Warner, Paul A.

AbstractStudy ObjectiveThe primary objective of this retrospective safety study was to determine the incidence of torsades de pointes (TdP) or death following perioperative administration of low‐dose, 4 mg, ondansetron for postoperative nausea and vomiting.Design and SettingThis is a single‐center retrospective clinical trial.PatientsThe authors identified 32,737 patients who received 37,589 doses of ondansetron during a 2‐year time frame between March 2009 and February 2011 for surgical nausea prophylaxis or treatment of nausea.Measurements and Main ResultsPatients were cross‐matched with an electrocardiogram and adverse outcome database; this identified 4759 patients with documentation of a QTc >450 milliseconds (ms), all ventricular tachycardias including TdP within 48 hours of receiving ondansetron, or death within 7 days of receiving ondansetron. No patients developed TdP or died as a direct result of ondansetron administration (n = 0; event rate = 0.0 per 10,000, 95% CI 0.0 to 1.1 per 10,000). Forty‐six of 32,737 surgical patients had documented monomorphic ventricular tachycardia (VT) (n = 14; event rate = 4.3 per 10,000, 95% CI 2.3 to 7.2 per 10,000) or died (n = 32; event rate = 9.8 per 10,000, 95% CI 6.7 to 13.8 per 10,000) within 48 h of ondansetron administration. All monomorphic VT episodes were precipitated by existing cardiovascular disease; and 7 of 14 patients had documented monomorphic VT prior to receiving ondansetron. Of the 32 surgical patients who died, all deaths were precipitated by pre‐existing disease.ConclusionNo episodes of TdP were identified in patients receiving ondansetron perioperatively. This suggests that low‐dose ondansetron does not contribute to the development of TdP.

Abstract Objective: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. Methods: Forty-one fourth-year medical school trainees were randomized as dyads (n=24) or individuals (n=17) for an education session on Day 1. Reassessment occurred on Day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. Results: On Day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p=0.02) and stress ratio (1.8 versus 0.9, p=0.045). On the Day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p=0.01) and time to initiation of pacing (p=0.04) in the dyad group on Day 1. On Day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (Hazard ratio [HR] = 2.26, p = 0.02).Conclusions: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

In this case, a 79-year-old male presented with new anteroseptal Q waves and T-wave inversions across the precordial leads following an otherwise uneventful endovascular repair of his thoracoabdominal aortic aneurysm. The patient had no history of cardiac disease and had undergone a dobutamine stress echocardiogram within the preceding 6 months that showed no evidence of inducible ischemia. Nevertheless, routine postoperative electrocardiogram (EKG) revealed new Q waves and T-wave inversions and transthoracic echocardiogram that demonstrated akinesis of the left ventricle (LV) apex with chronic-appearing apical thrombus. We will further discuss preoperative evaluation of cardiovascular risk along with postoperative interpretation of EKG abnormalities.

Perioperative serotonin syndrome has been associated with a number of medications and herbal supplements. We report a patient who developed serotonin syndrome immediately after an endoscopic procedure in which the preoperative use of black seed oil appears to have played a role in stimulating the syndrome. Black seed oil has not been previously reported in association with perioperative serotonin syndrome. Anesthesia professionals should be aware that patients taking black seed oil supplements may develop serotonin syndrome postoperatively.

Epicardial pacing wires are routinely used to avoid hemodynamic instability due to perioperative arrhythmias after cardiac surgery. In rare cases, pacing wires themselves can be associated with potentially life-threatening complications. Herein, we present a novel case of hemorrhagic shock and hemoperitoneum after temporary epicardial pacing wire removal.