Discuss how heart is tachy due to trying to compensate for decrease cardiac out put and aortic insufficiency Embolization – left sided IE embolization abd. Tenderness = possible splenomegaly hematuria = kidney joint pain = joint petechia = limbs
Subacute - pt. has preexisiting valve disease, has a clincal cause that may extend over months Acute – pt. with healthy valves and presents as a rapidly progressive illness
Explain Vegetation Explain Left side vs. right side vegetation
Mention #4 in case study – diagnostic criteria for IE = anemia, fever, and cardiac murmurs and explain cause murmur = valve insufficiency, aortic stenosis fever = infection spreading systematically from heart anemia = of chronic disease – inflammatory process release cytokines that causes inc. uptake and retention of iron within macrophage that leads to diversion of iron from circulation into storage sites.
J.F. is a 50 year-old married homemaker with a genetic autoimmune deficiency; she has suffered from recurrent bacterial endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus mutans infection of the aortic valve 1 month ago. During this latter hospitalization, an ECG showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago J..F. received an 18-month course of TPN for malnutrition caused by idiopathic, relentless N/V. she has also had CAD for several years, and 2 years ago suffered an acute anterior wall MI. In addition, she has a history of chronic joint pain.
Now, after being home for only a week, J.F. has been readmitted to your floor with endocarditis, N/V, and renal failure. Since yesterday she has been vomiting and retching constantly; she also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has a dental bridge. She is immediately started on TPN at 125 ml/hr and on penicillin 2 million units IV q4h, to be continued for 4 weeks. Other medications are furosemide 80 mg PO qd, amlodipine 5 mg PO qd, K-Dur 40 mEq PO qd (dose adjusted according to laboratory results), metoprolol 25 mg PO bid, and prochlorperazine (Compazine) 2.5 to 5 mg IVP prn for N/V.
Admission VS are 152/48 (supine) and 100/40 (sitting), 116, 22, 37.9 degrees Celsius. When you assess her, you find a grade II/VI holosystolic murmur and a grade III/VI diastolic murmur; 2+ pitting tibial edema but no peripheral cyanosis; clear lungs; orientation x3 but drowsy; soft abdomen with slight left upper quadrant (LUQ) tenderness; hematuria; and multiple petechiae on skin of arms, legs, and chest.
Antibiotic prophylaxis – used for high risk patients before they undergo certain procedures such as : dental, GI, and GU procedures or who are undergoing drainage/removal of infected tissue, renal dialysis, or have ventriculoatrial shunts for hydrocephalus
Long-term antibiotic – regimens dependent on organism that it is eradicating. Penicillin is a common antibiotic used unless there are allergies. The regimen can take weeks to complete.
Acetaminophen, ibuprofen, fluid and rest are recommended to treat the fever that accompanies IE
Interesting article on American Heart Association website regarding prevention of IE
“ The current practice of giving patients antibiotics prior to a dental procedure is no longer recommended EXCEPT for patients with the highest risk of adverse outcomes resulting from BE (bacterial endocarditis)” (americanheart.org)
Patients at highest risk and therefore should be given prophylaxis antibiotics are those who have:
Prosthetic cardiac valve
Congenital heart disease
Cardiac transplant recipient with cardiac valvular disease
PREVENTION OF BACTERIAL ENDOCARDITIS Wallet Card This wallet card is to be given to patients (or parents) by their physician. Healthcare professionals: Please see back of card for reference to the complete statement. Name:__________________________________________________________________________ Needs protection from BACTERIAL ENDOCARDITIS because of an existing heart condition. Diagnosis:_______________________________________________________________________ Prescribed by:____________________________________________________________________ Date:___________________________________________________________________________
American Heart Association. (2008). Endocarditis Prophylaxis Information . Retrieved September 28, 2008, from http://www.americanheart.org/presenter.jhtml?identifier=11086
Hill, E.E., Vanderschueren, S., Verhaegen, J., Herugers, P., Claus, P., Herreods, M.C. and et al. (2007). Risk factors for Infective Endocarditis and outcome of patients with Staphylococcus aureus Bacteremia. Mayo Clinic Proc., 82(10), 1163-1169.
Massoure, P., Reuter, S., Lafitte, S., Laborderie, J., Bordachard, P., Clementy, J., et al. (2007). Pacemaker endocarditis: clinical features and management of 60 consecutive cases. Pacing & Clinical Electrophysiology , 30 (1), 12-19.
Thalme, A., Westling, K., Julander, I. (2007). In-hospital and long-term mortality in infective endocarditis in injecting drug users compared to non-drug users: A retrospective study of 192 episodes. Scandinavian Journal of Infectious Diseases, 39, 197-204.
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