Twisted After Surgery: What Caused Torsades? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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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 – diuretic Active, exercises 4 X week strenuously History of post op nausea and vomiting following cholecystectomy No other active medical issues Unremarkable family history Stumper Copyright © 2015

Stumper Admit labs: Lytes normal, LFTs normal, renal function normal, CBC normal CXR: Nad ECG

Stumper Craniotomy What 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. Copyright © 2015

Gan TJ, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014;118:85–113 Copyright © 2015

Stumper Undergoes craniotomy without complication Fifteen minutes after return to ICU – Nausea  Rx ondansetron (zofran) Nausea persists  IV fluid No chest pain or dyspnea Hypotension, unresponsive 15 minutes later Copyright © 2015

Rhythm Strip Copyright © 2015

ECG Post Cardioversion QT Prolongation Copyright © 2015

Stumper The patient is now hemodynamically stable. At this point, what should we be doing?  Cardiac catheterization  CT angiogram of chest  AICD  Revise medical therapy Copyright © 2015

Fleisher LA, Fleischmann KE, Auerbach AD, et al 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:

Gupta Perioperative Cardiac Risk Copyright © 2015 Age: 48 Creatinine: < 1.5 mg/dL ASA Class: 1 (Healthy other than aneurysm) Functional status: Totally Independent Procedure site: Brain Estimated risk of perioperative myocardial infarction or cardiac arrest: 0.03%

CT Scan of Chest Copyright © 2015 Pulmonary embolism Aortic dissection

Tracy CM, et al ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. 2012;60(14):

Risk Factors Perioperative Torsades de Pointes Copyright © 2015 QTc prolongation Additional triggers:  Female  Craniotomy  Bradycardia (nausea – vagal)  Hypokalemia Drugs  Ondansetron (Zofran ) From the French “Twisting of the Spikes”

Quiz Copyright © 2015 Who was President of the U.S. when the first case of TdP was reported? 1. Andrew Johnson ( ) 2. Grover Cleveland ( ) 3. Theodore Roosevelt ( ) 4. Harry Truman ( ) 5. Lyndon Johnson ( )

Quiz Copyright © 2015 Who was President of the U.S. when the first case of TdP was reported? 1. Andrew Johnson ( ) 2. Grover Cleveland ( ) 3. Theodore Roosevelt ( ) 4. Harry Truman ( ) 5. Lyndon Johnson ( )

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