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