Long QT, does anyone care?

[caligas]

Took care of a patient recently with long QT and history of postop nausea. She specifically told me not to give her Zofran because of her asymptomatic history just seen on ekg. Admittedly this is not something I’ve been generally concerned with in the past although I am familiar with the black box warning on Zofran. But the reality is every drug just about that we use for nausea has been associated with increasing QT interval and you have to give these patients something. Any thoughts?

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[bigdan]

I avoid the ondansetron IF I think about it AND know of the long QT (which almost never).

We had a 40-something year old, otherwise healthy lady with GERD and heretofore asymptomatic LQTS experience a Torsades event in our GI Lab recovery shortly after getting ondansetron; she got midazolam and propofol for her case.

She mighta been the 1 in a million (or billion?) that had a significant event after the anesthetic. It sure changed my practice...

 

[Mikkel]

Give dexamethasone high dose, scopolamine, famotidine. Don't play with fire, especially if a patient told you not to.

 

[DM27]

Seeing a long QT on an EKG would not stop me from using an appropriate antiemetic in someone who needs it. However, if they had a history of torsades or the patient specifically asked me not to give it....then nope I am not giving it.

 

[caligas]

Yes, obviously not if they specifically say no to a drug, that’s almost battery.

But is anybody really checking QT intervals, (other than the guy who just dealt with a code? ) I doubt it.

 

[Mikkel]

Yes, obviously not if they specifically say no to a drug, that’s almost battery.

But is anybody really checking QT intervals, (other than the guy who just dealt with a code? ) I doubt it.

I don't measure QTc myself. The computer/cardiologist might write "prolonged QT interval", and I would definitely not use double therapy of reglan+zofran in that case.

Single therapy might be ok, but definitely not two of them. I would also make sure PACU is aware not to give too much in too short of time.

 

[propadope]

Maybe consider TIVA + decadron if known history. Low dose propofol or midazolam for PONV treatment/rescue.

 

[BLADEMDA]

If a patient asks me not to give them a drug and the request is reasonable like in this case then I honor that request.

I have Emend available to me along with a SCOP patch. Dexamethasone plus maybe a Propofol sandwich technique vs a pure TIVA. I do look at the EKG reads and if I see long QT I do think about a Zofran relative contraindication. I’ve never seen Torsades from Zofran but I know the problem can occur (rare).

Overall, we are in a business of probabilities and statistics. That means **** happens no matter what and we get paid to worry about such situations along with the best possible course to treat the issue.

The longer you do this the more you realize that rare events do happen from time to time and that you must be prepared to deal with them

 

[dhb]

But is anybody really checking QT intervals, (other than the guy who just dealt with a code? ) I doubt it.

No. I can't even remember the last time i asked for a pre-op ekg.

 

[BLADEMDA]

No. I can't even remember the last time i asked for a pre-op ekg.

Different systems with one having lots of lawyers and lawsuits vs the other with almost zero chance of being sued.

The legal system is so insane that companies can be put out of business without any factual scientific evidence. Lay person juries decide the fate of individuals as well as billions of dollars each year. These people are generally uneducated and lack the knowledge to make these decisions.

 

[zizzer]

Overall, no. I try to take a quick glance at the telemetry before giving it just in case the QT is subjectively long (our monitors don't display the QTc. I sure as hell don't measure and calculate it though. I wouldn't if a patient has a recorded history of some congenital long-QT or if the patient or some other physician has made a big deal about it in the past though.

 

[nimbus]

I avoid the ondansetron IF I think about it AND know of the long QT (which almost never).

We had a 40-something year old, otherwise healthy lady with GERD and heretofore asymptomatic LQTS experience a Torsades event in our GI Lab recovery shortly after getting ondansetron; she got midazolam and propofol for her case.

She mighta been the 1 in a million (or billion?) that had a significant event after the anesthetic. It sure changed my practice...

She had nausea after Midaz and propofol?

 

[jurassicpark]

Being in the hospital, we always see the exception to the rule. Does every urgent care, primary, or even ER get an EKG before giving azithro or levaquin to a patient? No, and 99.99% of the time nothing will happen. Unfortunately, I've seen it and I've been always cautious about it

 

[coffeebythelake]

Give dexamethasone high dose, scopolamine, famotidine. Don't play with fire, especially if a patient told you not to.

This. Especially if the patient's concerns are reasonable!

 

[Planktonmd]

If you know the patient has long QT why would you give a medication that could make it worse especially if you have alternatives?
We live in a litigious society and avoiding a law suit should be something you think about if you don't like wasting years of your life talking to lawyers.

 

[OneFellSwoop]

I thought I remember back when the black box warning came out it was directed for the higher dose chemotherapy antiemetic doses and that the recommendation for 4mg dosing was that it wasn’t a concern in prolonged QTc patients. Having said that if a patient requested not to get it, especially in conjunction with a known LQTc in an ekg I wouldn’t give it.


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[deleted171991]

Seeing a long QT on an EKG would not stop me from using an appropriate antiemetic in someone who needs it. However, if they had a history of torsades or the patient specifically asked me not to give it....then nope I am not giving it.

FYI: many QT intervals are miscalculated by the machine (and rubber-stamped by cardiologists). Whenever important, measure it yourself, manually.

Same goes for the diagnoses themselves, I remember that the EM literature appreciates the percentage of false negative "normal" machine-read EKGs at about 50%.

 

[Splenda88]

I don't know if anyone here uses Lorazepam... I have used it a couple of times in patients with long QTc and it worked well.

The problem with our profession is that once you do something that has a negative outcome (even if it's a relative contraindication), unscrupulous lawyers are quick to pounce... and even your own colleagues are quick to criticize you.

 

[Mman]

No. I can't even remember the last time i asked for a pre-op ekg.

you don't have patients that come in with preop EKGs? I mean I'd venture a guess that 60-70% (if not more) of my patients have had an EKG in the previous 6 months.

I do notice the QTc if it is notated and try not to auto order Ondansetron if I think about it but I am sure I miss it more than a few times.

 

[dhb]

you don't have patients that come in with preop EKGs? I mean I'd venture a guess that 60-70% (if not more) of my patients have had an EKG in the previous 6 months.

I do notice the QTc if it is notated and try not to auto order Ondansetron if I think about it but I am sure I miss it more than a few times.

Some do i never look at the QT

 

[Noyac]

Different systems with one having lots of lawyers and lawsuits vs the other with almost zero chance of being sued.

The legal system is so insane that companies can be put out of business without any factual scientific evidence. Lay person juries decide the fate of individuals as well as billions of dollars each year. These people are generally uneducated and lack the knowledge to make these decisions.

Think about how dumb the average person is. Then think about the fact that 50% are even dumber.

 

[Mman]

Some do i never look at the QT

are there other parts of the EKG you don't look at? Do you bother to notice ST segments?

 

[dhb]

are there other parts of the EKG you don't look at? Do you bother to notice ST segments?

Funny
How many times in the history of anesthesia has a patient suffered from an arythmia which unique cause was the administration of 4mg of odansetron?

 

[Arch Guillotti]

Funny
How many times in the history of anesthesia has a patient suffered from an arythmia which unique cause was the administration of 4mg of odansetron?

once for me.

 

[Mman]

Funny
How many times in the history of anesthesia has a patient suffered from an arythmia which unique cause was the administration of 4mg of odansetron?

I'm not asking about Zofran, I'm asking why you wouldn't analyze a relevant portion of the EKG and wondering what other parts of it you ignore.

 

[dhb]

I'm not asking about Zofran, I'm asking why you wouldn't analyze a relevant portion of the EKG and wondering what other parts of it you ignore.

The thread is about long QT and zofran...
And no i don't look at ST segments in asymptomatic patients

 

[Libertas]

There’s long qt syndrome and then there’s slightly prolonged non specific qt . Very different

 

[Mman]

The thread is about long QT and zofran...
And no i don't look at ST segments in asymptomatic patients

your direct quote was you don't look at the QT which I found to be exceedingly bizarre. I also find it difficult to believe you can look at an EKG but specifically exclude the ST segments from viewing. I mean that's quite the mental feat. Perhaps what you mean is you don't order EKGs on those patients, but that is a very different statement.

 

[MoMoGesiologist]

My place orders EKGs on every patient. Every. Single. One. I hate it. Because now I have to look at every single one. What am I supposed to do with asymptomatic patients with long QTs or nonspecific ST or T wave changes? Just makes me feel more liable for something I didn’t even want to check in the first place...

 

[nimbus]

My place orders EKGs on every patient. Every. Single. One. I hate it. Because now I have to look at every single one. What am I supposed to do with asymptomatic patients with long QTs or nonspecific ST or T wave changes? Just makes me feel more liable for something I didn’t even want to check in the first place...

Agree it’s a useless test in low risk asymptomatic patients. Also pretty useless in high risk, asymptomatic patients. Even a large proportion of patients with severe multi vessel CAD presenting for CABG have normal EKG’s.

 

[soccrwz]

Aprepitant does not prolong QT

 

[Ferrismonk]

If reported history of long QT, no matter what the EKG says, I'd stay away from Zofran and Sevo. If history of nausea, give Dexa, Scop patch, and pepcid.

 

[anbuitachi]

do tiva. avoid zofran.
i always look at qt but i dont measure myself...

 

[deleted171991]

My place orders EKGs on every patient. Every. Single. One. I hate it. Because now I have to look at every single one. What am I supposed to do with asymptomatic patients with long QTs or nonspecific ST or T wave changes? Just makes me feel more liable for something I didn’t even want to check in the first place...

 

[deleted171991]

Agree it’s a useless test in low risk asymptomatic patients. Also pretty useless in high risk, asymptomatic patients. Even a large proportion of patients with severe multi vessel CAD presenting for CABG have normal EKG’s.

Even patients with negative stress test a month ago can get heart attacks. None of these tests means more than cricoid pressure.

 

[MoMoGesiologist]

Is there any trial that shows getting a CABG or PCI before your surgery (if indicated) reduces complications post op?

 

[Ronin786]

There’s long qt syndrome and then there’s slightly prolonged non specific qt . Very different

Precisely. Once saw a patient code in the elevator on his way back from an ablation for long QT syndrome. He was feeling nauseous so the CRNA gave him zofran. 🤔

If there's a non-specific Qt prolongation, I'm probably not going to do anything different.

 

[nimbus]

Is there any trial that shows getting a CABG or PCI before your surgery (if indicated) reduces complications post op?

Not that I know of if there is no acute coronary syndrome.

Relevant slides start at 40.

https://www.acponline.org/system/files/documents/about_acp/chapters/mt/bigsky18/perioperative_cardiac_management_sargsyan.pdf

 

[chocomorsel]

Precisely. Once saw a patient code in the elevator on his way back from an ablation for long QT syndrome. He was feeling nauseous so the CRNA gave him zofran. 🤔

If there's a non-specific Qt prolongation, I'm probably not going to do anything different.

The ablation didn’t work then?

 

[chocomorsel]

I had a patient today who’s QTc was 770 per her EKG. I couldn’t really tell because I could hardly see the T wave as it was flat. In the OR it didn’t look too long though.

 

[nimbus]

Precisely. Once saw a patient code in the elevator on his way back from an ablation for long QT syndrome. He was feeling nauseous so the CRNA gave him zofran. 🤔

If there's a non-specific Qt prolongation, I'm probably not going to do anything different.

Was the patient on a transport monitor? Maybe he was nauseous from a nonperfusing rhythm before zofran was given.

 

[nimbus]

I had a patient today who’s QTc was 770 per her EKG. I couldn’t really tell because I could hardly see the T wave as it was flat. In the OR it didn’t look too long though.

Did you give any QT prolonging drugs?😉

 

[chocomorsel]

Did you give any QT prolonging drugs?😉

Avoided Zofran. She was on amio for Afib plus Metoprolol and was Brady so had to keep giving her a little glyco and ephedrine here and there.
In PACU her QT per the strip was 450 where as the EKG showed 550.

 

[deleted162650]

I’ve had cardiologists tell me that as long as the T wave is less than 1/2 the R-R distance you don’t need to be concerned. Makes for an easy eyeball test.

 

[Ronin786]

Was the patient on a transport monitor? Maybe he was nauseous from a nonperfusing rhythm before zofran was given.

They came out of the elevator doing chest compressions. Patient was on a transport monitor.

 

[nimbus]

They came out of the elevator doing chest compressions. Patient was on a transport monitor.

And did he have torsade temporally related to zofran administration?

 

[Ronin786]

And did he have torsade temporally related to zofran administration?

"He felt nauseous, so I gave him some zofran and he went into VT" -CRNA

 

[MoMoGesiologist]

"He felt nauseous, so I gave him some zofran and he went into VT" -CRNA

Did the CRNA know about the prolonged QT? Did u specifically tell him not to give zofran? Did u say anything to the CRNA?

 

[Ronin786]

Did the CRNA know about the prolonged QT? Did u specifically tell him not to give zofran? Did u say anything to the CRNA?

I was a resident at that time. Happened to be next to the elevator. I hope the CRNA knew because they did the case in EP...

 

[nimbus]

Got a warning for this dangerous combination😕