FU(14): Infectious Diseases & Diseases related to Immune System Dysfunction

Question 1

During a routine abdominal surgery, a 55-year-old patient with a history of diabetes mellitus type 2 and recent antibiotic therapy presents with an unexpected operative finding of a small abscess in the peritoneal cavity. Culture results are pending, but initial gram stain suggests a gram-positive organism. Given the patient’s history and the increasing prevalence of antibiotic-resistant pathogens, which antibiotic regimen would be most appropriate for perioperative prophylaxis?

Answer 1

Vancomycin and piperacillin-tazobactam

Question 2

A 65-year-old patient undergoes elective hip replacement surgery. Despite receiving prophylactic antibiotics within 1 hour before incision and adherence to surgical aseptic techniques, the patient develops signs of a deep surgical site infection (SSI) two weeks post-operatively. Which of the following factors is most likely to have contributed to the development of this infection?

Answer 2

Use of internal prosthetic material

Question 3

A postoperative patient exhibits signs of a superficial surgical site infection. Culture of the wound exudate grows coagulase-negative staphylococci. Considering the pathophysiology of SSIs and the organism identified, which of the following treatment strategies is most appropriate?

Question 4

A 60-year-old patient scheduled for elective abdominal surgery has been identified as a carrier of S. aureus in the anterior nares. Which of the following preoperative interventions is most appropriate to reduce the risk of surgical site infection (SSI)?

Answer 4

Application of topical mupirocin to the anterior nares

Question 5

During a prolonged (>4 hours) is most appropriate to minimize the risk of surgical site infections?

Question 6

For a patient undergoing elective surgery, which of the following intraoperative management strategies is most effective in reducing the incidence of surgical site infections?

Answer 6

Maintaining normothermia to increase subcutaneous oxygen tension

Question 7

In the preoperative planning for a patient requiring central venous catheter placement, which of the following strategies is considered most effective in reducing the incidence of CLABSIs according to evidence-based practices?

Answer 7

Utilizing full-barrier precautions during catheter insertion

Question 8

For a critically ill patient undergoing a complex surgical procedure that necessitates both central venous catheter placement and potential blood transfusions, which of the following integrated management strategies is most effective in simultaneously minimizing the risk of central line-associated bloodstream infections (CLABSIs) and transfusion-related bloodstream infections?

Answer 8

Using chlorhexidine impregnated dressing for the central line site and implementing leukodepletion for all transfused blood components

Question 9

A patient with sepsis is scheduled for urgent source control surgery. Which of the following preoperative goals is essential to optimize the patient’s condition and improve surgical outcomes?

Answer 9

Achieving a mean arterial pressure (MAP) above 65 mmHg through fluid resuscitation and vasopressor support

Question 10

For a patient with severe sepsis undergoing emergency surgery, which intraoperative strategy is paramount to minimize the risk of worsening sepsis and supporting organ function?

Answer 10

Comprehensive invasive monitor- ing, including intraarterial blood pressure and central venous pressure, to guide fluid and vasopressor therapy

Question 11

In the immediate postoperative period for a patient with sepsis, which of the following is a critical priority to reduce the risk of further organ dysfunction and support recovery?

Answer 11

Continuation of goal-directed therapy, including targeted antimicrobial therapy and support of failing organ systems

Question 12

For a patient undergoing surgery due to fulminant C. difficile colitis, which intraoperative management strategy is paramount to minimize the risk of exacerbating the infection and supporting patient stability?

Answer 12

Utilizing opiates judiciously to manage pain without significantly decreasing intestinal motility, which may exacerbate toxin-mediated disease

Question 13

A patient presenting with necrotizing soft tissue infection shows signs of septic shock. Which of the following preoperative interventions is most appropriate for optimizing hemodynamic status?

Answer 13

Administer IV fluids to achieve a CVP of 8-12 mmHg, aiming to optimize preload before surgical debridement

Question 14

When choosing an induction agent for anesthesia in a patient with tetanus undergoing emergency surgery, which consideration is paramount to minimize risk and optimize patient stability?

Answer 14

Select ketamine for its ability
to maintain hemodynamic stability through sympathetic stimulation

Question 15

Following surgical debridement for necrotizing soft tissue infection, how should antibiotics be managed to effectively combat infection while preventing resistance?

Answer 15

Transition to targeted antibiotic therapy based on culture and sensitivity results as soon as they are available

Question 16

A patient with diagnosed community-acquired pneumonia requires urgent non-thoracic surgery. Which of the following preoperative assessments is most critical to guide anesthesia management and optimize patient outcomes?

Answer 16

Evaluation of arterial oxygen saturation to assess the extent of intrapulmonary shunting

Question 17

In managing anesthesia for a patient with a recent history of aspiration pneumonia, which consideration is paramount to minimize the risk of exacerbating the condition?

Answer 17

Careful airway management to prevent further aspiration, especially during induction and extubation

Question 18

For a patient with ventilator-associated pneumonia (VAP) scheduled for a tracheostomy, which of the following anesthesia management strategies is most appropriate to maintain pulmonary status and minimize postoperative complications?

Answer 18

Ensuring continuity of the patient’s ICU ventilator settings, including PEEP, to avoid de-recruitment of alveoli

Question 19

In managing anesthesia for a patient presenting with symptoms suggestive of influenza requiring emergency non-respiratory surgery, which of the following strategies is crucial to minimize transmission and optimize patient outcomes?

Answer 19

Implementing droplet precautions and using a high-efficiency particulate air (HEPA) filter between the anesthesia circuit and the patient’s airway

Question 20

A patient with a history of SARS now presenting with symptoms of a new respiratory illness requires urgent surgery. In addition to standard preoperative assessment, which of the following is most critical to ensure safe anesthesia management?

Answer 20

Detailed history taking to identify potential recent exposure to known outbreaks or travel to endemic areas

Question 21

For a patient with active TB undergoing an urgent surgical procedure, which of the following anesthesia management strategies is paramount to minimize the risk of transmission?

Answer 21

Ensuring all the operating room (OR) staff use N95 respirators and implementing negative pressure ventilation in the OR

Question 22

When evaluating an HIV-positive patient for elective surgery, which of the following assessments is most critical in determining the patient’s readiness and optimizing perioperative management?

Answer 22

Obtaining a recent CD4+ count to assess the degree of immunosuppression and risk for opportunistic infections

Question 23

In selecting an anesthetic technique for an HIV-positive patient with a moderate CD4+ count undergoing minor outpatient surgery, which of the following considerations is paramount to minimize postoperative complications?

Answer 23

Use of regional anesthesia to avoid systemic immunosuppressive effects of general anesthetics

Question 24

For an HIV-positive patient on HAART scheduled for surgery, which of the following is the most important consideration to manage potential HAART-related anesthetic drug interactions?

Answer 24

Reviewing the patients HAART regimen for potential interactions with planned anesthetic drugs

Question 25

In considering perioperative corticosteroid supplementation for an HIV-positive patient undergoing major surgery, which of the following factors is most critical in guiding this decision?

Answer 25

Evidence of adrenal insufficiency due to either HIV infection or concurrent opportunistic infections

Question 26

In the postoperative monitoring of an HIV-positive patient who initiated HAART shortly before undergoing elective surgery, which of the following is most important for early identification and management of immune reconstitution inflammatory syndrome (IRIS)?

Answer 26

Vigilant monitoring for the paradoxical worsening of general clinical symptoms or unmasking of opportunistic infections

Question 27

For a pediatric patient with cyclic neutropenia scheduled for elective surgery during a neutrophil nadir, which preoperative measure is essential to mitigate the increased risk of infection?

Answer 27

Initiating prophylactic broad-spectrum antibiotics 24 hrs before surgery to minimize infection risk

Question 28

In preparing for surgery in an adult patient experiencing chemotherapy-induced neutropenia, what is the most critical consideration to ensure the patient’s safety and minimize the risk of infection?

Answer 28

Scheduling the surgery based on detailed monitoring of the patients neutrophil count to avoid periods of profound neutropenia

Question 29

In managing anesthesia for a patient with chronic granulomatous disease (CGD) scheduled for elective surgery, which of the following is the most critical strategy to minimize the risk of postoperative infections?

Answer 29

Prophylactic administration of broad-spectrum antibiotics and antifungals agents tailored to cover organisms commonly associated with CGD

Question 30

For a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency undergoing elective surgery, which preoperative consideration is paramount to avoid intraoperative complications?

Answer 30

Avoidance of drugs known to trigger hemolysis in G6PD-deficient patients, such as certain antibiotics and antimalarials

Question 31

When planning surgery for a patient with leukocyte adhesion deficiency, which of the following perioperative management strategies is essential to address the patient’s increased risk of recurrent bacterial infections?

Answer 31

Rigorous aseptic technique and the use of prophylactic antibiotics to prevent postoperative bacterial infections

Question 32

In preparing for major surgery on a patient with marked neutrophilia, potentially indicative of a deep-seated infection or myeloproliferative disorder, which of the following anesthetic considerations is paramount to minimize perioperative risk?

Answer 32

Close monitoring for signs of leukostasis, including splenic infarction and decreasing lung oxygen diffusing capacity, especially if leukocyte counts exceed 100,000/µL

Question 33

For an elective surgery patient with monocytosis associated with an underlying inflammatory disorder, such as systemic lupus erythematosus, which preoperative management strategy is most important to ensure patient safety?

Answer 33

Comprehensive preoperative evaluation to assess the activity of the underlying inflammatory disorder and adjust immunosuppressive therapy accordingly

Question 34

For a patient with hereditary angioedema due to C1 esterase inhibitor deficiency undergoing elective surgery, which of the following is the most appropriate prophylactic strategy to prevent an acute angioedema attack triggered by surgical stress?

Answer 34

Administration of C1 esterase inhibitor concentrate prior to surgery to prevent bradykinin-mediated edema

Question 35

In managing the airway of a patient presenting with acute ACE inhibitor-induced angioedema and potential upper airway obstruction, which of the following approaches is crucial for maintaining airway patency and ensuring patient safety?

Answer 35

Immediate cessation of the ACE inhibitor and preparation for potential tracheal intubation, with equipment for tracheostomy ready if intubation fails

Question 36

In preparing a pediatric patient with X-linked agammaglobulinemia for elective surgery, which of the following interventions is essential to reduce the risk of postoperative infections?

Answer 36

Intravenous immunoglobulin (IVIG) infusions to maintain protective IgG levels

Question 37

For a patient with Waldenström macroglobulinemia scheduled for cardiac surgery requiring cardiopulmonary bypass, which of the following preoperative treatments is most appropriate to prevent complications associated with hyperviscosity?

Answer 37

Treatment consists of plasmaparesis to remove the abnormal proteins and reduce plasma viscosity. Chemotherapy may be instituted in attempts to decrease proliferation of cells responsible for production of the abnormal immunoglobulins

Question 38

During anesthesia, if a patient experiences a sudden onset of bronchospasm, urticaria, and hypotension immediately after administration of a medication, indicating a possible Type I allergic reaction, which of the following is the first-line treatment

Answer 38

Epinephrine into vastus lateralis muscle

Question 39

In a patient with a history of drug-induced Type IV hypersensitivity reaction, such as Stevens-Johnson syndrome, which of the following is the most important preventive measure to consider before prescribing medications?

Answer 39

Detailed review of the patient’s drug history to identify and avoid any previously implicated drugs

Question 40

For a patient with a known history of IgE-mediated anaphylaxis to penicillin undergoing elective surgery, which of the following preoperative measures is most important to prevent recurrence of anaphylaxis?

Answer 40

Elective skin testing should be considered for any patient with a convincing history of Ig-mediated penicillin allergy to avoid inappropriate avoidance of lactam antibiotics and unnecessary use of more expensive and broad-spectrum antibiotics.
Penicillin allergy is almost never a contraindication to cefazolin or other cephalosporin administration. A documented history of anaphylaxis or other serious reaction (angioedema, hives, bronchospasm, Stevens-Johnson syndrome, or toxic epidermal necrolysis) is the exception. Determine the severity of a patient’s lactam allergy prior to choosing an alternative antimicrobial

Question 41

In a patient developing a severe exfoliative dermatitis suspected to be a drug-induced type IV hypersensitivity reaction, which of the following steps is crucial in the initial management?

Answer 41

Discontinuation of all non-essential medications suspected to be the causative agent

Question 42

In planning anesthesia for a patient with DiGeorge Syndrome, which of the following considerations is most important given the potential for T-cell dysfunction?

Answer 42

Ensuring meticulous infection control measures given the patient’s immunocompromised state

Question 43

A 45-year-old patient scheduled for elective surgery reports a history of penicillin allergy since childhood, characterized by rash and angioedema. The patient has avoided penicillin since the event. Preoperative evaluation includes planning for antibiotic prophylaxis and potential neuromuscular blockade.
Which of the following strategies is most appropriate for managing this patient’s reported penicillin allergy in the perioperative period?

Answer 43

Conduct elective skin testing for penicillin and, if negative, proceed with penicillin or a first-generation cephalosporin for ABT prophylaxis

Question 44

A 60-year-old woman with a history of anaphylaxis to succinylcholine during a previous surgery is scheduled for another surgical procedure. Her medical history is significant for multiple allergies, including latex and certain fruits. The anesthesia team is concerned about potential cross-reactivity with other NMBAs.
Which of the following preoperative assessments is most appropriate for this patient?

Answer 44

Preoperative skin testing for all NMBA’s likely to be used during surgery to identify a safe alternative

Question 45

A 62-year-old patient undergoing major abdominal surgery develops acute onset hypoxia and bilateral pulmonary infiltrates within 4 hours following the transfusion of fresh frozen plasma. The patient’s history is negative for cardiac failure, and there is no evidence of volume overload. Based on the clinical presentation, TRALI is suspected.
Which of the following is the most appropriate initial management strategy for this patient?

Answer 45

Stopping the transfusion and instituting supportive measures(mechanical ventilation) (stoeltings p. 580)
Ï blood bank notified and quarantining all units from donor. (Millers anesthesia, p. 1853)
The management of TRALI focuses on supportive measures to limit lung injury and optimize oxygenation. This includes maximizing positive end-expiratory pressures, avoiding volume overload, and using low tidal volume lung protective strategies during mechanical ventilation.
The treatment of TRALI includes discontinuation of the transfusion along with ventilatory and hemodynamic support.

Question 46

A patient receiving a red blood cell transfusion during surgery exhibits sudden onset of fever, hypotension, and dark urine approximately 2 hours post-transfusion. The surgical team suspects an acute hemolytic transfusion reaction (AHTR).
What is the most crucial next step in managing this suspected AHTR?

Answer 46

Immediately stop the transfusion, send blood samples for direct antiglobulin test, and maintain urine output to prevent acute kidney injury

Question 47

A patient with a long history of systemic lupus erythematosus (SLE) is scheduled for elective surgery. The patient’s medical history is significant for renal involvement and chronic use of corticosteroids. During the preoperative evaluation, the nurse anesthesiologist is most concerned about

Answer 47

Evaluating renal function and adjusting the anesthetic plan to minimize nephrotoxicity, given the patient’s SLE-related renal injury and chronic corticosteroid use

Question 48

A 55-year-old patient with chronic autoimmune hepatitis undergoing non-cardiac surgery is at an increased risk of perioperative cardiovascular complications primarily due to

Answer 48

Patients with long-standing autoimmune disorders have the risk of accelerated atherosclerosis and associated cardiovascular complications such as heart disease and stroke (pg. 581)

Question 49

During a complex abdominal surgery, a patient with a history of multiple previous surgeries requiring allogenic blood transfusions is assessed for potential perioperative blood transfusion. Given the known effects of TRIM, the nurse anesthesiologist’s primary consideration to minimize immunosuppression should be

Answer 49

Many factors related to surgery and anesthesia impair immune function, which may precipitate infection and cancer progression in susceptible patients
The main factor, is the neuroendocrine response to surgical stress, which includes release of catecholamines and glucocorticoids that impair both the innate and adaptive immune responses Anesthetic agents, including volatile anesthetics and opioids, also impair immune function.
Regional and neuraxial with local anesthetics may help preserve immune function (pg. 583)

Question 50

A patient undergoing a major surgical procedure requires multiple transfusions of allogenic blood products. Postoperatively, the patient demonstrates signs of immunosuppression. This scenario highlights the necessity for the nurse anesthesiologist to understand the potential for

Answer 50

Transfusion-associated immunomodulatory (TRIM) effects can occur and include increased susceptibility to infection and promotion of tumor growth. Specific TRIM effects include decreased NK (natural killer lymphocytes)
cell and phagocytic function

Question 51

Considering the potential for anesthesia and surgery to influence tumor progression, a patient with a localized solid tumor is scheduled for surgical excision. The nurse anesthesiologist aims to minimize the impact of surgery and anesthesia on tumor recurrence. Which anesthetic technique is most appropriate for this patient?

Answer 51

Preferentially utilize regional anesthesia to attenuate the surgical stress response and reduce