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Infective endocarditis and non-cardiac surgery

January 19, 2015

You are on call and asked to see an inpatient consult.

The patient is a 60 yo man who was admitted to cardiology with infective endocarditis.  Strep bovis was initially cultured from the blood and he is on IV antibiotics.

What specific disease is associated with Strep bovis endocarditis? What additional tests should be done?

GI was consulted for colonoscopy, and a large rectosigmoid lesion was found.  General Surgery was then consulted, and they want to do a hemicolectomy.

What other investigations do you want? What are you concerned about with infective endocarditis?

TTE shows a large pseudoaneurysm in the aortic root with colour flow within the abscess.  There is some thickening of the mitral leaflets.  LV function is preserved.

CT scans shows the lesion in the rectosigmoid junction.  CT brain also shows a subacute infarct.

Lab work showed a moderate hyponatremia (Na 125).

The patient is hemodynamically stable, afebrile, and on broad spectrum IV antibiotics.  There is a 2/6 systolic ejection murmur. No Osler’s nodes or Janeway lesions were found. There is no neurological findings and the patient does not ever recall having had a stroke.

The patient is very persistent on having the colon cancer removed, and that the heart valve issue is “getting better” with antibiotics. The general surgeons want to know if they can proceed.

What is your plan?

Your anesthesia consult includes a recommendation for the patient to be evaluated by Cardiac Surgery for consideration of endocarditis repair/replacement.

The decision to treat the IE with antibiotics vs. operate early is a difficult one.  One recent study looked at early valve surgery vs. conventional treatment showed some benefit with a composite endpoint.

Conclusion:

The patient decides to undergo hemicolectomy / Hartmann’s procedure first, without replacing the valve.

There are no right or wrong answers. Please tag all replies with #gasclass.

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Categories: Anaesthesia, Cardiac, Preop
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