NMS. Casos Clínicos

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Chapter 1 ♦ Preoperative Care

Case Variation 1.9.2. The patient had chronic mitral valve stenosis and an episode of congestive heart failure 1 month ago.

◆ ◆ Mitral valve stenosis with underlying CHF increases mortality to as high as 20%. More extensive cardiac workup and perioperative monitoring may be necessary, and ECG and echocardiography are indicated to determine the extent of disease. If urgent surgery is needed, intraoperative monitoring may include an arterial line and transesophageal echo- cardiography. Case Variation 1.9.3. The patient has known aortic stenosis and a grade IV systolic murmur. ◆ ◆ The obstruction to left ventricular outflow leads to left ventricular hypertrophy and in- creased left ventricular end-diastolic pressure, which may cause angina, dyspnea, syncope, or sudden death . The outflow obstruction causes an inability to increase cardiac output. In patients who need elective surgery, cardiac assessment and possibly valve replacement would take priority. In patients who need urgent surgery, perioperative hemodynamic monitoring with a pulmonary artery catheter, an arterial line, and transesophageal echo- cardiography should be considered.

Case 1.10  Endocarditis Prophylaxis in a Surgical Patient with Valvular Heart Disease A 58-year-old woman with mitral valve disease secondary to rheumatic fever is scheduled to undergo a hemicolectomy for diverticular disease. Q: When would you consider bacterial endocarditis prophylaxis? A: AMA guidelines recommendations state: Antibiotic prophylaxis is indicated for the follow- ing high-risk cardiac conditions: ◆ ◆ Prosthetic cardiac valve ◆ ◆ History of infective endocarditis ◆ ◆ Congenital heart disease (CHD) ( except for the conditions listed, antibiotic prophylaxis is no longer recommended for any other form of CHD ): • Unrepaired cyanotic CHD, including palliative shunts and conduits • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization) ◆ ◆ Cardiac transplantation recipients with cardiac valvular disease For patients with high cardiac risk, antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. Antibiotic prophylaxis is recommended for invasive respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (e.g., tonsillectomy, adenoidectomy). Antibiotic prophylaxis is not recommended for bronchoscopy unless the procedure involves SAMPLE