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

2. Copyright © 2015 Terms of Use The Consult Guys ® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys ® slide sets constitutes copyright infringement.

3. 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

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

5. 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

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

7. 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

8. Rhythm Strip Copyright © 2015

9. ECG Post Cardioversion QT Prolongation Copyright © 2015

10. 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

11. 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?

12. Gupta PK, et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery. Circulation. 2011;124:381-387.

13. 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%

14. CT Scan of Chest Copyright © 2015 Pulmonary embolism Aortic dissection

15. 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.

16. 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”

17. 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)

18. 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)

19. Copyright © 2015 COPYRIGHT © 2015, ALL RIGHTS RESERVED Produced by and