UREMIC

PERICARDITIS
Anamnesis

A male patient, 65 years old, is hospitalized in emergency for:

- 2-day dyspnea
- chest pain relieved by leaning forward and worsened when taking a big
breath
Anamnesis

Pathological personal history:

 End stage chronic kidney on the background of an infectious

glomerulonephritis 5 years ago

 Elevated blood pressure values

Anamnesis

 retired , smoking;
denies chronic consumption of alcohol.

 the history of the disease:

- we present the case of a male patient in the age of 65 known with
hypertension, with a history of a chronic end-stage kidney disease, who is
hospitalized in emergency because of dyspnea and chest pain
Anamnesis

The last treatment at home :

- Antihypertensive treatment: Amlodipine 5 mg / day etand Ramipril 2.5 mg /

day

- Antiplatelet treatment: Aspirin complicated 100 mg / day

 CLINICAL EXAMINATION

 BMI 30 Kg / m2
 BP 90/ 60 mmHg, HR 100 / min, SaO2 = 95%, dyspnea, polypnea
 muffled heart sounds
 paradoxical pulse , turgescence of jugular veins
Laboratory
• WBC 9000 / mmc • CKMB 35 IU
• RBC 4.4 mil / mmc • TGO 30 IU; TGP 32 UI; LDH 350 IU
• Hb 10 wt% • Urea 128 mg%
• Ht 28 % • creatinine 5, 4 mg%
• platelets 171000/ mmc • Cl creatinine 15 ml / min
• INR = 1 • K 4.5 mmol / l
• fibrinogen 700 mg% • Total cholesterol 256 mg / dl
• CRP 25 mg / dl • HDL 23 mg / dl
• VSH 100 mm / h • LDL 185 mg / dl
• glucose 110 mg% • triglycerides 90 mg / dl
ECG AT ADMISSION
THORACIC RADIOGRAPH

Enlargement of the
cardiac
silhouette (cardiothoracic
ratio (CTR) >50%)
“ water bottle sign"
 THORACIC RADIOGRAPH
Enlargement of the cardiac
silhouette (cardiothoracic ratio (CTR)
>50%)
“ water bottle sign"
 Echocardiography

- the larger the echo-fre space, the higher the amount of liquid; In the case of large
pericardial effusions, the appearance of a "swinging heart" may occur.
Echocardiography
 Echocardiography

Undilated left ventricle with normal global and segmental systolic function
(FE vol 55%), with massive pericardial fluid arranged circumferentially around
the heart (appearance of "swinging heart")

Aspects characteristic of large pericardial effusions: ample type movement

swinging heart balance
Echocardiography
Echocardiography
Echocardiography
Echocardiography
COMPUTER TOMOGRAPHY
 DIAGNOSTIC

• HEART TAMPONADE

• UREMIC PERICARDITIS

• END STAGE CHRONIC KYDNEY DESEASE

• ANEMIC SYNDROME
WHAT IS NEXT…..?
Pericardiocentesis / drainage
THERAPY

- PERICARDIOCENTESIS
- DIALYSIS AFTER HEMODYNAMIC STABILIZATION
 Pericarditis

I. GENERAL DATA

II. PATHOPHYSIOLOGY

III. DIAGNOSTIC

IV. MANAGEMENT
ANATOMY OF THE CORD
Pulmonary
valve
Aorta

Right pulmonary artery Left pulmonary

artery
Upper vena cava Pulmonary artery
trunk
Straight
pulmonary veins Left atrium
Aortic valve
Right atrium
Fosa ovalis Mitral valve

Papillary muscles
Tricuspid valve Left ventricle

Inferior vena cava

 pericarditis

Pericardial cavity
Pericardium = thin shell,
consisting of two membranes: endocarditis
● external fibrous = parietal
pericardium myocardium
● internal - the visceral myocardium
pericardium, which covers the endocarditis
heart.
Visceral pericardium
Parietal pericardium
The two membranes delimit the
pericardial cavity, which normally
contains about 50 ml of pericardial
fluid, with an electrolyte
composition similar to that of
blood, but with less protein.
 DEFINITION
● Pericarditis = inflammatory diseases of the pericardium, occurring
alone or in other heart or systemic conditions.
 Etiology
Etiology

● viral infection = the most common cause of pericarditis in

childhood
● acute rheumatoid arthritis = common in certain parts of the world
● bacterial infection (purulent pericarditis): S. aureus,
Streptococcus pneumoniae, Haemophilus influenzae, Neisseria
meningitidis and streptococci
● tuberculosis
 Etiology
HEART TAMPONADE - CAUSES

● after heart surgery

● collagen disease (Ex. rheumatoid arthritis)
● complication of cancer or therapy irradiated
● uremia (pericarditis uremiccomplicated) - rare
I. GENERAL DATA

II. Pathophysiology

III. DIAGNOSTIC

IV. MANAGEMENT
Pathophysiology

● surfaces parietal + visceral of

pericardium = inflamed

● Pericardial effusion may be

serofibrinos / hemorrhagic /
purulent
Pathophysiology

● symptoms+ signs are determineded by 2 factors:

1. speed of accumulation of the liquid

2. myocardial competence

● A rapid accumulation of a large amount of liquid pericardial

→ hemodinamic instability

● A slow accumulation of a amounts relatively small and of liquid

→ good clinical tolerance
BECK’S TRIAD = MUFFLED heart sounds (liquid)
+ turgescent jugular veins
+ hypotension
Compensatory mechanisms:
- systemic and pulmonary venous
constriction to improve filling of
diastole
- increase in systemic vascular
resistance for growth blood
pressure
- tachycardia to improve cardiac
output
I. GENERAL DATA

II. Pathophysiology

III. DIAGNOSTIC

IV. MANAGEMENT
● the patient can have lately the presence of upper respiratory tract
infections in anamnesis

● precordial pain (deaf /stab) with irradiance occasional into the shoulder
and neck; the pain can be relieved by leaning forward and can be
aggravated by lying on your back or deep inspiration
 CLINICAL EXAM

● the heart is quiet and hypodynamic in the presence of a large amount

of pericardial fluid
● the paradoxically pulse it is characteristic for tamponade
● the heart murmurs are usually absente
● children with purulent pericarditis show septic fever, tachycardia,
angina and dyspnoea

● may be present stamponade: muffled heart sounds, tachycardia,

paradoxical puls, hepatomegaly, venous distension, hypotension
complicated with peripheral vasoconstriction
 PARACLINICAL EXAMINATIONS

● Chest X-ray
- enlargement of heart silhouette
- specific shape of the heart in wide pericardial effusions
- tamponade may also occur without dilation in case of rapid onset
PARACLINICAL EXAMINATIONS

● Electrocardiography
- low voltage of QRS (Inconstant)
- changes over time
- initial ST-segment elevation
- return of the ST segment to the isoelectric line with T-wave reversal (2-
4 weeks from onset)
- the pericardial fluid is first identified posteriorly; the presence of fluid in
the posterior position without being present and anterior suggests limited
pericarditis
● echocardiography
- the larger the echo-fre space, the higher the amount of liquid; In the
case of large pericardial effusions, the appearance of a "swinging
heart" may occur.
I. GENERAL DATA

II. Pathophysiology

III. DIAGNOSTIC

IV. MANAGEMENT
 TREATMENT

● Pericardiocentesis/Surgical
drainage

● Study of the pericardial fluid

PERICARDIOCENTESIS

● position - the patient should be positioned at 40-60 degrees - to maximize fluid

drainage
● continuous monitoring - blood pressure, electrocardiogram, clinical
appearance, patent venous line
● echocardiography to choose the puncture site
● the puncture site is disinfected with iodinated antiseptic solution and the area is
shaved and anesthetized with lidocaine (a local anesthetic)
● a long needle is usually inserted subxiphoid (or in place of maximum fluid
accumulation) under imaging guidance until the needle reaches the pericardium
 PERICARDIOCENTESIS

● the insertion of the needle is done under continuous aspiration, the aspiration
of liquid confirming the correct placement at the level of the pericardial sac
● if the procedure is performed for diagnostic purposes, the aspirated fluid is
collected in special tubes and sent to the laboratory for analysis (cell analysis for
cancer cells in case of malignant effusion, identification of Koch's bacillus in case
of TB, etc.)
● if the procedure is performed for therapeutic purposes (cardiac tamponade) the
most complete aspiration of the fluid is practiced; sometimes a pericardial
catheter can be attached and fixed in a position that allows continuous drainage
● When removing the needle, apply pressure to the puncture site for five minutes
to stop bleeding, and then the area is bandaged.
 TREATMENT

What are the risks of this procedure?

Pericardiocentesis is an invasive procedure so it is associated with risks.

Complications are possible, but have become rarer due to imaging guidance that
has significantly improved the old "blind" technique. Possible risks associated
with pericardocentesis are:
- Myocardial puncture (heart muscle)
- Puncture of a coronary artery (which brings blood to the heart muscle)
- Myocardial infarction
- Needle-induced arrhythmias
- Pneumopericard
- Pericarditis (infection of the pericardial membranes)
- Accidental puncture of the stomach, lungs or liver.
 TREATMENT

● is required surgical drainage

when the liquid is purulent
(followed by IV antibiotic therapy for
4 - 6 weeks)
 TREATMENT

● There is no specific treatment for viral pericarditis

● Treatment focuses on the underlying disease itself

● salicylates - for precordial pain and pericarditis rheumatic or

nonbacterial

● Therapy with corticosteroids - severe rheumatic carditis

 TREATMENT

● NSAIDs drugs
- ibuprofen 300-800 mg every 6-8 hours X days or weeks
- Aspirin 800 mg every 6-8 hours time of 7-10 days, followed of decrease
gradual of dose

● corticosteroid - administered only into the case answer slow or lack

answer the NSAID →cycle short of 60-80 mg /day prednisone, divided
into the 4-6 sockets, dose decrease progressive, into the steps of by 10
mg /day every 5 days

● colchicine - improving pain and prevention recurrence patients with

pericarditis acute. - 0.5 mg X 2 / day - alone or associated NSAIDs into
the Episode initial of pericarditis acute and for prevention recurrence
Thank you!