Bedside Grand Round – 1 Feb 2023

On the 1^st February 2023, JJJ Cardiothoracic surgeons hosted the second bedside grand round for the year at Midlands Medical Centre, CICU.

The case discussed today by Dr James Fulton, is Mr. N 71 years old, who had multiple admissions of acute exacerbations of Chronic Obstructive Airway disease in 2022, he was admitted for long periods at a time. He has a history of heavy smoking (40/day for 40 years). Most of his symptoms were initially thought to be related to his smoking induced lung disease. He was known to have unimportant mitral valve regurgitation in 2022. He was readmitted `Jan 2023 with class 3 symptoms, acute onset shortness of breath, bronchospasm and was thought to of had an acute exacerbation of his COPD. Echocardiography on this admission showed severe mitral valve regurgitation, the mitral valve appeared myxomatous and redundant. He was noted to have chordal rupture of the posterior leaflet with left atrial dilatation indicating long standing mitral valve regurgitation.

(See P2 on diagram below)

He was worked up for surgery including coronary angiography which was normal. He developed an acute pyrexial illness with cardiac and renal decompensation and had positive blood cultures for staphylococcus aureus. Appropriate intravenous antibiotics were commenced, and a presumptive diagnosis of native valve INFECTIVE ENDOCARDITIS was made. He was treated for 2 weeks with intravenous antibiotics of Cloxacillin and Gentamycin. He then underwent mitral valve surgery. At the time of surgery, the mitral valve was found to be repairable. A successful mitral valve repair was carried out and his left atrial appendage was excluded. The advantages of repair over replacement were highlighted.

Today is day 2 post op, he will complete a further 2-week course of antibiotics. The patient has been extubated, currently has no inotropes and is making a good recovery.

JJJ’s clinical programs co-ordinator, René Gomes then held a discussion around the importance of CLABSI prevention.

Guidelines discussed-

1. Hand hygiene
2. Maximal barrier precautions on insertion
3. Chlorhexidine skin antisepsis
4. Optimal catheter insertion site selected after weighing infection risk (avoid femoral, subclavian lowest risk of infection)
5. Daily review of necessity for line prompt removal of unnecessary lines
6. Line secured
7. Dressing is clean and intact (marked with date changed, Tegaderm CHG can last 7 days without changing, please change if oozing extends past chlorhexidine patch only)
8. Scrubbing the hub if used with alcohol swab for minimum 15 seconds
9. Changing of intravenous administration lines every 72 hours, daily for blood products or fat emulsions.

Thank you to Midlands for the welcoming hospitality and superb attendance for this event.