Immune system Flashcards
what is most common opportunistic infection in HIV patients
pneumocystic carini
what is most common adverse reaction to a blood transfusion
a febrile reaction
the appearance of hives on a person getting a blood transfusion indicates what
an allergic reaction
what are the signs of a hemolytic reaction in the anesthetized patient
1) first sign is HGB in urine
2) bleeding in surgical field
3) unexplained tachycardia and hypotension
4) rise in temperature
what are the signs of a hemolytic transfusion reaction in awake patient
fever chills chest and flank pain, nausea
what immunoglobulin are latex allergies mediated by
- some might be contact dermatitis (type IV)
- serious reactions to latex are type I mediated IgE reactions to polypeptides in latex
name 2 common protocols used for latex allergies
1) schedule for first case of the day to prevent exposure of latex particles in the air from other cases in room
2) removal of rubber stoppers from drug vials
what 3 factors are associated with risk for developing a latex allergy
1) spinal bifida
2) multiple procedures on urogenital tract
3) spinal cord injury
what food allergies are associated with latex allergies
tropical fruit allergies such as bananas, mangoes, peaches, avocados kiwi, passion fruit, celery, buckwheat, papa, and chestnuts
how long after exposure to latex will a latex sensitive person develop an allergic reaction
onset of symptoms to latex allergy do not genuine until after 30 minutes of exposure compared to 5-10 minutes with other allergies
what family of viruses are HIV a part of
retroviruses
what type of lymphocyte does HIV destroy
T helper cells (CD4 cells)
what are odds of seroconversion after exposure from open bore needle infected with HIV
0.3-0.4%
what are respiratory complications from pneumocystis carinii pneumonia
breathlessness, nigh sweats, bacterial lung abscesses, tuberculosis, fungal infections, pneumothorax, pulmonary kaposi’s sarcoma, and respirator failure. pulmonary adenopathy can be so severe that it results in tracheobroncial and pulmonary vessel compression. Kaposis sarcoma in lungs can cause massive hemoptysis. HIV can also lead to emphysematous destruction to alveolar tissue
How does CXR in a patient with HIV infected with pneumocystis carinii appear
often normal, or with a ground glass appearance and pneumothoracies
what does a positive acid fast bacilli test indicate in a patient with HIV
tuberculosis
what are potential cardiac complications in a person with HIV/AIDS
- abnormal echo in 50% of patients
- pericardial effusions
- myocarditis with ventricular dilation resulting from infection with cryptococcus, coxsackie B virus, CMV, toxoplasmosis, and aspergillus
what does the HAART acronym stand for
Highly active antiretroviral therapy -prevents advancement of HIV infection to AIDS
An HIV patient takes non-nucleoside reverse transcriptase inhibitor-how might this effect your anesthetic plan
prolong the half life and effects of drugs such as diazepam, midazolam, fentanyl, and meperidine
what are the five major classes of antiretroviral dugs used in treatment of HIV
-nucleoside analogue reverse transcriptase inhibitors, non nucleoside reverse transcriptase inhibitors, protease inhibitors, entry inhibitors, and integrate inhibitors
what is zidovudine and what is its principle side effect
nucleoside analogue reverse transcriptase inhibitor use to that HIV, side effect is bone marrow suppression
what is underlying pathology of joints in patients with rheumatoid arthritis
cellular hyperplasia occurs in the synovium with progressive infiltration by lymphocytes, plasma cells, and fibroblasts, which destroy articular cartilage
name symptoms of RA
- symmetric polyarthropathy effecting weight bearing joints and proximal interphalangeal and metacarpophalangeal joints
- symptoms worse in the AM
- every joint may be effected except lumbar and sacral spine
what are treatment options for RA
palliative medial therapy such as corticosteroids(surpression of inflammatory symptoms)
- anticytokine agents such as etanercept, adimumab, and infiximab interfere with cytokine growth known as tumor necrosis factor (slow progression of the disease)
- methotrexate(reduces symptoms)
- immunosuppressive drugs (cyclophosphamide and cyclosporine)
Name major anesthetic considerations for patients with RA
- laryngeal, tempomandibular, and cervical joint issues
- perform careful evaluation
- use of cyclophosphamide can inhibit plasma cholinesterase and prolong duration of action for succinylcholine
- use of long term corticosteroid therapy will warrant extra steroid coverage
what is most common hematologic abnormality in RA patients
anemia
what is the most common pulmonary complication os RA
pleural effusion
what cardiac complications may be present in the patient with RA
- pericardial thickening with effusion in 1/3 of patients
- pericarditis, myocaridits, and coronary artery arteritis
- aortitis may produce dilation of the aortic root and cause aortic regurgitation
- cardiac conduction system issues from rheumatoid nodules
what are airway management concerns in patient with RA
tempomandibular joint and restricted mouth opening
- joints of larynx and cause edema and laryngeal swelling
- cervical spine instability
- atlantoaxial subluxation can push the odontoid process into the foramen magnum during laryngoscopy
what is primary focus of PMNs
phagocytosis of pathogens, recognize self verses non self via pathogen associated molecular patters present on surface of pathogens
what is an interferon
cytokines with anti viral activity-interfere with viral replication
natural killer cells
kill virally infected “self”cells, important for killing cancer cells, release interferon gamma
what is passive immunity
lasts hours to weeks
produced by administering preformed antibody to provide protection against an invasive pathogen or toxin-examples botulism, diphtheria, snake bite-pre-formed antibodies from humans or animals
What type of immunity are B lymphs responsible for
formed in bone marrow-provide humoral immunity via soluble antibody production directed against a specific antigen
what type of immunity are T lymphocytes responsible for
formed in thymus-cell mediated immunity directed against a particular antigen
-most common type are CD4 and CD 8
describe vaccination
type of acquired immunity in which specific diseases by deliberate exposure to a pathogenic antigen. can administer dead organisms
-toxoid vaccines=chemical modifications
attenuated=mutated pathogens that do not cause disease, but produce immunity when exposed via vaccine
mononuclear cells
injection and destruction of damaged and neoplastic cells and bacteria
PMNs
ingestion of phagocytosis, killing microorganisms, facilitation of bodily clearance of dead cells
Eosinophils
phagocytosis of parasites, defense in allergic reponses
neutrophils
phagocytosis, cytokine release, secretion of hydrolytic enzymes, secretion of reactive oxygen species
basophils/mast cells
sources of histamine and heparin, increase vascular permeability, smooth muscle contractility, inflammatory response
platelets
facilitation of coagulation, influence of reactivity of tissue to injury
B cells
humoral immunity, plasma cell transformation, produce antibodies and imunoglobulines, active in circulatory system, cytokine release
T cells
recognition and reaction to foreign material inside fixed tissues and to harmful organisms such as neoplastic and tuberculosis cells, important in transplant rejection, cytokine release
plasma cells
active ein protein synthesis for the formation of immunoglobulins
inflammation
involves innate and acquired immunity
- vasodilation, blood flow, capillary permeability, extraversion of plasma proteins (key coag factors, complement)
- erythemia, edema, pain
allergies
antibodies attach to mast cells and basophils
release histamines and other substances, lead to abnormal response
clinically-urticaria, hay fever like symptoms, asthma, and anaphylaxis
describe histamine
stored in granules of basophils and mast cells, released when antigen reacts with IgE or when complement components C3a and C5a interact with specific membrane receptors=vasodilation(h1), increased capillary permeability(h1), contraction of smooth muscle(h1), cardiac stimulation(h2), stimulation of gastric secretion (H2)
describe “triple response”
erythema from local vasodilation
wheal from increased vascular permeability and protein and fluid extravasation,
flare from axon reflex in sensory never release a peptide mediator
type I hypersensitivity
IgE mediated
tryptase is a marker for allergic reactions (>25mcg/L) indicates an allergic mechanism
-tissue mast cells, peripheral basophils
-pruitis, urticaria, angioedema, hypotension, wheezing, bronchospasm, nausea, vomiting, abdominal pain, diarrhea, uterine contractions, cardiac events, arrhythmia
50% fluid shift
type II hypersensitivity
antibodies specific to antigen attach to cell surface
transfusion reactions, auto immune hemolytic anemia, myasthenia graves, good pastures syndrome
anaphylactoid
non-IgE-may occur with first exposure, identical response to anaphylaxis
example-protamine reaction
type III hypersensitivity
immune complex disease in which antigen antibody complexes deposit in tissues and cause injury=activation of complement, recruitment of phagocytes
-SLE, RA, glomerulonephritis
type IV hypersensitivity
delayed, at least 12 hours after contact with antigen
migration of specific CD4 lymphocytes to reaction site followed by cytokine release and local inflammatory response
-contact dermatitis, granulomatous hypersensitivity (TB, sarcoidosis, Crohns disease)
which type of local anesthetic is most likely to cause a drug reaction? what additives cause allergic reactions in LA
-ester anesthetics more likely to cause reaction because of PABA
-methylbaraben preservatives, and propylparaben. sulfite components
adverse reactions from accidental intravascular injection
what does atopic mean
people with increased allergic tendencies hay fever asthma food/drug allergies
in the atopic patient, what are anesthetic implications
60-70% cross reactivity among muscle relaxant allergies
avoid histamine releasing drugs (morphine, etc.)
-give H1 an dH2 blocker before
treating allergic reaction
O2, airway patency maintained, IV epic, fluids, antihistamines, glucocorticoids (decrease protracted anaphylaxis)
which commonly given agents induce reactions
rocuronium (NMB)>latex>abx>opioids>local anesthetics
what does Epi do in an allergic reaction
increases cAMP which restores normal capillary permeability and relaxes smooth muscle
if on beta blocker may get poor response-give fluids and glucagon
IgA deficiency
susceptible to pyogenic infections, type III sensitivity reactions, strep penumo and haemophilus influenzae
SCID
low levels of circulating lymphocytes, need bone marrow transplant
diGeorge syndrome
abnormal development of parathyroid gland and thymus gland
Hereditary angioneurtonic edema
caused by absence of C1-inhibits Complement system=angioedema upper airway obstruction
chronic granulamatomus disease
defective PMNs, ingested pathogens trigger cell mediated immune response and formation of granulomas
glucocorticosteriods
cause 2ndary immunodeficiency syndrome, reduce monocytes and lymphocytes one dose only for 24 hours
mycophenylate mofetil
inhibits lymphocyte proliferation by blocking last step for purine synthesis and DNA replication
cyclosporine, FK506 (tacrolimus) and rapamycin
inhibit t cell proliferation
what is SLE
chronic inflammatory disease associated with production of antinuclear antiboides
what are most common signs of SLE
polyarthritis, macular rash, renal disease (out common cause of death), risk of vasculitis, high risk of seizures, stroke, neuropathy, psychosis, pericardial effusion
what drugs can exacerbate SLE
procainamide, hydralazine, catorpil, enalopril, isoniazid, d penicllamine, methyldopa
pulmonary issues with SLE
pleural effusion, pneumonitis, alveolar hemorrhage, pulmonary hypertension
airway issues with SLE
cricoarytenoid arthritis, RLN palsy
if a patient with SLE takes corticosteroids and cyclophosphamide, how can this alter your anesthetic plan?
give more steroids during preoperative period because cyclophosphamide inhibits plasma cholinesterase, the effects of ester local anesthetic and succinylcholine may be prolonged
what is scleroderma
collegen vascular disease characterized by inflammation, vascular sclerosis, and fibrosis of skin and organs
- injury to vascular epithelium
- vascular obliteration and leakage of proteins in interstitial space
- tissue edema and lymphatic obstruction
- tissue fibrosis
anesthetic implications for scleroderma
positioning (may be difficult due to contractors)
fiberoptic intubation (decreased mandibular motion)
pharyngeal telangiectasis (bleeding due to airway manipulation)
chronic hypertension
hypotonia of LES (gerd)
avoid acidosis hypoxia can worsen pulmonary hypertension
*regional better because of peripheral vasodilation and improved post op analgesia
pulmonary fibrosis, avascular necrosis of femoral head, renal artery stenosis
what airway complications in SLE
cricoid arthritis, RLN palsy
symptoms of SLE may occur after administering which drugs
hydrazine, phenytoin, isoniazid (mild symptoms resolve in 4 weeks after discontinuation)
patients with SLe have which type of respiratory deficit
restrictive deficit due to pleural effusion, pneumonitis, alveolar hemorrhage, and pulmonary hypertension
which symptoms would you expect to see in a patient with SLE a)nephritis, b)thrombocytopenia, c)cognitive dysfunction, D)spinal arthralgia with limited ROM (select 3)
a, b, c
SLE is very likely if a patient exhibits three of the following characteristic manifestations: antinuclear antibodies, nephritis, serositis, thrombocytopenia, or a characteristic rash. SLE often results in symmetric arthralgias in the hands, wrists, knees, and ankles, but does not involve the spine. Cognitive dysfunction occurs in about 1/3 of patients with SLE.
what is most common cause of death in SLE
renal disease
all of the following pathologies are associated with sarcoidosis except a)cor pulmonae b)chronic extrinsic restrictive lung disease c)restrictive cardiomyopathy d)hypercalcemia
B)chronic extrinsic restrictive lung diseaseSarcoidosis is associated with diffuse granulomatous lesions resulting in intrinsic restrictive lung disease, cor pulmonale, and restrictive cardiomyopathy which may present as heart block and dysrhythmias. Other classic signs are hypercalcemia, hepatic granulomas, splenomegaly, and involvement of the parotid gland and facial and optic nerves.
in regards to HIV drugs, what do NNRTIs do
induce the CYP450 system
what is treatment for RA
corticosteroids, methotrexate, immunosuppressants, NSAIDS
what is cyclophosphamide inhibit
plasma cholinesterase
ester LA, succinylcholine last longer
