Twisted After Surgery:

What Caused Torsades?

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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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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

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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)

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