ENDOCARDITIS WITH TRICUSPID

VALVE REPLACEMENT
A case of IV drug abuse
By: Jenn Kanetsky
Sodexo Dietetic Intern

THE HEART
Hollow muscular organ
Pumps oxygen and nutrient rich blood
throughout the body, 2,000 gallons/day
4 valves: aortic, mitral, tricuspid, pulmonary
Control direction of
blood flow
WHAT IS ENDOCARDITIS?
Infection of the hearts valves
Common in those who have damages,
diseased, artificial heart valve.
Caused by bacteria that enters the
bloodstream
Bacteria forms vegetation on the heart
valves.
VALVE REGURGITATION
Backflow of blood through a valve.
Backflow leads to a change of pressure,
ventricle enlarges to pump harder and the
tricuspid valve can become stretched out.
TRICUSPID VALVE REGURGITATION
STAPHYLOCOCCUS AUREUS
Staphylococcus aureus bacterium is the most
common cause of infective endocarditis in IV drug
users
Methicillin-resistant staphylococcus aureus (MRSA)
Sexually transmitted diseases, such as Chlamydia
or gonorrhea make it easier for bacteria to get in
and make their way to your heart.
TYPES OF INFECTIVE ENDOCARDITIS
Native valve endocarditis (NVE)
Prosthetic valve endocarditis (PVE)
Intravenous drug abuse endocarditis (IVDA)
50% involve tricuspid valve
Males 20-40 yrs old
Antibiotic therapy is given before surgery is considered
TRICUSPID VALVE REPLACEMENT
Indications:
Right heart failure 2 to severe tricuspid
regurgitation
IE caused by organisms which are difficult
to get rid of
Bacterium (S. Aureus)
Tricuspid valve vegetations (>20mm)
VALVE REPLACEMENT
2 kinds
Artificial (mechanical)
Metal/plastic
Require lifelong dependency of
medication
Last longer
Natural (biologic)
Donors
Dont require anticoagulant therapy

MEET MS. C
28 yr old white
female
D.O.B 12/ 27/85
Admitted 09/12/13
Ht: 64
Admission Wt: 70
kg
IBW: 61 kg
IBW % = 114%
UBW: 70 kg
UBW% = 100%
BMI= 26.4
overweight


PAST MEDICAL HISTORY
Admitted with fever of 103F and severe
body aches.
Diagnosis: gonorrhea, chlamydia, IV drug
user, hepatitis C, MRSA, tricuspid valve
endocarditis, sepsis, acute renal
insufficiency, anemia, hemoptysis and septic
pulmonary emboli, and respiratory failure.
LABS
Na: 133 L
K: 3.9
Cl: 94 L
BUN: 54 H
Creat: 2.89 H
Glucose: 80
Ca: 7.8
Albumin: 2.7 L
H/H: 7.4/22.6 L
Her BUN/Creatinine are high showing renal
insufficiency due to dehydration, this was
resolved with IV fluids.
MEDICATIONS
Heparin
(anticoagulant)
Fluconazole
(antifungal)
Lasix (diuretic)
Duoneb
Insulin

Metoprolol
(Lopressor)
Protonix
Diprivan
(anesthetic)
Fentanyl
(anesthetic/ pain
reliever)
HOSPITAL COURSE
Respiratory arrest, went to the ICU.
09/30/13 tricuspid valve replacement
all leaflets had vegetation, 50% of the
anterior leaflet had been destroyed.
31 mm St. Jude tissue tricuspid valve
10/10/13 ventilator-dependent respiratory
failure, received a tracheostomy
HOSPITAL COURSE CONT.
A GI consult evaluated PEG placement,
PEG tube placed.
10/25/13 peritonitis, intra-abdominal
abscesses, and a dislodged PEG tube. She
returns to ICU with a G-tube.
10/28/13 family decides comfort care
hospice is best.
NUTRITION
S: Patient intubated, sedated, on ventilator.
O: Current Enteral Nutrition: Jevity 1.2 @ 70 ml/hr
Enteral Nutrition Providing:
2016 kcalories (29 kcal/kg body weight)
93 gm protein (1.5 gm/kg IBW)
1370 ml free water
Meds: Insulin, Lasix

A: Nutrition Diagnosis continues: Inadequate po intake related to
intubation status as evidenced by enteral nutrition support.
Current rate of TF meets estimated nutrient needs.

P:
Continue TF Jevity 1.2 @ 70 ml/hr
Follow-up in 3-4 days

CONCLUSION
The overall prognosis for IE is good
Uncomplicated cases are successfully
treated without surgery needed in 80% of
patients, 20% will end up needing surgery.
10% mortality rate in hospital.
Ms. C was in the hospital for 47 days,
unfortunately her case was extremely
complicated leading to inpatient hospice
care.