Immunity Flashcards
Respiratory complications HIV
PCP, bacterial pna, TB, aspergillosis, CMV, oral/pharyngeal candidiasis, kaposi’s sarcoma, herpes, direct HIV pulm destruction (leads to RF and chronic disease like emphysema). Tracheobronchial/great vessel compression w/adenoma they, endobronchial kaposi’s (massive hemoptysis)
Cardiac complications HIV
Chronic trophic viral infection, co infection, drug related. Pericarditis, pericardial effusion, myocarditis (late stages), dilated CM, endocarditis (IVDA), pulm htn, thromboembolism, CAD/MI, abd aortic aneurysm/dissection
Gi complications of HIV
Diarrhea, proctitis, GI bleed, cholecystitis, anorexia, NV, dysphagia, candida, esophagitis, hep B/C.
Renal and endocrine complic of HIV
Nephropathy, ATN, nephrotic syndrome, adrenal insufficiency, glucose intolerance (HAART)
Hematologist complic HIV
Leukopenia, lymphopenia, thrombocytopenia, anemia
Neuro complic HIV
Sensory neuropathy (parasthesias, painful), encephalopathy/AIDS dementia complex, opportunistic infections, behavioral changes, HAART related CVD
NRTI effects
Nausea, diarrhea, myalgia, inc LFTs, pancreatitis, peripheral neuropathy, renal toxic, marrow supp, anemia, lactic acidosis, inhib P450 (zidovudine + steroids can lead to severe myopathy inc respiratory muscle dysfunction)
Protease inhibitor effects (ritonavir)
Hyperlipidemia, glucose intolerance, abnormal fat
distribution, altered LFTs, inhibition of cytochrome
P-450 3A4 (decreased fentanyl clearance ~ 67%)
NNRTI effects
Delavirdine inhibits cytochrome P450 may inc
conc of sedatives, antiarrhythmics, warfarin,
Ca-channel blockers. Nevirapine induces cytochrome P450 by 98%!
Integrates strand transfer inhibitor fx
Appear well tolerated, may have unknown SE
CCR5 antagonists and entry inhibitors SE
Appear well tolerated, may have unknown SE. Interacts w midazolam, alters clearance/effect
Ritonavir interactions w anesthetic drugs, avoid what drugs
Midazolam and versed (increased fx- sedation, confusion, resp dep). Avoid: demerol, amio, diazepam (life threatening)
HIV pre op prep
Universal precautions. Na hypochlorate kills virus. Look at disease progression/organ fx. Drug reg/SE. Lab results: CD4 (<200 bad, 500-700 good), T lymph (200 low), viral load, CBC, BMP, coags, cxr, ekg, echo, puts
HIV GA considerations
Avoid intubation if extensive pulm disease. Titrate according to anemia, autonomic neuropathy, adrenal insuff, upper a/w obstruc/difficult a/w w kaposis sarcoma. Careful w sux if periph neurop/SC involvement.
HIV regional consid. Why it is good
Still good for pregnant pts. Decreases opioid req- good bc decreased opioid clearance w/protease inhib
HIV regional consid: contraindications, careful w what
Coagulopathy, infection at site, focal neuro lesions, inc ICP. Try other methods before epidural blood patho (risky)
TB s/s
Non productive cough, wt loss, fever, night sweats, malaise, hemoptysis, chest pain
SE isoniazid
Hepatotoxic, periph neurotoxic, renal toxic possible, drug interactions
Rifampin SE
Hepato and renal toxic, anemia, thrombocytopenia, GI upset, drug interactions
Pyrazinamide and ethambutol SE
P- hepatotoxic, GI upset, arthralgia. E- ocular neuritis
TB drugs
Isoniazid, rifampin, pyrazinamide, ethambutol
No elective sx on tb pt until what
No longer contagious: 3 neg sputu, smears, improving symptoms, chest x ray
How to minimize TB: OR room
N 95 mask (pt wears when outside of rm). Keep pt in neg p rm whenever possible. Use separated OR when most ppl not there, keep doors shut
TB protection for vent
Dedicated machine, filter b/w pt circuit and y piece, bacterial filter on exhalation limb to decrease room exposure, staff wears n 95
Prophylactic abx consid in normal pt
Goal to prevent SSI, within 1 hr before incision. Larger dose if obese. Repeat if sx >4 hrs. Avoid hypothermia/hypocarbia/hyperglycemia/blood transfusions/hypoxia
Endocarditis: pts who should get prophylaxis
Artificial heart valve, hx endocarditis, some congenital malformations (repaired <6 mo ago or issues still in valve), damaged heart valves, hypertrophic CM, transplant w problem in valve
Sx where pts get abx if high risk
Dental/oral w mucosa perf, invasive Resp tract infec where mucosa perf (tonsillectomy, adenoids, abscess), infec GI/GU/skin/MS tissue procedure, cardiac sx, hepatobilliary w high risk bacteremia
Abx proph
Still give up to 2 hrs after. Amp 2g (50mg/kg peds), cefazolin 1g (50 mg/kg peds), ceftriaxone 1 g (50 mg/kg), clindamycin 600 mg (20 mg/kg peds)
Type 1 allergic rxn
Antigen-Antibody (IgE, mast cells,
basophils - anaphylaxis, immune-mediated
hypersensitivity)
Type 2 allergic rxn
cytotoxic - Complement Activation (IgG
or IgM binding of the antigen-drug; alternate
pathway, kinin or plasmin activation)
Type 3 allergic rxn
damage secondry to immune complex
formation or deposition
Type 4 allergic rxn
T lymphocyte mediated delayed
hypersensitivity
Anaphylactoid reaction
Chemical Mediator w/no antigen-antibody
reaction (mast cells and basophils activate in a
non-immune reaction)
Anaphylactioid: magnitude of histamine related to what. Hypotension fx. Drugs more apt to do it
total
dose of drug admin and rate of infusion. Basophils release large amounts of histamine in
response to such drugs as muscle relaxants, opioids,
and protamine. Hypotension unlikely unless histamine concentration
doubles
Anaphylactoid prophylaxis in pts w hx
Steroid, h1 and h2 receptor antagonist
Common anaphylaxis offenders
Abx (pcn mostly), anesthetics (except for ketamine and benzos), radiocontrast dyes, foods, insect venom
What anesthetic causes most anaphylaxis. Other things we give than can cause
50% of total from Muscle relaxants. Induction agents (thiopental), abx, protamine (seafood allergy), VA, opioids, LAs, blood (even w match), dextran, hetastarch, vascular grafts, latex
PCN allergy predisposes pt to what
3-4x > risk of rxn to any drug
Differential dx for anaphylaxis
PE, PTX, AMI, CVA, hemorrhage, aspiration, pulm edema, venous air embolism, vasovagal rxn, med OD, asthma, arrythmia, tamponade, postextubation stridor, sepsis
Make sure what equipment is latex free
Mask, ambu bag, suction cath, anesthesia circuit, tourniquet, gloves, stethoscope, IV bags/ports/syringe, pen rose drain, tape, bandage, electrode pads, bp cuff, bair hugger
Early s/s anaphylaxis
Flushing, itching, hypotension, difficult intub (edema), inc PIP/cant ventilate, cv collapse (ischemia and arrhythmias), bradycardia if MR
Biggest abx offenders
B lactam, quinolones, sulfonamides, vanc
What to do when notice anaphylaxis
Communicate to surgeon and team, stop admin of agent, oxygenate, elevate legs, volume: at least 10-25 ml/kg (colloids preferred 10 ml/kg)
Anaphylaxis pharm: 1st line
Epi. Inhib inflammatory mediator release. Relaxes bronchial muscle. Inc bp and notropy.
Adult and child epi doses
Adult 10 mcg/1 mg q 1-2 min. Child 1-10 mcg/kg q 1-2 min
What to give if resistant to epi for anaphylaxis and doses
Glucagon (1-5 mg bolus, gtt 1-2.5 mg/hr). Levo (.05-.1 mcg/kg/min). Vaso (2-10u bolus, gtt .01-.1 unit/min)
Secondary meds for anaphylaxis
B2 ag (albuterol). Diphenhydramine 0.5-1 mg/kg, ranitidine 50 mg. Steroids. Hydrocortisone is favored 250mg IV (Methylprednisolone also OK 80 mg IV)
Anesthesia for septic pt. Pre op focus, arrange for what
ABG/VS/UOP/mental status/pressors/sedation. Large bore/2 IVs. Ensure red cells in fridge. Monitors: a line, CVP/PA, TEE maybe
Optimization goals for septic pt
Normal temp/bg/UOP/ph. MAP >65, CVP 8-12, MV02 >70%, TV 6-8 ml/kg, PIP <30, hgb 7-9, prevent additional infection
Induction for septic pt
Maintain SVR. Etomidate. Consider length of immobility before giving sux
Maintenance consid for septic pt. And emergence
Inotropic/pressors support if needed (dopa, doubt, epi, levo, vaso), consider steroid if unresponsive. May remain intubated on pos pressure to icu
Regional in septic pt
Absolute contraindication to epidurals. Esp w hemodynamic instability- wont tolerate SVR lability. Epidural abscess if bacteremic blood introduced into epidural space
