Appendectomy for an adult with cyanotic congenital heart disease

Few patients with cyanotic congenital heart disease reach adulthood without a cardiac operation. The prognosis for ''unrepaired'' pulmonary atresia with ventricular septal defect is approximately 8% in the 1st decade of age. Consequently, the number of adults with this particular heart disease (unrepaired) who are expected to need a non-cardiac surgery is extremely low. General anesthesia may aggravate the preexisting right to left shunt and lead to persistent severe hypoxemia. The goal of anesthetic management should be to maintain intravascular volume. Systemic and pulmonary vascular resistance changes, such as might occur due to acidosis, hypothermia, hypercarbia or excessive airway pressures, should be avoided. Maintenance of preload, contractility and sinus rhythm is of major importance. The complex pathophysiology of such heart disease, in addition to the circumstances of emergency operation, exacerbate the total anesthetic risk. We present here a rare case of an acute appendectomy with successful outcome in an adult with pulmonary atresia and ventricular septal defect.

Antibiotic prophylaxis for infective endocarditis

Dentists routinely treat patients who require antibiotic prophylaxis for infective endocarditis. In this article, the signs and symptoms of infective endocarditis as well as the hemodynamic events involved are discussed. Furthermore the rationale for the choice of antibiotic, the type of patient requiring prophylaxis, and the different regimes as recommended by the American Heart Association are presented.

[Chemoprophylaxis of endocarditis in dental practice]

The mortality of patients with bacterial endocarditis is still high in spite of great progress made in cardiac surgery. Dental diseases and their treatment are discussed as a cause for endocarditis induced by Streptococcus viridanz. Thus the dentist plays an important role in the prophylaxis of bacterial endocarditis in cardiac risk patients.

Therapeutic considerations in special patients

Careful attention to patients' histories and their medical problems and consultation with their physicians should provide sound bases for selection of drugs. Antibiotic prophylaxis for patients with cardiovascular disorders is described for American Heart Association standards, but for other indications sound judgment based on the principles of antibiotic prophylaxis must be the rule. Patients with end-stage renal disease and severe liver impairment may be at risk with certain drugs. The most critical time for consideration of use of drugs during pregnancy is the first trimester. However, careful selection of drugs for use during the balance of the term can reduce the risk of harm to the mother and fetus.

Principles of anti-infective therapy

Antimicrobial drugs, along with competent surgical procedures, provide an effective means for restoration of oral health. In dentistry, antibiotics are indicated for either treatment of acute infections or for prophylactic coverage of patients at risk for developing bacterial endocarditis or other infections as the result of bacteremia caused by dental procedures. Whenever possible, a bactericidal agent is preferred because of greater effectiveness and less reliance on host defense mechanisms. For maximal effectiveness of antibiotic therapy of orodental infections, several factors must be evaluated in choosing an antibiotic: (1) antibacterial spectrum and specificity of the agent; (2) degree of bacterial resistance reported for the antibiotic; (3) concentrations achieved at various sites; (4) age, type, and extent of infection; and (5) various host factors.

Antibiotic prophylaxis of subacute bacterial endocarditis for adult patients by dentists in Dade County, Florida

To determine compliance with 1977 American Heart Association (AHA) recommendations for antibiotic prophylaxis (AbP) of subacute bacterial endocarditis (SBE), we mailed a questionnaire to 1019 licensed dentists from Dade County, Florida. Of the 614 practicing dentists who responded, 97.7% believe that AbP prevents SBE and 94.2% always obtain a cardiac history from new patients. AbP is given to patients with known rheumatic or other valvular heart disease by 98.9% of responders and to patients with known prosthetic heart valves by 81.5%. The majority of dentists prescribe the antibiotics recommended by the AHA, but the dosage, route, frequency and duration of therapy are usually not according to AHA guidelines. AbP completely consistent with these guidelines is prescribed by 15.4% of dentists for patients with heart disease and by only 6.7% of dentists for patients with prosthetic heart valves. The AHA recommends parenteral AbP for most patients with prosthetic heart valves, but approximately 80% of dentists use only oral agents for these patients. We conclude that most dental patients predisposed to SBE receive AbP, but not in accordance with AHA guidelines. The widest deviation occurs among patients with prosthetic heart valves.

Use of antibiotics in the outpatient setting

Antibiotics with small but definable mortality, such as chloramphenicol, should not be used when safer drugs will suffice. Antibiotics with a low (1 to 5 per cent) morbidity should not be used when safer drugs are available. Therefore, cleocin, minocycline, or oral erythromycin estolate should rarely be used and regular erythromycin base is almost always preferable. Fever should not be treated with antibiotics since they are not antipyretics. "Colds" should not be treated with antibiotics, but antibiotics should be administered to patients with a history of chronic bronchitis, sinusitis, and recurrent otitis as soon as any symptoms begin. Intramuscular antibiotics should not be given except for benzathine penicillin. Use placebos instead of antibiotics when the patient's psyche demands an intramuscular injection. Make certain that the needle, syringe, and solution are sterile. Agents other than penicillin or cephalosporins should be used in patients with a definite history of penicillin allergy. Combination antibiotics or broad spectrum antibiotics like cephelosporins or tetracyclines should not be used when narrow spectrum antibiotics of known efficacy are available for specific syndromes such as streptococcal pharyngitis.