2024 FSA Podium and Poster Abstracts
P070: PERIOPERATIVE MANAGEMENT OF TORSADES DE POINTES IN A 34-YEAR-OLD FEMALE WITH ALCOHOLIC CIRRHOSIS
Drew Hicks, DO; Ellie Zhang, BS; Maksym Doroshenko, MD; University of Miami/Jackson Health System
Introduction/Background: Torsades de Pointes (TdP) is a rare, yet distinctive, type of polymorphic ventricular tachycardia that is associated with QTc prolongation. Although there is no threshold of QTc prolongation at which Tdp is certain to occur, a QTc greater than 500 milliseconds is associated with a 2-3x higher risk of developing Tdp, with each 10-millisecond increase thereafter contributing to an additional 5-7% increase in risk [1]. Common etiologies include medications, anesthetic agents, electrolyte abnormalities, and congenital long QT syndrome. The incidence of Tdp secondary to acquired QTc prolongation in the hospital setting is shown to be between 0.0036% - 0.16% [2,3]. Although uncommon, immediate recognition and treatment of Torsades de Pointes is essential in the prevention of potential cardiovascular collapse and death, as the mortality of Tdp is approximately 10% [3]. The purpose of this case report is to reiterate the importance of thorough preoperative assessment in a patient with alcoholic cirrhosis, as well as to review the perioperative management of Torsades de Pointes.
Methods: Individual case of Torsades de Pointes at a single trauma center. Clinical data was collected from the electronic medical record system.
Results: The case presented is of a 34-year-old female with a past medical history of alcoholic cirrhosis who presented to Ryder Trauma Center following a fall from bed where she sustained significant facial trauma. Due to the severity of her injuries not correlating with the mechanism reported, assault was suspected. CT brain imaging was obtained and the patient was diagnosed with severe orbital compartment syndrome secondary to presumed retrobulbar hemorrhage. Ophthalmology performed an emergency right lateral canthotomy and cantholysis before taking her to surgery for orbital floor blowout reconstruction and evacuation of hematoma. Preoperative labs showed Na 132, K 3.5, Hgb 10, Hct 28.7, Plt 19, PT 27, PTT 46, and INR 2.44, otherwise unremarkable. The course of the surgery was uneventful, however, as facial dressings were being applied at the end of the case, multiple 2-5 beat runs of ventricular tachycardia were noted on electrocardiogram. The patient then progressed into polymorphic ventricular tachycardia with unstable hemodynamics, concerning for Torsades de Pointes. Treatment included intravenous magnesium infusion and asynchronous cardioversion. In total, 6 grams of magnesium were given and the patient was asynchronously cardioverted 3 times with return of spontaneous circulation after each event. Once hemodynamically stable, the patient was taken to the intensive care unit. Postoperative labs showed K 3.6, Mg of 3.2, and phosphate of 2.7. Postoperative EKG demonstrated sinus tachycardia with a prolonged QTc of 528. The diagnosis of Torsades de Pointes was confirmed.
Discussion/Conclusion: This case report aims to discuss the anesthetic considerations of alcoholic cirrhosis and Tdp. Patients with alcoholic cirrhosis are predisposed to electrolyte disturbances and QTc prolongation, which places them at increased risk for Tdp and mortality. TdP is a rare occurrence in the perioperative setting, but immediate recognition and treatment are crucial to prevent progression to ventricular fibrillation and death.