Pericarditis

pericardiris

1. PERICARDITIS Mrs.D.Melba Sahaya Sweety M.Sc Nursing GIMSAR

2. INTRODUCTION The pericardium is a fibroelastic sac made up of visceral and parietal layers separated by a (potential) space, the pericardial cavity. In healthy individuals, the pericardial cavity contains 15 to 50 mL of an ultrafiltrate of plasma. Pericarditis  is swelling and irritation of the pericardium, the thin saclike membrane surrounding your heart.  The sharp chest pain associated with pericarditis occurs when the irritated layers of the pericardium rub against each other.

3. Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart Pericarditis is inflammation of the pericardium, a sac-like structure with two thin layers of tissue that surround the heart to hold it in place and help it work. DEFINITION

4.   Pericarditis occurs after pericardectomy in 5 % - 30% patients. 1% - 3 % of cases develop after 10 days to 2 months after acute myocardial infarction.  In the developed world, viruses are believed to be the cause of about 85% of cases. In the developing world tuberculosis is a common cause but it is rare in the developed world. INCIDENCE

5.  Idiopathic Infections A.Viral - Coxsackievirus , echovirus, adenovirus, EBV, CMV, influenza, varicella , rubella, HIV, hepatitis B, mumps, parvovirus B19, B. Bacterial - Staphylococcus, Streptococcus, pneumococcus , Haemophilus , Neisseria ( gonorrhoeae or meningitidis ), Chlamydia ( psittaci or trachomatis ), Legionella , tuberculosis, Salmonella, Lyme disease . ETIOLOGY

6. C. Mycoplasma D. Fungal - Histoplasmosis , aspergillosis , blastomycosis , coccidiodomycosis , actinomycosis , nocardia , candida E. Parasitic - Echinococcus , amebiasis , toxoplasmosis F. Infective endocarditis with valve ring abscess ETIOLOGY

7. 3. Neoplasm A. Metastatic – Lung or breast cancer, Hodgkin's disease, leukemia , melanoma B. Primary – Rhabdomyosarcoma , teratoma,fibroma , lipoma , leiomyoma , angioma C. Paraneoplasm ETIOLOGY

8. 4. Cardiac A. Early infarction pericarditis B. Late postcardiac injury syndrome (Dressler's syndrome) C. Myocarditis D. Dissecting aortic aneurysm ETIOLOGY

9. 5.Autoimmune A. Rheumatic diseases – Including lupus, rheumatoid arthritis, vasculitis , scleroderma, mixed connective disease B. Other – Granulomatosis with polyangiitis (Wegener's), polyarteritis nodosa , sarcoidosis,IBD ( Crohn's , ulcerative colitis), Whipple's Disease, giant cell arteritis,Behcet's disease,rheumatic fever ETIOLOGY

10. 6.Drugs Pericarditis can also develop from a drug-induced lupus syndrome caused by medications including procainamide , hydralazine , methyldopa, isoniazid , mesalazine , and reserpine . Doxorubicin: The anthracycline antineoplastic agents, such as doxorubicin and cyclophosphamide , have direct cardiac toxicity and can cause acute pericarditis ETIOLOGY

11. 6.Drugs Penicillin : Penicillin and cromolyn sodium, induce pericarditis through a hypersensitivity reaction Methysergide : Methysergide antimigraine drug belongs to the group of medicines known as ergot alkaloids. It causes constrictive pericarditis through mediastinal fibrosis ETIOLOGY

12. 7. Metabolic A. Hypothyroidism - Primarily pericardial effusion B. Uremia C. Ovarian hyperstimulation syndrome ETIOLOGY

13. Trauma A. Blunt, Penetrating B. Iatrogenic - Catheter and pacemaker perforations, cardiopulmonary resuscitation Radiation ETIOLOGY

14. BASED ON THE SYMPTOMS :- TYPES

15. Constrictive pericarditis Viral pericarditis Purulent pericarditis Tuberculous pericarditis Radiation Pericarditis   TYPES BASED ON THE CAUSES :- Traumatic pericarditis Serous pericarditis   Fiberous pericarditis Hemorrhagic pericarditis Adhesive mediastino pericarditis

16. Constrictive pericarditis When the pericarditis is associated with a thickening or scarring of the pericardial layers, this starts constricting the heart within the thoracic cavity, which in turn limits its effective functioning. This condition is known as constrictive pericarditis . TYPES

17. Viral pericarditis Viruses that cause pericarditis is known as viral pericarditis This kind of pericarditis is simple and can be handled as an outpatient procedure. Tuberculous pericarditis This condition is also seen in a very minor percentage of patients having pulmonary tuberculosis. Some of the developing countries remain the leading risk groups of tuberculous pericarditis . TYPES

18.   Purulent or suppurative pericarditis :- It is due to causative organisms may arise from direct extension, hematogenous seeding, or lymphatic extension, or by direct introduction during cardiotomy . Immunosuppression facilitates this condition. TYPES

19. Radiation Pericarditis This type of pericarditis is caused due to recent mediastinal radiation at any time from weeks to months after the exposure. Traumatic pericarditis Sharp or blunt trauma causes traumatic pericarditis . Invasive cardiac procedures also may give rise to this type of pericarditis , which includes cardiac diagnostic catheterization and electrophysiological ablation procedure. TYPES

20. Serous pericarditis Is usually caused by noninfectious inflammation such as occurs in rheumatoid arthritis and systemic lupus erythematosus . TYPES

21. Fibrous and serofibrinous pericarditis It represent the same basic process and are the most frequent type of pericarditis . Common causes include acute myocardial infarction (MI), postinfarction (including Dressler syndrome), uremia , radiation and trauma TYPES

22. Hemorrhagic pericarditis It involves blood mixed with a fibrinous or suppurative effusion, and it is most commonly caused by tuberculosis or direct neoplastic invasion. This condition can also occur in severe bacterial infections. Hemorrhagic pericarditis is common after cardiac surgery and may cause tamponade . The clinical significance is similar to suppurative pericarditis TYPES

23. Chronic pericarditis Adhesive mediastino pericarditis Is a reaction that usually follows suppurative or caseous pericarditis , cardiac surgery, or irradiation. This condition is rarely caused by a simple fibrinous exudate . The pericardial potential space is obliterated, and adhesion of the external surface of the parietal layer to surrounding structures occurs. TYPES

24. when microbes are inhaled or ingested, they migrate to myocardium and cause inflammation PATHOPHYSIOLOGY Accumulation of fluid in the pericardial sac called pericardial effusion. Compression of the heart Increased Intra Pericardial pressure Decreased ventricular filling and emptying Increased venous pressure De creased cardiac output De creased Arterial pressure Cardiac Failure

25. CLINICAL MANIFESTATION Chest pain beneath the clavicle, in the neck region worsens with deep inspiration, relieved with sitting or leaning forward.It is the cardinal sign of pericarditis Mild fever, chills and night sweats. Malaise, myalgia Dyspnea due to constriction or cardiac tamponade Palpitation

26. Ewart sign: Ewart's sign is a set of findings on physical examination in people with large collections of fluid around their heart (pericardial effusions).Dullness to percussion ("woody" in quality), egophony , and bronchial breath sounds may be appreciated at the inferior angle of the left scapula when the effusion is large enough to compress the left lower lobe of the lung •  Beck’s triad: falling BP; rising JVP; CLINICAL MANIFESTATION

27. In Constrictive Pericarditis : Pedal edema Hepatomegaly Ascites JVD Kussmaul’s sign Pericardial knock (early diastolic sound) heard at the apex Usually - no friction rub CLINICAL MANIFESTATION

28. History Collection- regarding the etiological factors Physical Examination- check for Ewart’s sign,pedal dema , hepatomegaly JVD etc.. CBC- Increased WBC, ESR, and CRP Cardiac Enzymes- increased but not as much as with MI ECG- diffuse St elevation *important to different from MI changes (acute pericarditis ) DIAGNOSTIC EVALUATION

29. Echo- for heart wall movement Chest X ray-   shows an enlarged heart and pericardial calcification Doppler imaging- to measure the amount of blood flow through your arteries and veins DIAGNOSTIC EVALUATION

30. CT Scan   to look for calcium in the pericardium, fluid, inflammation, tumors and disease of the areas around the heart. Iodine dye is used during the test to get more information about the inflammation . Pericardiocentesis fluid- determine cause; treat cardiac tamponade DIAGNOSTIC EVALUATION

31. Cardiac MRI to check for extra fluid in the pericardium, pericardial inflammation or thickening, or compression of the heart. A contrast agent called gadolinium is used during this highly specialized test. Cardiac catheterization To get information about the filling pressures in the heart. This is used to confirm a diagnosis of constrictive pericarditis . DIAGNOSTIC EVALUATION

32. Cardiac tamponade   Accumulation of pericardial fluid raises intra- pericardial pressure, hence poor ventricular filling and fall in cardiac output.  The drop in blood pressure can cause blurred vision, nausea, confusion, and weakness.  COMPLICATIONS

33. Pericardial effusion. Accumulation of fluid in the pericardial sac. may have symptoms such as:Chest pain or discomfort, Enlargement of the veins of the neck,Fainting,Fast breathing, Increased heart rate,Nausea,Pain in the right upper abdomen,Shortness of breath,Swelling in the arms and legs COMPLICATIONS

34. Chronic effusive pericarditis   It is an uncommon pericardial   syndrome characterized by concomitant tamponade , caused by tense pericardial effusion, and constriction, caused by thevisceral  pericardium.  the symptoms are chest pain, lightheadedness , hiccups, and shortness of breath.  COMPLICATIONS

35. ASA or tylenol Acetaminophen decreases fever and pain , but does not help inflammation.Adult dosing is 2 regular strength (325 mg) every 4 hours or 2 extra-strength (500 mg) every 6 hours. Maximum dose is 4,000 mg per day. Aspirin or NSAIDs  are recommended as first-line therapy for acute pericarditis with gastroprotection . Commonly used NSAID regimens include : Ibuprofen — Depending on the severity of the pericarditis and individual medication response, a dose of 400 to 800 mg of ibuprofen three times daily is usually adequate for symptom relief. Ibuprofen can be the preferred NSAID because of its rare side effects, favorable impact on coronary artery blood flow, and large MEDICAL MANAGEMENT

36. Aspirin — Aspirin can be given at a dose of 750 to 1000 mg every six to eight hours followed by gradual tapering every week for a treatment period of three to four weeks. Corticosteroids Corticosteroids are strong medications that fight inflammation. Your doctor may prescribe a corticosteroid such as prednisone if your symptoms don't get better with other medications, or if symptoms keep returning. Colchicine   anti-inflammatory agent It is recommended as first-line therapy for acute pericarditis as an adjunct to aspirin/NSAID therapy. You should not take this drug if you have liver or kidney disease MEDICAL MANAGEMENT

37. Indomethacin — Indomethacin (NSAID)can be administered at a dose of 50 mg three times daily for one to two weeks followed by slow tapering But commonly it is not rcommended due to its adverse effects Penicillin - for Bacterial infection ACE Inhibitors - relax the blood vessels in the heart and help blood flow more easily • Beta-blockers are avoided because it decreases the strength of ventricular contraction (have a negative inotropic effect)   MEDICAL MANAGEMENT

38. Anticongestive measures such as diuretics And Inotropics agents ( Inotrtropic agents such as milrinone , digoxin , dopamine, and dobutamine are used to increase the force of cardiac contractions.) Anti-anxiety medication ( Alprazolam Diazepam , Estazolam , Flurazepam ) Proton pump inhibitors ( Omeprazole , Pantoprazole )   MEDICAL MANAGEMENT

39. Pericardiocentesis :- is the aspiration of fluid from the pericardial space that surrounds the heart.  SURGICAL MANAGEMENT

40. Pericardial window   a small opening made in the pericardium, may be performed to allow continuous drainage into the chest cavity.  SURGICAL MANAGEMENT

41. Percutaneous balloon pericardiotomy :- is a procedure done to drain excess fluid in the sac around the heart. The procedure uses a long thin tube with a balloon attached. During PBP, a doctor inserts a needle through the chest wall and into the tissue around the heart. Once the needle is inside the pericardium, the doctor removes it and replaces it with a long, thin tube called a catheter. This tube has an inflatable balloon at its tip. Repeated inflation of the balloon creates a small hole or “window” in the pericardium. When the hole is large enough, the doctor removes the catheter and balloon replaces them with a new catheter for final draining. This allows fluid to drain out of the pericardium, which improves heart function. SURGICAL MANAGEMENT

42. Percardiectomy may be necessary to release both ventricles from the constrictive and restrictive inflammation and scarring Pericardiectomy is performed through a median sternotomy , an incision through the breastbone (sternum) in the middle front part of the ribs that allows the surgeon to reach the heart. The surgeon will remove the pericardium from the heart, wire the breastbone and ribs back together and close the incision with stitches . SURGICAL MANAGEMENT

43. Collaboration of oxygen and delivery of analgesic drugs and drug side effects observed. Observation of vital signs. Perform 12 lead ECG, 24 lead if necessary Bed rest with Fowler position / semi- Fowler position client with pillows. Positioning/sit up/lean forward Instruct client to deep breathe or use incentive spirometery every 1 - 2 hours NURSING MANAGEMENT

44. Monitor urine output Prevent complications of immobility Psychological support Monitor the drainage of pericardial fluid Manage the anxiety of the client Provide health teaching regarding the disease condition and its treatment process NURSING MANAGEMENT

45. Ineffective Breathing Pattern related to inflammatory process and decreased lung capacity as evidenced by dyspnea,shortness of breath Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation as evidenced by patient facial expression, forward leaning posture,patient compaint for sharp chest pain Impaired thermoregulation , hyperthermia, related to infection and inflammation as evidenced by Raised temperature NURSING DIAGNOSIS

46. Ineffective tissue perfusion related to decrease blood flow as evidenced but delayed capillary refilling,pale mucous membrane Activity Intolerance related to imbalance between oxygen supply and metabolic as manifested by fatigue,decreased activity of daily living Anxiety related to therapeutic interventions and uncertainty of prognosis as manifested by Facial flushing , Restlessness , Voice quivering NURSING DIAGNOSIS

47. Risk for Decreased Cardiac Output related to structural abnormalities of the heart Risk for cardiogenic shock related to decreased cardiac output . NURSING DIAGNOSIS