Exam 1 Flashcards
_______ is an immediate severe systemic hypersensitivity reaction c/b the rapid IgE mediated immune release of potent mediators from tissue mast cells and peripheral blood basophils.
anaphylaxis
_______ responses are those clinical events c/b mediator release from mast cells and basophils by non-IgE mediated triggering events. They can be potentially life threatening reactions like anaphylaxis, although typically are self limiting.
anaphylactoid
90% of allergic reactions of IV drugs occur within _______.
3 minutes
The specific immune system is aka _______. Immune responses are directed against a particular antigen. Responses can be _______ involving B lymphocytes, or _______ involving T lymphocytes. B lymphocytes arise from _______ or _______. They use _______ and combat primarily _______.T lymphocytes arise from the _______.
acquired immunity; humoral; cell-mediated; plasma cells; bone marrow; antibodies; bacterial infections; thymus
Nonspecific immunity, aka _______, includes _______ and _______. Leukocytes perform _______. A foreign body can activate the _______, in which a cascade of plasma proteins is activated.
innate immunity; physical barriers; leukocytes; phagocytosis; complement system
A vaccination provides what type of immunity?
acquired
_______ is when antibodies and/or activated T cells are administered to provide protection from an invasive agent. The effect is ______, from hours to weeks.
passive immunity; temporary
The _______ is a system of 20 different plasma proteins. The principal proteins are _______ and are normally inactive but can be activated by 2 pathways: _______ or _______. It’s major function is to _______.
complement system; C1-C9, B & D; initiated by IgG or IgM (antibody) binding to antigen; an alternative path by endotoxic or drug reaction; recognize bacteria directly and indirectly
Angioneurotic edema (hereditary or acquired) is the result of _______ and causes _______.
deficiency of C1 complement system inhibitor; excess C1 release
_______ are molecules capable of stimulating an immune response when injected. This response is specific and produces antibodies against the _______. _______ are low molecular weight substances (_______MW), and must combine with a protein or macromolecule to elicit and immune response. This complex becomes an _______ and causes an allergic response. Haptens are not antigenic by themselves, only _______.
Antigens; chemical structure; Haptens; <8,000; antigen; in combination with macromolecules
Examples of haptens include:
drugs or their metabolites
chemicals in dust
animal dander
poison ivy
_______ are protein immunoglobulin that can recognize and bind to a specific antigen. They function as specific receptor molecules are are located _______. They consist of 2 portions: the _______ which binds antigen and attaches specifically to a particular type of antigen, and the _______ responsible for unique binding.
antibodies; on different immune cells; Fab (Ab fixing); Fc (complement fixing)
Effector cells and proteins of the nonspecific immune response include:
monocytes and macrophages neutrophils eosinophils basophils mast cells
_______ are involved in processing and presenting antigens to T cell lymphocytes. They are predominant cells at sites of _______. They perform _______ and digest invading microorganisms. _______ arise from ________ or may be confined to specific organs such as the _______, _______, _______.
monocytes and macrophages; chronic inflammation; phagocytosis; macrophages; monocytes; lung; lymph nodes; spleen
_______ are the first cells to appear in an acute inflammatory reaction and contain substances that aid in microbial killing such as enzymes, proteases, acids, hydroxyl radicals, hydrogen peroxide, and superoxide.
neutrophils
_______ are associated with parasitic infections. They secrete enzymes that _______ to try to balance things out (negative feedback). One such enzyme is _______ that breaks down histamine. Other cells such as _______ & _______ secrete eosinophilic chemotactic factors to recruit eosinophils to accumulate at sites of _______, _______ & _______.
Eosinophils; limit the response of other inflammatory cells; histaminase; mast cells; basophils; infections; tumors; allergic reactions
On the surface of _______ are IgE receptors that release mediators when activated. A type of _______. Function similarly to mast cells, but have the capacity for _______.
basophils; granulocyte; chemotactic migration in response to other stimuli
_______ are important mediators of immediate hypersensitivity reactions. They are located in the tissue of perivascular spaces of the skin, lung and intestine. On the surface there are _______ that bind to specific antigens and once activated these cells release physiologically active mediators important to immediate hypersensitivity responses such as _______, _______ & _______. A central step in anaphylactic syndrome is the activation of _______ and _______. Mediators released from mast cells and basophils cause _______.
mast cells; IgE receptors; histamine; Heparin; proteases; mast cells; basophils; severe and abrupt physiologic alterations (what we see)
A _______ is an immediate hypersensitivity reaction caused by foreign protein (antigen) binding to IgE antibody on the surface of mast cells, triggering the release of intracellular granules. Examples include _______, _______ & _______.
Type I hypersensitivity response; anaphylaxis; extrinsic asthma; allergic rhinitis
A _______ is a cytotoxic hypersensitivity reaction caused by foreign protein binding with IgG or IgM, causing cytolysis or phagocytosis. AN example is _______.
Type II hypersensitivity response; hemolytic reaction
A _______ is an immune complex disease caused by external or internal antigens binding with IgG, IgM or IgA which results in an inflammatory reaction. Examples include_______, _______, _______, & _______.
Type III hypersensitivity reaction; snake venom reaction; SLE; post strep; nephritis
A _______ is a delayed response involving sensitized T lymphocytes to specific antigens. It does not require _______ for reaction. Examples include _______ and _______.
Type IV hypersensitivity reaction; antibodies; contact dermatitis; tissue rejection
Antigen binding to IgE antibodies initiates _______. _______ to the antigen or to a substance of similar structure is required to produce sensitization. On _______, binding of the antigen to bridge two immunospecific IgE antibodies located on the surfaces of mast cells and basophils releases histamine and chemotactic factors of anaphylaxis. This can occur _______.
anaphylaxis; prior exposure; re-exposure; the first time
_______ stimulates H1 and H2 receptors which causes _______ and _______. It also causes tachycardia, decreased SVR, & _______ which can be detrimental in those that are cardiac compromised. It is rapidly metabolized by _______ and you would need samples immediately (unrealistic).
Histamine; vasodilation; increased capillary permeability; coronary vasoconstriction; endothelial enzymes
_______ released from mast cells and basophils cause granulocyte migration (_______). Granulocyte acitvation may be responsible for _______.
Chemotactic factors of anaphylaxis; chemotaxis; recurrent manifestations of anaphylaxis
Chemical mediators of anaphylaxis include:
histamine chemotactic factors of anaphylaxis leukotrienes prostaglandins kinins platelet-activating factor tryptase
_______ are a slow reacting substance of anaphylaxis. They are a product of breakdown of _______. They produce _______, _______, _______ & _______.
leukotrienes; arachidonic acid; bronchoconstriction; capillary permeability; vasodilation; myocardial depression
_______ are products of arachidonic acid metabolism by way of the cyclooxygenase pathway. They are potent _______ and produce _______, _______, _______, & _______. _______ is the major metabolite of mast cells and produces _______ and _______. _______ is a potent vasoconstrictor.
prostaglandins; mast cell mediators; vasodilation; bronchospasm; pulmonary hypertension; increased capillary permeability; prostaglandin D2; bronchospasm; vasodilation; PGE2
_______ are small peptides synthesized in mast cells and basophils that produce _______, _______ and _______.
Kinins; vasodilation; increased capillary permeability; bronchospasm
\_\_\_\_\_\_\_ is a potent material producing aggregation of platelets and possibly leukocytes for inflammatory products. Produces clinical manifestations of anaphylaxis such as: - - - -
platelet-activating factor (PAF); decreased myocardial force; coronary vasoconstriction; pulmonary edema; increased pulmonary vascular resistance
_______ is released with histamine. It also increases vascular permeability and may be a cause of _______. It has _______ and therefore is a good marker of histamine liberation. ___ hours max.
tryptase; airway edema; longer half life (hours); 2.5
Non-IgE mediated reactions/anaphylactoid reactions include _______ and _______. It is different from antigen or anti-IgE mediated histamine release because _______. These types of reactions include the reactions to _______ and _______.
complement activation; non-immunologic histamine release; histamine alone is released; opiates; NDMRs
Physiologic alterations of mediator release include:
urticaria laryngeal edema nausea vomiting abdominal pain diarrhea bronchospasm (increased PIP's, decreased breath sounds, wheezing) CV collapse
With clinical manifestations of anaphylaxis individuals will vary in onset of symptoms. It is usually soon after introduction of the causative agent (may be delayed _______). Some patients describe a _______. _______, _______, _______, & _______ systems are affected. _______ predominate during anesthesia.
2-20 minutes; a sense of impending doom; cutaneous; GI; CV; respiratory; CV signs
Respiratory manifestations include:
rhinitis
laryngeal edema
bronchospasm
CV manifestations include:
circulatory collapse (lightheadedness, syncope, ischemic heart symptoms, tachycardia, hypotension, shock) dysrhythmias (palpitations, EKG changes, PACs, PVCs, A fib)
Hematological manifestations include:
fibrinolysis
DIC
CNS manifestations include:
They are secondary to _______ and _______.
headache confusion apprehension anxiety seizures coma (late) cerebral hypoxia; hypoperfusion
You may not see _______ symptoms when the patient is asleep.
CNS
GI manifestations include:
dysphagia cramping/abdominal pain (d/t smooth muscle contraction) increased mucus secretion N&V diarrhea
GU manifestations include:
pelvic pain
urinary incontinence
Cutaneous manifestations include:
urticaria
pruritis
angioedema
Eye manifestations include:
conjunctivitis
increased tearing
ocular itching
Reactions may mimic: (differential diagnosis)
MI
PE
irritant induced bronchospasm
aspiration
Diagnostic tests include:
RAST (radioallergosorbent test, which has a lot of false negatives); ELISA (enzyme linked immunosorbent assay); and skin testing
Initial treatment of anaphylaxis includes:
stop administration or reduce absorption of offending agent
maintain airway and administer 100% O2
D/C all anesthetic agents ASAP
consider SQ or aerosolized epi for laryngeal edema
intubation or cricothyrotomy (not an LMA)
**rapid IV volume expansion (25-50ml/kg:2-4L) of crystalloid or colloid for hypotension due to increased vascular permeability
IV epi dose:
1-3ml of 1:10,000 aqueous solution (0.1mg/ml) given over 10 minutes OR
1-4mcg/min (0.25-1ml/min of a solution of 4mcg/ml made with 1ml of 1:1,000 epi in 250ml fluid)
SQ epi dose:
0.01-0.03ml/kg increments of 1:1,000
ETT epi dose:
10ml of 1:10,000
Dose of epi should be _______. _______ reduces sympathetic response (_______).
titrated to effect; anesthesia; may have to give more epi
Epi is a _______. Alpha effects include: _______. Beta effects include _______, _______ & _______.
alpha and beta agonist; increased PVR which reverses peripheral vascular permeability; bronchodilation; positive inotropic/chronotropic effects; increased production of cAMP
Secondary therapy for treatment of anaphylaxis includes:
- antihistamine (Benadryl 1mg/kg, max dose 50mg)
- ranitidine 1mg/kg (max dose 50mg)
- glucocorticoid (hydrocortisone 0.25-1gm or methylprednisone 30-35mg/kg)
- aminophylline (loading dose 5mg/kg followed by continuous infusion 0.5-1mg/kg/hr & check level)
- inhaled beta 2 agonists
- continuous catecholamine infusion (epi, NE, dopamine)
- sodium bicarb 0.5-1mg/kg; titrate to ABGs
One of the primary causes of anaphylaxis and allergic reactions under anesthesia is _______. There is _______ between muscle relaxants as they have similar chemical structures, especially _______. IgE mechanism directly against the _______ present in muscle relaxants. There is cross sensitivity with other compounds (_______, _______, _______, _______, _______) as they have similar structures. 90-95% occur in females possibly due to _______.
muscle relaxants; cross-sensitivity; quaternary ammonium groups; quaternary or tertiary ammonium ions; drugs; foods; cosmetics; disinfectants; industrial materials; ion epitopes in cosmetics
Induction agents, _______, may cause allergic reactions. Those that experience a reaction often have allergies to food, and reported _______ or ______. Another induction agent, _______, has cause severe anaphylaxis. Those that have had a reaction are allergic to _______ and _______ and are also allergic to _______, _______ & _______. Patients allergic to eggs can be allergic to propofol because of the _______. Etomidate allergic reaction differs from other drugs in that it causes _______ and _______.
barbiturates; asthma; rhinitis; propofol; group phenyl nucleus; isopropyl side chain; muscle relaxants; LAs; antibiotics; protein base; GI; cutaneous symptoms
_______ allergy is rare. It is often confused with vasovagal changes, IV injection, epi, psychomotor responses. May see cross sensitivity _____ classes, not _____ classes. IgE sensitivity reported to _______.
LA; among; across; parabens
Opioids have _______, therefore reactions are rare. Morphine and Demerol cause _______ and most reactions are _______.
close chemical structures to body endorphins; non-immunologic mediated histamine release; self limiting
_______ is the most common antibiotic to cause anaphylaxis. It is a _______, and must combine with tissue macromolecules. _______ have a cross sensitivity to PCN. Patient with a _______ should not receive cephalosporins. If a patient has a PCN allergy ask what happens, if it is severe _____. Newer beta-lactim antibiotics, carbapenems and monobactans _______.
PCN; hapten; cephalosporins; + skin test to PCN; do not give a cephalosporin; also have a cross sensitivity to PCN
_______ creates a non-immunologic mediated histamine release that is not necessarily an allergic reaction. It occurs when _______ or ______. AKA _______.
Vancomycin; given rapidly; as a concentrated solution; red man syndrome
_______ produces skin eruptions and fever that appear ______ (delayed reactions). Incidence of reaction is 10-15 times higher among patients with _____. _______ is required to convert the native sulfonamide into its immunogenic metabolite. IgE antibody.
sulfonamide; between 7-10 days of treatment; AIDS; hepatic metabolism
Reactions to contrast dye are not likely _______. Most reactions occur in the first ______. _______ is activated. _______ due to hypertonicity of solution.
IgE mediated; complement system; non-immunologic histamine release from mast cells and basophils
Protamine is derived from_______. _______ have an increased risk for life threatening reactions when given protamine IV. _______ patients develop and antibody against protamine. Patient with _______ may develop antibodies. Symptoms include ______, ______, ______ & ______. Has to be given _____.
salmon testis; diabetics receiving insulin containing protamine; vasectomy; fish allergies; rash; urticaria; bronchospasm; hypotension; slow
Latex allergy is seen in _______ and _______. Other populations at risk include_______, _______, _______, _______. Each subsequent systemic reaction occurs with ______ and _______. In most severe cases contact occurs between latex and _______, but in some exposure through _______ has caused severe reactions. The problem with lab tests/skin tests is that _______. Management is through _______.
pediatric pathology-spina bifida; healthcare workers; patients experiencing multiple surgeries; chronic bladder catheterizations; atopic individuals; fruit allergies; less provocation; greater magnitude; mucous membranes; aerosolized latex; there is not one universal protein/latex allergen; avoidance and symptomatic therapy
Managing the patient with a known latex allergy includes:
- making it the first case of the day
- minimize exposure in preop
- remove all latex from the OR
- use only latex free IV ports
- remove stoppers from multidose vials
- communicate allergy to all other caregivers
Latex reaction symptoms usually manifest within _____. Symptoms in the awake patient include:
30 minutes but can occur from 10-290 minutes post exposure; itchy eyes, pruritis, SOB, wheezing, faintness, impending doom, restlessness, agitation, N&V, abdominal cramping and diarrhea; *hoarseness and laryngeal edema are common
Latex allergy symptoms in the anesthetized patient include:
tachycardia hypotension wheezing bronchospasm cardio/RR arrest flushing facial edema laryngeal edema urticaria
