Chapter 14, 15, 16: Vaccines, Anaesthesia, Poisoning COPY Flashcards
Antibodies of human origin are termed as what?
Immunoglobulins
What are the two types of human immunoglobulin?
Normal
Disease- specific
Normal immunoglobulin is available from regional Public health labs for the control and outbreak of what 3 conditions?
For any other indications, where should the immunoglobulins be purchased from?
Hepatitis A
Measles
Rubella
All other indications- purchased from the manufacturer
What disease-specific immunoglobulin would you not be able to get from public health labs?
Tetanus - get this from manufacturer, hospital pharmacies
True or false:
Hepatitis B immunoglobulin required by transplant centres should be obtained commercially
True
How is normal immunoglobulin administered for protection of conditions?
Intramuscular injection
What is normal immunoglobulin?
Non-specific
Has antibodies for conditions such as measles, mumps, rubella, Hepatitis A and other viruses that would affect the general population
After how long of an injection of normal immunoglobulin are you protected?
Immediately
Normal immunglobulin for protection is administered via IM. For what indication would you give it IV?
Replacement therapy
Is immunoglobulin recommended for Hep A protection in travellers?
No
Hep A vaccine by itself is recommended for individuals visiting high risk areas
Public Health England recommends normal immunoglobulin in addition to Hep A vaccine in which individuals?
- If in close contact with Hep A positive people
- > 60 years
- Chronic liver disease/Hep B or C positive
- HIV infection
In non-immune patients who have had exposure to measles can be given the MMR vaccine, although this is not suitable for prophylaxis as the effect is too slow.
In what patient groups would this be inappropriate for, and what should be given instead?
IM normal immunoglobulin for the following patient groups:
Non-immune pregnant women (if clinically appropriate- it will not prevent infection but may prevent clinical attack)
Infants under 9 months
True or false:
After a pregnant woman is exposed to rubella, it is recommended they have IM immunoglobulin to prevent infection
No
It is not recommended and it does not prevent infection in non-immune patients. However, it may reduce the risk of a clinical attack so may reduce the risk to the foetus
It should only be used if termination of pregnancy is not possible, and should be given as soon after the exposure
Risk of rubella transmission in pregnant women to the foetus is greatest in the first how many weeks of gestation?
Great risk in the first 11 weeks
Females of childbearing age should avoid getting pregnant until how long after getting the MMR vaccine?
At least 4 weeks
True or false:
Pregnant women should have the MMR vaccine
False
Live vaccines should not be administered routinely to pregnant women because of the theoretical risk of fetal infection but where there is a significant risk of exposure to disease
If a patient requires rabies prophylaxis after a bite, where should the rabies immunglobulin be administered?
Bite should be washed with soapy water
All of the dose should be injected around the site of the wound; if this is difficult or the wound has completely healed it can be given in the thigh (remote from the site used for vaccination).
If a patient is bitten in a high risk rabies area, what should happen?
Bite should be washed with soapy water
Specific rabies immunoglobulin should be injected into site of wound when possible (if not, thigh)
Rabies vaccine should also be given IM at a different site
How do you manage tetanus prone wounds?
Tetanus immunoglobulin should be used
Wound cleansing
Antibacterial prophylaxis if appropriate (Ben Pen, co-amox, or metronidazole)
Tetanus vaccine
How do you treat established cases of tetanus?
Tetanus immunoglobulin
Metronidazole
Wound cleansing
Varicella-zoster immunoglobulin is recommended in what patient groups?
Increased risk of severe infection in those who have few/no antibodies to the virus:
Neonates, pregnant women, immunosuppressed
In immunocompromised patients on long term antiviral prophylaxis, if they are exposed to the virus, what is the recommendation regarding their antiviral prophylaxis?
Increase the dose temporarily
Immunosuppressed patients receiving regular intravenous immunoglobulin replacement therapy only require varicella-zoster immunoglobulin if the most recent dose was administered more than how many weeks before exposure?
3 weeks
What is the anti-D (Rho) immunoglobulin used for?
In rhesus-negative pregnant women to prevent sensitisation if e.g. gives birth to a rhesus-positive baby
Is the MMR vaccine live or inactivated?
Live
Is the BCG vaccine live or inactivated?
Live
Is the influenza vaccine live or inactivated?
Inactivated
Are live or inactivated vaccines more likely to require booster injections?
Inactivated
Vaccination in HIV depends on their immunity status, however there are 3 vaccines that should always be avoided. What are these?
BCG
Typhoid
Yellow fever
What vaccines are recommended in asplenic patients?
Influenza
Pneumococcal
Haemophilus influenza type B with meningococcal type C
Meniningococcal (B and ACWY)
From what age is the influenza vaccine recommended in adults?
65 years
From what age is the pneumococcal vaccine recommended in adults?
65 years
From what age is the varicella-zoster vaccine recommended in adults?
70 years
At 80 years, they are no longer eligible
How is the cholera vaccine given?
Orally
How long does the diphtheria vaccine last?
10 years
A Hep A booster dose is given how long after the initial dose?
6-12 months after
Primary immunisation of Hep B requires how many doses?
3
HPV vaccination is how many doses if the first dose is given before 15 years of age?
What time frame?
2
Second dose to be given 6-24 months after the initial one
HPV vaccination is how many doses if the first dose is given after 15 years of age?
Within what time frame?
3
All in the space of a 12 month period
What are the ideal months for influenza vaccination?
Between September and early November
True or false:
People with diabetes are recommended to get the flu vaccine
True
True or false:
Morbidly obese patients are recommended to get the flu vaccine
True
What is the MMR vaccination regimen in children?
2 doses
1st dose at 1 year of age
2nd dose at 3 years 4 months (before starting school)
Menningococcal vaccination is not recommended after what age?
25 years
Pertussis vaccine is prophylaxis against what condition?
Whooping cough
What book can you refer to if you need advice of immunisation against infectious diseases?
Green Book
Is the rabies vaccine indicated in pregnancy?
Yes if there is substantial risk of exposure to rabies and rapid access to post-exposure prophylaxis is likely to be limited.
The rotavirus vaccine is given via what formulation?
Oral suspension
For tetanus prone wounds, what antibacterial prophylaxis options are there/
Ben Pen, co-amox or metronidazole
Typhoid vaccine comes in what 2 formulations?
Oral capsule
IM injection
How long does the typhoid vaccine last for?
However, how often should you have a booster if typhoid risk continues?
Lasts for 10 years
Booster every 3 years if risk continues
How long does the yellow fever vaccine last?
10 years is the accepted time period
However probably lasts for life
In areas where sanitation is poor, good food hygiene is important to prevent what 4 conditions?
Hepatitis A
Typhoid
Cholera
Other diarrhoea diseases
What website can healthcare professionals and travellers go on to find the latest information on immunisation whilst travelling?
Nathnac
What is the MHRA warning regarding vaccines?
Reports of death in neonates receiving live vaccines following exposure to TNF-a
IM vaccines should not be given to what group of patients?
What is the alternative route of administration that should be done in these patients?
Those with bleeding disorders e.g. thrombocytopenia, haemophilia
Deep subcut is an alternative
What is the advice regarding a patient needing MMR and yellow fever vaccine?
MMR vaccine should not be administered on the same day as yellow fever vaccine; there should be a 4-week minimum interval between the vaccines
What is the advice regarding a patient needing MMR and varicella-zoster vaccine?
MMR and varicella-zoster vaccine can be given on the same day or separated by a 4-week minimum interval.
What is the green book advice regarding immunisation in children born to mothers receiving immunosuppressant biological therapy?
Live vaccines should be delayed until 6 months of age
So not eligible to receive rotavirus then
What is the advice regarding pregnant women receiving live vaccines?
Should not happen due to risk of foetal infection
Should not travel to high risk areas but if this is not possible, the vaccine must be given as the benefit outweighs the risk
What is the risk of patients with adrenal atrophy (resulting from long-term corticosteroids) undergoing surgery?
How is this avoided?
Fall in blood pressure unless corticosteroid cover is provided during anaesthesia and in the immediate post-op period
What do you need to consider in patients undergoing surgery who are on MAOIs?
Interactions with drugs used in surgery e.g. pethidine
TCAs don’t need to be stopped for surgery, but what is the risk associated with these during the surgical period?
Risk of arrhythmias and hypotension
NB - there may be dangerous interactions with vasodilator drugs
When should lithium be stopped before major surgery?
24 hours before
For minor surgery, how are patients on lithium managed?
Continue lithium at normal dose but monitor fluid and electrolytes
Why would potassium sparing diuretics need to be stopped before surgery?
Hyperkalaemia may develop if renal perfusion is impaired or if there is tissue damage
How are patients on potassium sparing diuretics managed for surgery?
Stop it the morning of surgery
How are patients on ACEi and ARBs managed for surgery?
Why?
Discontinue 24 hours before surgery
Severe hypotension can occur after induction of anaesthesia
Aspiration of gastric contents can be a complication of anaesthesia, especially in cases like emergency surgery. This can also be the case in patients with GORD / delayed gastric emptying.
What is done to prevent this?
Prophylaxis against acid aspiration - H2 antagonist orally 1-2 hours before surgery
What do you need to ensure in patients receiving neuromuscular blocking drugs (relaxes diaphragm, abdomen, vocal cords) during surgery?
Should always have their respiration assisted/controlled until the drug has been inactivated or antagonised
What is used to reverse the effects of non-depolarising neuromuscular blocking drugs?
Anticholinesterases - neostigmine
When adrenaline is being administered with a local anaesthetic, should a low or high concentration of adrenaline be used?
Low concentration (no more than 1 in 200,000) - total dose should not exceed 500 micrograms
Do local anaesthetics cause dilation or constriction of blood vessels?
Dilation
Why is adrenaline added to local anasethetic?
What is the risk?
Diminishes local blood flow, slowing the rate of absorption and thereby prolonging the anaesthetic effect.
The risk is ischaemic necrosis so should not be given in digits (toes and fingers) or appendages
Local anaesthetic with adrenaline can help prolong the anaesthetic by decreasing blood flow around the area. In what patient groups would you not want to give this with adrenaline?
In patients with severe hypertension or unstable cardiac rhythm
What is used in lidocaine toxicity?
Intralipid
What is used for benzodiazepine toxicity?
Flumazenil
What is used for digoxin toxicity?
Digoxin-specific antibody
What is used for heparin toxicity?
Protamine sulphate
What is used for opioid toxicity?
Naloxone
What is used for paracetamol toxicity?
Acetylcysteine
What is the MHRA advice surrounding the use of acetylcysteine?
Reminder for possible need to continue treatment even after the recommended 3 dose regimen over 21 hours
This is on an individual patient case-by-case basis
What two places can you find information on poisoning?
Toxbase
UK National Poisons Information Service
Within how much time of poisoning should activated charcoal ideally be taken?
Within 1 hour
Activated charcoal should not be used in the poisoning of what substances?
Petroleum distillates, corrosive substances, alcohols, malathion, cyanides and metal salts including iron and lithium salts
What is the treatment of choice for severe aspirin poisoning?
Haemodialysis
In opioid poisoning, are the patient’s pupils pinpoint or dilated?
Pinpoint
What is the disadvantage of naloxone administration in opioid poisoning?
Has a shorter duration of action of many opioids so may require repeated doses
Can however be given via continuous infusion
When would you consider the use of activated charcoal in paracetamol overdose?
If paracetamol in excess of 150 mg/kg is thought to have been ingested within the previous hour.
In what situations would you give acetylcysteine in paracetamol overdose?
- If on the treatment line on the paracetamol overdose graph
- Who present 8–24 hours after taking an acute overdose of more than 150 mg/kg of paracetamol
- Staggered overdose if ingested more than 150mg/kg, if patient’s risk of toxicity is uncertain
- Patients with features of hepatic injury, jaundice
When is a paracetamol overdose classed as staggered?
If they have taken a toxic dose over more than 1 hour
The paracetamol treatment graph is unrelieable in what kind of overdose?
Staggered
What is the dosing regimen for acetylcysteine in paracetamol overdose?
1st infusion for 1 hour 150mg/kg
2nd infusion for 4 hours 50mg/kg
3rd infusion for 16 hours 100mg/kg
Does TCA overdose result in dilated or pinpoint pupils?
Dilated
What is used to treat bradycardia in acute overdose of beta blockers?
Atropine
Therapeutic lithium concentrations are usually within what range?
0.4–1 mmol/litre
What lithium level is associated with serious toxicity?
> 2
May need treatment with haemodialysis
Oxygen should be administered to patients with what types of poisoning?
Cyanide
Carbon monoxide
What is used for ethylene glycol and methanol poisoning?
Fomepizole
Ethanol
All these side effects are linked to suxamethonium except:
- Malignant hyperthermia
- Hyperkalaemia
- Myopathies
- Hypertension
Hypertension
It is used as part of general anaesthesia and causes hypotension
Sodium thiosulphate is used for what type of poisoning?
Cyanide
For a child born in the UK, what 4 vaccines should they have at 8 weeks?
1st 6 in 1 vaccine
1st Rotavirus
1st Pneumococcal
1st Men B
For a child born in the UK, what 2 vaccines should they have at 12 weeks?
2nd 6 in 1 vaccine
2nd Rotavirus
For a child born in the UK, what 3 vaccines should they have at 16 weeks?
3rd 6 in 1 vaccine
2nd Men B
2nd pneumococcal
For a child born in the UK, what 2 vaccines and 2 boosters should they have at 12 months?
Hib and Men C
1st MMR
Booster pneumococcal and booster Men B
Under the NHS child vaccination programme, what age should healthy children get the flu vaccine and how is this given?
Flu vaccine given via nasal spray
From the age of 2 to 9 (pre-school to Year 5)
For a child born in the UK, what 1 vaccines and 1 booster should they have 13-18 years?
3 in 1 booster (diphtheria, tetanus, polio)
Men ACWY
What does the 6 in 1 vaccine protect against?
Diphtheria, tetanus, pertussis (whooping cough), polio, haemophilus influenzae type b (Hib) and hepatitis B
True or false: Some flu vaccines contain egg so you need to be careful if the patient has an egg allergy
True
Can you continue glaucoma medication during surgery?
Yes
When administering live vaccines, why should the alcohol/disinfectant be allowed to dry before administering?
As it may inactivate the vaccine
What is the only childhood vaccine where paracetamol is recommended as part as the routine immunisation schedule?
Men B
Dose 1 — 2.5 mL (60 mg) as soon as possible after vaccination.
Dose 2 — 2.5 mL (60 mg) 4–6 hours after the first dose.
Dose 3 — 2.5 mL (60 mg) 4–6 hours after the second dose
Other than this, parents should not routinely give their children paracetamol to prevent fever
What is the most widely used IV anaesthetic and why?
Propofol
Associated with rapid recovery and less hangover effect than other intravenous anaesthetics.
What is an advantage of etomidate over propofol in anaesthesia?
Causes less hypotension
What are the advantages and disadvantages of etomidate for anaesthesia?
Rapid recovery without a hangover effect
Causes less hypotension
However can cause muscle movements but this can be minimised by opioid/benzodiazepine before induction
Is ketamine used in anaesthesia?
What are the disadvantages?
Rarely in adults
It is used mainly for paediatric anaesthesia, particularly when repeated administration is required (such as for serial burns dressings)
The main disadvantage of ketamine is the high incidence of hallucinations, nightmares, and other transient psychotic effects; these can be reduced by a benzodiazepine such as diazepam or midazolam.
For inhaled anaesthetics, to prevent hypoxia, the inspired gas mixture must contain what % oxygen at all times?
Minimum of 25% oxygen
Higher concentrations of oxygen (greater than 30%) are usually required during inhalational anaesthesia when nitrous oxide is being administered.
The “flurane” anaesthetics are what formulation?
Volatile liquid
What is a rare but serious side effect of anaesthesia?
What are the symptoms?
Malignant hyperthermia
Rapid rise in temperature, increased muscle rigidity, tachycardia, and acidosis.
What type of anaesthetics carry the highest risk of malignant hyperthermia?
Volatile anaesthetics (fluranes) Suxamethonium
How do you treat malignant hyperthermia?
Dantrolene
