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Spring '20/ L. BASICS- Immune, OR Hazards, OP > immune 2 > Flashcards

immune 2 Flashcards

1
Q

name the two reasons for antibiotic resistance

A

overprescribing and inappropriate use of current antibiotics

limited choice of ABX that manipulate only a narrow range of bacterial functions.

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2
Q

what disease was eradicated that is making a resurgence

A

TB

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3
Q

multidrug- resistant TB and

extremely drug resistant TB are a concern why?

A

resistant to previously effective antimicrobials

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4
Q

why are newer antibiotic developments slow

A

d/t regulations disincentives, market failures, lack of profitability

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5
Q

is there abs that are active against resistant gram negative pathogens

A

NO

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6
Q

SSI account for what percent of all nosocomial infections in hospitalized patients?

A

14-16%

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7
Q

following an SSI what % more likely are patients to spent time in the ICU?

how many more times likely to require readmission

how many more times likely to die

A

60%

5x more likely to readmit

2x more likely to die

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8
Q

in general dark terms…SSI is a major source of

A

morbidity and mortality

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9
Q

what percent of SSI for extrabdominal surgery

A

2-5%

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10
Q

what percent of SSI for intraabdominal surgery

A

20%

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11
Q

SSI affect how many people annually

A

500,000

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12
Q

what did the CMS and CDC implement in 2002

A

national surgical infection prevention project

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13
Q

list the three key measure for SSI

A

IV abs within 1 hours prior to incision (2hours vancomycin and fluroquinolones)

proportion of patients receiving prophylactic abs is consistent with published guidelines

proportion whose prophylactic abs is D/c’ed within 24 hours after surgery.

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14
Q

what is the predominate SSI

A

MRSA

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15
Q

SSI are divided into three layer sections-

A

superficial infections (skin and SQ)

deep infections (fascial, muscle layers)

organ & tissue spaces

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16
Q

SSI are attributed to (4)

A

bacterial resistance

increased implantation of prosthetics

foreign materials

poor immune status

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17
Q

increased proportion of SSI are caused by resistant pathogens and candida species- which may reflect what type of patients and their history

A

increasing number of severely ill patients

immunocompromised surgical patients

impact of wide use of broad spectrum ABX

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18
Q

SSI is affected by patient related factors

A 
extremes of age
poor nutritional status
ASA physical status>2
diabetes mellitus
smoking
obesity
co-existing infections
colonization
immunocompromise
longer preoperative hospital stay
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19
Q

SSI microbial factors

A

enzyme production

polysaccharides capsule

ability to bind to fibronectin

biofil and slime formation

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20
Q

SSI wound related factors

A

devitalized tissue

dead space

hematoma

contaminated surgery

present of foreign material

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21
Q

when do SSI present themselves

A

30 days

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22
Q

name some S/s of SSI

A

localized inflammation at surgical site

evidence of poor wound healing

fever

malaise

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23
Q

what is the “gold standard” for documenting a wound infection

A

is to document the growth of organisms in an ascetically obtained culture specimen

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24
Q

what are the nonspecific indicators of SSI

A

elevated WBC

poor glucose control

elevated levels of inflammatory markers (CRP)

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25
Q

1/3 organism cultured are

A

staphylococci (aureus, epidermidis)

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26
Q

> 10% organisms cultured are

A

enterococcus

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27
Q

what makes up the bulk of the remainder of organisms

A

enterobacteriaceae

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28
Q

PREOP- patient shows signs of infection- what do you do?

what do you do if the infection is at the surgical site

A

fever, chills, malaise- assess to identify source of infection

aggressively treat acute infections before surgery

cancel surgery if localized area of infection is present at intended surgical site

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29
Q

what does smoking do for your infection risk?

how many weeks should they stop smoking before orthopedic surgery?

A

smoking increases incidence of respiratory tract infection and wound infection

stop 4-8 weeks before orthro surgery to decrease incidence of wound healing complications

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30
Q

what does alcohol do to your surgical risk

when should they stop drinking

A

significant preop alcohol consumption may result in general immunocompromise.

stop 1mo reduces post morbidity in alcohol users

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31
Q

hair clipping vs shaving?

A

hair clip

shaving gives tiny cuts- increased risk of infection

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32
Q

s. aureus most commonly implicated in SSI- can be found in the nares, what can we use ahead of time? what is the concern with treating it?

A

topical mupirocin to anterior nares as prophylactic but concern of developing resistant strain to s aureus

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33
Q

cachexia/obesity concerns with surgery

A

both extremes have increased peri-op infection- proper diet and or weight reduction can be beneficial

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34
Q

concern for DM patients and infection

A

DM is an independent risk factors for infection. optimize pre-op DM treatment may decrease periop infection

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35
Q

when are preop ABX stopped
regular surgery
cardiac surgery

A

24 hours after surgery

48 hours after cardiac surgery

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36
Q

how many doses of ABX are given in surgery

A

1 hour prior to surgery

give additional if surgery greater than 4 hours

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37
Q

infections associated with clean surges:

A

staphylococcal

38
Q

infections associated with contaminated surgeries

A

polymicrobial and involve the flora of the viscus entered

39
Q

what coverage do we use for small bowel entrance

A

gram negative coverage

40
Q

what coverage is needed with large bowel and female genital tract surgeries

A

anaerobic organism

41
Q

what drug is effective intraop

A

cephalosporins: ex. cefazolin

42
Q

why is hypothermia a concern during surgery

A

can increase incidence of SSI

43
Q

radiant heating to 38 degree celsius increases

A

sub q 02 tension and may be a mechanism for decreasing SSI risk

44
Q

increasing concentration of inspired oxygen may help decrease surgical site infection although what is the concern with this method?

book says up to 80%

A

high inspired oxygen may cause pulmonary damage

45
Q

how does treating surgical pain help decrease incidence of SSI

A

increases post op sq oxygen partial pressures at wound sites.

46
Q

how does hypocapnia harm the patient under anthesia

A

vasoconstriciton

vasoconstriction that impairs perfusion to vital organs

47
Q

how does making the patient slightly hypercapnia aid in healing

A

it causes vasodilation and increases skin perfusion

48
Q

blood sugar should be maintained in normal range- what are the effects of high blood sugar on the body?

A

high blood sugar concentrations inhibit leukocyte function providing environment for bacterial growth

49
Q

what is the effect of administration of glucose, insulin and potassium

A

stimulates lymphocytes to proliferate and attack pathogens

plays an important role in restoring immunocompetence to patients with immunocompromise

50
Q

what is one of 10 leading causes of death in the us

A

community acquired pna

51
Q

mycoplasma PNA, chamydia, legionella, adenovirus, and other microorganisms may cause atypical pna - are they common. do they respond to abx, are their symptoms normal?

A

not common pna and do not respond to common antibiotics and cause uncommon symptoms

52
Q

what is the most frequent cause of bacterial pna in adults and cause typical pna

A

streptococcus pneumonia

53
Q

aspiration PNA- most commonly from.

A

alcohol

drugs induced alteration of conscousness

head trauma

seizures and other neurologic disorders

administration of sedatives

54
Q

other reasons for aspiration PNA

A

Abnormalities of swallowing/esophageal motility from NGT

Esophageal CA

Bowel obstruction

Repeated vomiting

Poor dental/ oral hygiene d/t
development of bacterial flora after aspiration

Induction and recovery from anesthesia

55
Q

what can we give while walking to the OR do minimize our patients risk of aspiration(per hammon)

A

bicitra 30cc

56
Q

the manifestations of aspiration pna depend on

A

nature and volume of aspirated material

57
Q

aspiration of large volumes of acidic gastric fluid produces

A

fulminant (Sudden, great intensity or severity) PNA and arterial hypoxemia

58
Q

aspiration of particulate materials result in

A

airway obstruction and smaller particles may produce atelectasis

59
Q

which anaerobes are most likely cause of aspiration PNA

A

PCN sensitive anaerobes

60
Q

what is different about hospital acquired pna

A

it alters the usual oropharyngeal flora, aspiration PNA in hospitalized patients often involve pathogens that are uncommon in community acquired pna

61
Q

obesity, age greater than 70 and operations lasting longer than 2 hours have an increase risk of?

A

post op pna

62
Q

chronic lungs disease increases the risk of post op pna how many fold?

A

3 fold

63
Q

what percent of patients undergoing major thoracic, esophageal, upper abdominal surgery develop post op pna

A

20%

64
Q

lung abscess may be seen in what three situations

A

after bacterial PNA

alcohol abuse and poor dental hygiene

septic PE- seen with Iv drug users

65
Q

what are the characteristics of lung abscess?

A

air fluid level of CXR signifies rupture of abscess into bronchial tree

foul smelling sputum

66
Q

treatment for lung abscess

A

abx

67
Q

when is surgery indicated for a lung abscess

A

complications such as empyema

68
Q

physical exam findings associated with worse outcomes of PNA

A 
T:  temp < 35 C or >  40 C
R:  Resp rate > 30
A:  altered mental status
S:  Systolic BP < 90 mmHg
H:  HR > 125 bpm
69
Q

lab findings associated poor prognosis

A 
H:  hypoxia PO2 < 60 mmHg or Sats < 90% on Room Air
E:  effusion
A:  anemia Hct < 30%
R:  renal BUN ? 29 mg/dL
G:  glucose > 250 mg/dL
A:  acidosis pH < 7.35
S:  sodium < 130 mmol/L
70
Q

if acute pna is present what do we do about surgery.

what is it usually associated with

A

Surgery should ideally be deferred if acute pneumonia is present

dehydration and renal insufficiency

71
Q

what are the protective measures during general anesthesia for a patient with pna

A

vt 6-8ml/kg or ideal body mass

mean airway pressure and plateau pressure less than 30cmh20

pulmonary hygiene bronc if necessary

ett gives opportunity to obtain secretions for culture

72
Q

concerns with fluid management for pna patient

A

over hydration can worsen gas exchange and morbidity

73
Q

what is the most common nosocomial infection in the ICU and makes up 1/3 of all nosocomial infections

A

VAP

74
Q

what is the definition of VAP

A

pna developing more than 48 hours after mechanical ventilation has been initiated via endotracheal tube or tracheostomy

75
Q

map increases hospital stay by how many days

can increase hospital cost by

A

7-9 days

40,000 per patient

76
Q

Between_________ of patients who have endotracheal tubes and undergo mechanical ventilation for longer than 48 hours acquire VAP, with mortality rates ranging from ______

A

10% and 20%

5%–50%.

77
Q

Decrease occurrence of VAP

A

meticulous hand hygiene for all caregivers,
providing oral care
limiting patient sedation
positioning patients semi-upright
performing repeated aspiration of subglottic secretions
limiting intubation time if feasible
considering the appropriateness of noninvasive ventilatory support.

78
Q

when is VAP usually suspected

A

VAP is usually suspected when a patient develops a new or progressive infiltrate on chest radiograph, together with leukocytosis and purulent tracheobronchial secretions

79
Q

is VAP difficult to differentiate from other causes?

A

VAP is difficult to differentiate from other common causes of respiratory failure such as acute respiratory distress syndrome (ARDS) and pulmonary edema.

80
Q

Treatment of VAP includes supportive care for respiratory failure plus antibiotics against the organism most likely to be implicated. The most common pathogens (2)

A

Pseudomonas aeruginosa and S. aureus.

81
Q

Patients with VAP frequently require anesthesia for___

should major surgery commense

A

for tracheostomy- may be ill advised if the patient has minimal pulmonary reserve

major surgery should be deferred until the pna has resolved and respiratory function has improved

82
Q

when transporting patients with VAP from the OR what must we use to keep their alveoli open

A

Because patients with respiratory failure may be positive end-expiratory pressure (PEEP) dependent, a PEEP valve should be used to decrease the likelihood of “de-recruitment” of alveoli during transport to the operating room. In the operating room, protective mechanical ventilation should be used.

83
Q

what respiratory viruses may be associated with rampant courses, high virulence and high mortality

many death cases are in__

A

influence a

sars

h5n1- avian flu-subtype of a

young children

84
Q

infection control precautions for SARS & H5N1 influenza A virus

A

Since primary transmission is via direct and indirect respiratory droplet spread, these viruses are highly contagious.
Contact precautions are also necessary because the viruses can be spread via fomites such as clothing, contaminated surfaces, and exposed skin
Barrier precautions include use of full-body disposable over-suits, double gloves, goggles, and powered air-purifying respirators with high-efficiency particulate air filters. If these are not available, N95 masks (which block 95% of particles) should be used rather than regular surgical masks.

85
Q

intraoperative precaution for ears & h5n1 influenza A

A

Aerosolized particles may be generated during all invasive airway procedures, ventilation with noninvasive and positive pressure ventilator support modes, suctioning, sputum induction, high-flow oxygen delivery, aerosolized or nebulized medication delivery, and interventions that stimulate coughing
If mechanical ventilation is required, protective ventilation is indicated. Tidal volumes should be limited to 6–8 mL/kg lean body mass, and mean airway pressure should be less than 30 cm H2O.
Sudden cardiorespiratory compromise could indicate an expanding pneumothorax.
Drainage of pleural effusions may improve ventilation and gas exchange.

86
Q

innate immunity:

A

rapid and nonspecific – it recognizes pathogen-associated molecular patterns (targets common to many pathogens) and requires no prior exposure to elicit an immune response.
is passed on to each generation, apparently to protect the species

87
Q

adaptive immunity (also known as acquired immunity):

A

is a more mature system present only in vertebrates. Each individual must develop their own adaptive immunity.

88
Q

what is the onset and memory of adaptive immunity

A

delayed onset of activation- capable of developing memory and very specific antigenic responses

89
Q

adaptive immunity consists of {what} and is mediated by {what}

A

humoral component mediated by b lymphocytes that produce antibodies and a cellular component composed of T lymphocytes

90
Q

what two subsets are t cells divided into

A

cytotoxic (tc) cells and helper modulatory (th) cells- and are distinguished by their different combinations of surface antigens

91
Q

what cell responses are most important in mounting ineffective response to trauma ,infection, and tumorigenesis

A

t cell responses

Spring '20/ L. BASICS- Immune, OR Hazards, OP (18 decks)

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