医療倫理の進歩
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概要

Surgery in septic patient with acute aortic endocarditic-case report

Tanja Anguseva

Abstract

Introduction: Despite antibiotic treatment, active infective endocarditis continues to be a devastating and often fatal condition, which needs to be treat with urgent life threatening , high-risk surgery.Essential adequate debridement of the infective material is followed by repairmen (excisement of the vegetations) or replacement of the valve . The postoperative intensive care treatment usually is faced with septic shock patient with predicted high mortality rate. A 37years old patient was admitted to our unit with an acute endocarditis of the aortic valve, diagnosed by transoesophageal echo (TEE) with a great vegetations on the right and non- coronarial cusp with a aortic regurgitation +2 as well as left ventricle failure.Biochemistry was positive for infection (neutrophilia in blood, increased CRP and procalcitonin) and positive blood culture for staphulococcusepidermidis MR. Patient had been treated with Linezolid according to antiniogram.

 

Background: After 10 days he developed pulmonary edema, due to high grade aortic regurgitation due to rupture of the non-coronarial cusp (confirmed on 3D TEE) and in a septic shock under catecholamine he was operated. Intraoperativelly his aortic valve was completely destroyed with a lot of vegetations and rupture of the non coronarial cusp. Patient got a mechanical prosthesisSorin 25mm. After surgery he was high fevered, on high dosage of catecholamine and positive biomarkers for infections. On a first postoperative day he was put on antibiotics according to antibiogram and on CRRT treatment with Oxiris filter on Prisma-flex machine. After forth hour hemodynamic stabilization was notified, due to which catecholamine had been excluded second postopoperative day, and patient dieresis had been normalized. Patient had been extubated after 7 days. After 2o days he had been discharged at home.

 

Method:- The explanation that this microbe has a higher proclivity for the endocardium is because of its capacity to discharge exopolysaccharide, empowering it to cling to fibronectin in the extracellular matrix. In these cases, IE advances gradually, however notwithstanding its affectability to antimicrobials, around half of patients need careful administration, similar to the case with our patient. The distinguishing proof of Abiotrophia is troublesome on account of its development prerequisite and its confounding Gram stain appearance. It needs a high clinical doubt and might be a demonstrative test that may require further developed diagnostics modalities, for example, polymerase chain response (PCR) or potentially network helped laser desorption ionization time-of-flight mass spectrophotometry (MALDI-TOF-MS). MALDI-TOF-MS is a generally basic and modest strategy for identification.2 At our organization, we don't offer these testing techniques, and thusly, this was a "convey" test to another establishment which utilized MALDI-TOF-MS technique for recognizable proof. Given that this distinguishing proof was from two distinctive blood tests, this was a hematogenous disease instead of just colonization. On the off chance that the recognizable proof had been from only one example, it more probable would have been less critical and consequently simply spoke to colonization. Likewise, the Bacillus cereus, Bacillus thuringiensis, Bacillus magaterium and Bacillus subtilis recognizable proof was from a solitary example, and hence, it was deciphered as most likely brought about by defilement from skin or maybe an uncleaned test bottle top.

 

Results: Surgery in acute endocarditis is a high risk procedure which can be performed with a better haemodynamic stability and less postoperative complications, if patient is treated with adequate antibiotics as well as CRRT- Oxiris filter to remove the endotoxins. In spite of the fact that as expressed already, Abiotrophia species is additionally viewed as ordinary verdure of the oropharyngeal plot, and there were no clinical signs or side effects to recommend an oropharyngeal source (for example dental sore, tonsillitis, upper respiratory plot disease). Additionally, this patient was not immunocompromised and didn't have any history of intrinsic coronary illness, for example, bicuspid aortic valve or prosthetic heart valve arrangement at the hour of beginning introduction. For our situation, open heart medical procedure with complex sedation the executives because of sepsis and hemodynamic weakening was required for authoritative treatment, which was trailed by a simple postoperative course. This case report features that patients with known AD contaminations are at high hazard for IE with extreme cardiorespiratory trade off, even without realized hazard factors. Cardiovascular anesthesiologists and clinical experts associated with the consideration of these patients, for example, nervous system specialists, hospitalists and irresistible illness advisors, ought to know about this uncommon yet possibly lethal contamination, which may introduce a noteworthy sedative test, and consider it as a reason for intense decay and organ disappointment in danger patients in the emergency unit.

 

Biography: Tanja Anguseva is Subspecialist cardiologist in Special Hospital for surgical diseases ZanMitrev. Scientific work titled “SyScheechan”, Clinic of Obstetrics, Faculty of Medicine, Skopje. Graduation at the Faculty of Medicine within Ss. Cyril and Methodius Skopje, Macedonia. Doctor – general practitioner, Military Outpatient Clinic, Veles. Specialization in internal medicine at the University Ss. Cyril and Methodius.Assistant at the Department of Hemodialysis - Department for Internal diseases, Military Hospital,Skopje. Postgraduate studies at the Clinic of Cardiology, Faculty of Medicine, Skopje. Topic: Immunoactivity of patients in end-stage ischemic heart failure. Intensive Care Unit – Department of Internal Diseases, Military Hospital, Skopje. Coronary (cardiac) stress test, Echocardiography, 24-hour ECG and ABP Holter monitoring – Department of Internal Diseases, Military Hospital, Skopje. Doctor in charge at the Intensive Care Unit, PHI FILIP VTORI, Skopje.