Torsades de Pointes

Prolonged  Q-T Syndrome

 

Precautions for Surgeries

 

Precautions for Surgeons & Anesthesiologists:

This information applies to all surgical procedures, including simple office procedures or Dental procedures. Again, this information is based on my personal experience as a Torsades patient, but it may be helpful for other Torsades patients as well.

  • Anesthesiologist selection – Never use any anesthesiologist who is not experienced in Torsades de Pointes or prolonged Q-T for any surgical procedure. The surgeon should verify all of the medications and anesthetics the anesthesiologist plans to use prior to the day of surgery. I have been known to fire many anesthesiologists just prior to surgery for failing to have enough experience, insisting on using high risk drugs or refusing to take the proper precautions. I personally require my anesthesiologist to have a minimum of 10 years experience and a thorough knowledge of Torsades. Even though the anesthesiologists are sent through a group practice, I now request the anesthesiologist by name and will call their office and speak directly with that anesthesiologist to ensure the request does not slip through the scheduling cracks. I also review all medications and anesthetics before the surgery begins since it is my life that depends on it being correct.
  • Review Torsades drug list – Prior to any surgery, both the surgeon and anesthesiologist should do a full review of the list of contraindicated Torsades and prolonged Q-T medications to ensure the patient does not accidentally receive the wrong medicine. Prior to surgery, double-check all medications. Also double check medication instructions for post surgery recovery, any in-patient hospital stay and medications to be taken by the patient at home.
  • Presurgery blood work & EKG – as always, it is a sensible idea to run a blood test and EKG reading on your patient at least a week prior to the surgery. CBC, CMP, CRP, sed rate, prothrombin time, kidney functions, liver functions, magnesium, calcium and potassium levels and cardiac enzyme levels. It wouldn’t hurt to verify their blood type in advance as well, even though it is not currently a standard presurgical blood test.
  • Cardiologist & Electrophysiologist – Be sure to consult with the patient’s cardiologist or electrophysiologist about the patient’s condition, medications and other pertinent information prior to surgery. It is a good idea to have the patient cleared by the cardiologist prior to surgery. Also check to see if a cardiologist will be handy at the proposed surgical facilities or if the patient’s cardiology group has a cardiologist available at that location for the day of surgery.
  • Plastic & cosmetic surgery procedures – Due to the dangerous nature of a Torsades patients deadly reaction to drugs (particularly antibiotics and epinephrine), AICD issues and need for an absolute sterile environment; all procedures of this type should be performed only in a hospital environment with an experienced anesthesiologist. Do not take risks with Torsades patients by performing surgeries outside of a hospital or hospital day surgery environment. I would not recommend Botox for Torsades patients due to the same issues with antibiotics and avoiding bacterial infections of the heart and AICD wiring.
  • Anesthesia – Propoful, versed, lidocaine, Duranest, Sodium Pentothal have worked well for me, but I also take Imdur and benadryl prior to the surgery to prevent Torsades reactions. Do not use Ketamine. I was surprised to find some surgeons wanting to use this veterinary anesthetic. Not a smart idea. The more anesthetics mixed into a cocktail, the more likely the chances for a fatal reaction. I had one oral surgeon who wanted to mix 8 different anesthetics including Ketamine, when one or two of the anesthetics listed above would have been safer and adequate. This surgeon also would not check with my electrophysiologist when I cautioned her about the dangers of the anesthesia cocktail she intended to use. Needless to say, I terminated her services and she did not perform the surgery. Torsades patients should not allow any medical professional to bully them into using medications or other drugs, which pose an unreasonable risk. More than once, my electrophysiologist has had to intercede on my behalf to set a surgeon straight in regard to their insistence on using a medication, which would be fatal during surgery while the AICD is disabled.
  • Imdur taken before surgery will help to prevent a Torsades episode. However, even with Imdur, never give a Torsades patient antibiotics by IV or Injection if that drug appears on the Torsades or prolonged Q-T lists. Imdur will only be effective against oral medications. Resuscitating a Torsades patient following the IV or injection of a Torsades or Prolonged Q-T episode trigger drug will likely be unsuccessful.
  • Nitro cream – Nitroglycerin cream applied to the patient’s skin during surgery will be an excellent episode preventative. If you cannot apply nitro to the skin during surgery, please be sure to have it handy on the tray in the operating room.
  • Methylprednisone – My anesthesiologist prefers to administer methylprednisone just prior to surgery as an additional preventative measure against any unanticipated reactions to the drugs. While I realize this could mask presence of an infection, I take antibiotics before and after each surgery as a preventative measure and have a CBC blood work run about a week following the surgery.
  • Benadryl – I always take a plain Benadryl antihistamine prior to surgery as a preventative measure. No decongestants.
  • Surgery Premeds & Antibiotics – I usually receive a broad spectrum antibiotic (safe for Torsades) prior to surgery and oral antibiotics Post surgery as a preventative since I usually end up with a post surgical infection if no antibiotics are used. Again, I strongly caution the danger of sudden cardiac death with Torsades medication especially when administered by IV or injection. I had one surgeon who was insisting on giving me Levaquin by IV during surgery. Once again, my electrophysiologist had to intercede on my behalf and select and alternative antibiotic. It is not easy to work with a Torsades patient if the physician or surgeon is inflexible. It seems to be difficult for some surgeons to break from their routine mode to make the changes necessary for a Torsades patient, while other surgeons who are understanding about the situation and willing to work with the Torsades patient and take the necessary precautions tend to calmly sail right through surgery with no difficulties.
  • Extraordinary Sterile Room precautions - It is imperative for the surgeon & support team to take additional extreme preventative measures in the operating theater to avoid the introduction of bacteria when performing surgical procedures on a Torsades patient. Infections in a Torsades patient cannot be treated with IV antibiotics such as Cipro, Levaquin or Vancomycin (see oral dose exceptions in conjunction with Imdur under “Prescribing Methodologies” section). I have seen some hospital operating rooms, which are far from clean with questionable sterile practices. Opt for the best available surgical facilities in the area. The surgical facilities for open-heart surgery are the best rooms to use for a Torsades patient since they are usually kept highly sterile and contain a handy array of cardiac equipment and systems for emergencies.
  • AICD – Avoid the software disabling of an AICD during surgery unless the AICD is implanted too deeply for a surface magnet to be effective. Instead, use a special circular magnet placed on top of the AICD, secured in place with tape to temporarily disable the defibrillator if you plan to perform electrocautery (which can cause the defibrillator to mistake the current as fibrillation and unnecessarily shock the patient). If an emergency occurs during surgery requiring defibrillation, simply remove the magnet from the patient’s skin and the AICD will automatically reset and defibrillate as required. As a patient, I usually bring my own AICD magnet for surgical procedures to ensure we have one available.
  • Portable defibrillator – It is always a good idea to ensure a defibrillator is available in the operating theater when performing a surgical procedure for non-AICD patients. Do not use an external defibrillator if the patient already has a functioning AICD implanted
  • Post surgery – Be sure to review all medicines with the Torsades list. If applicable, continue with Imdur as a Torsades preventative while the patient is on medications. My personal preference is to take a baby aspirin immediately following surgery and one a day for at least 3 weeks. Too many patients are dying from post op blood clots. As I have heard many medical professionals express, “they would rather bleed than clot”. If the patient has to be in bed, be sure to use the pressure devices for their legs to prevent clotting. The less time the patient has to be hospitalized the less chance they will encounter hospital bacterial strains. With contract nursing, the patients admitted to the hospital are not getting the same quality of care and infection control we once had when the nursing staffs were full time employed by the hospitals.

 

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