Lecture 1: Immunity and Infection CO Flashcards
SURGICAL SITE INFECTIONS
- 14-16% of ?
- 14-16% of nosocomial infections
SURGICAL SITE INFECTIONS
- Highest rates in ?
- Highest rates in intra-abdominal cases
SURGICAL SITE INFECTIONS
- Patient, microbial, & wound related factors: review table 26.1 (slide 3)***
- Patient, microbial, & wound related factors: review table 26.1 (slide 3)***
SURGICAL SITE INFECTIONS
- _______, including _____, is predominant cause
- S. aureus, including MRSA, is predominant cause
SURGICAL SITE INFECTIONS
- Presentation usually w/i __ days of surgery (Local inflammation, poor wound healing, sx of systemic infection)
- Presentation usually w/i 30 days of surgery (Local inflammation, poor wound healing, sx of systemic infection)
SURGICAL SITE INFECTIONS
- Gold standard dx ?
- Gold standard dx: aseptically obtained wound culture
SURGICAL SITE INFECTIONS
- Widespread use of broad-spectrum abx are contributing to ?
- Widespread use of broad-spectrum abx are contributing to resistant infections
SSI PREVENTION #1
Frequent handwashing
SSI PREVENTION
Appropriate administration of prophylactic antibiotics (abx):
- Usually within _ hour prior to incision (within _ hours for vancomycin and fluoroquinolones)
- Redose in prolonged surgery (>_ hours)
- Usually within 1 hour prior to incision (within 2 hours for vancomycin and fluoroquinolones)
- Redose in prolonged surgery (>4 hours)
SSI PREVENTION
Appropriate administration of prophylactic antibiotics (abx):
- Most common abx is a first-generation ?
- Most common abx is a first-generation cephalosporin (broad spectrum, low side effects, high tolerability)
SSI PREVENTION
Appropriate administration of prophylactic antibiotics (abx):
- Small bowel also needs ___________ coverage; large bowel and female genital tract surgery need ___________ coverage
- Small bowel also needs gram-negative coverage; large bowel and female genital tract surgery need anaerobic coverage
SSI PREVENTION
Smoking increases respiratory & wound infections
- Preferred to abstain for ?
ETOH: Significant consumption leads to ?
- ? abstinence recommended
Attempt to optimize diabetics preoperatively
- *check ?
Encourage ____________________ in cachexia or obesity before major surgery
If possible, postpone surgery with ?
Non-specific sx’s (fever, malaise, elevated WBC): attempt to ?
4-8 weeks
immunocompromise, one month
A1C
nutritional optimization
active infection at intended surgical site
ID source of infection prior to surgery
SSI PREVENTION
____________ increases likelihood of SSI***
Provide active warming: __________ increases SSI***
Adequate __________ decreases SSI by improving subcutaneous oxygen tension
__________ should be avoided due to vasoconstriction
Optimize glucose control: hyperglycemia inhibits ___________ function***
Tissue hypoxia
- Optimize oxygenation with titration of inspired O2
hypothermia
analgesia
Hypocapnia
leukocyte
BLOODBORNE INFECTIONS
***
Central line infection: the best “treatment” is _________
CDC “Top 5 recommendations” =
Routine practice of using hand sanitizer & scrubbing ports with alcohol before every use of CVL!!!
prevention
(1) handwashing prior to insertion or maintenance (soap & water or hand sanitizer)
(2) using full-barrier precautions (hat, mask, sterile gown, sterile area covering) during insertion
(3) cleaning the skin with chlorhexidine
(4) avoiding the femoral site & peripheral arms when possible - IJ & Subclavian with lower risk; consider pneumothorax risk in Subclav
(5) routine daily inspection of catheters w/ removal ASAP
TRANSFUSION
_________ contamination is the greatest risk of transfusion-transmitted disease (NOT complication)
1: 5,000 for ________ (stored at room temp) &
1: 50,000 for ________
Bacterial
platelets
PRBCs
TRANSFUSION
Viral contamination very high or low due to ?
Risk of HIV-1 and hepatitis C virus transmission: 1 in __________ blood transfusions
low, vigorous screening (minipool nucleic acid amplification)
2 million
TRANSFUSION
Dual risk of?
Risk conferred even in autologous transfusion r/t ?
Leukodepletion increases or decreases risk?
Platelets: X of every 1000 to 3000 units of PLT have bacterial contamination
? is a major factor in microbial growth
bacterial contamination of product & immunosuppression
NK cell inhibition
decreases risk
one
Room temp storage
SEPSIS: Septic shock
defined by ?
Sepsis: SIRS w/ ?
*Surgery and anesthesia should be postponed to at least initiate treatment
defined by hypotension not reversed with IVF’s
Sepsis: SIRS w/ infectious source..... Bacteremia Fungemia Parasitemia Viremia Other
SEPSIS: SIRS
- SIRS response can lead to ?
- Surgery & anesthesia should be postponed to at least initiate treatment
systemic vasodilation, altered capillary permeability, & MSOF
Pancreatitis
Burns
Trauma
Other
SEPSIS: Classic distributive shock
defined by?
*Surgery & anesthesia should be postponed to at least initiate treatment
high output cardiac failure with hypotension, bounding pulses, & wide pulse pressure
Source control surgery:
4-Ds of Source Control:
Underlying cause of infection requires urgent surgery (REMOVE SOURCE)
Ex: abscesses, infective endocarditis, bowel perforation or infarction, infected prosthetic device, endometritis, and necrotizing fasciitis
4-Ds of Source Control: Drainage Debridement Device Removal Definitive Control (bowl resection, cholecystectomy)
SEPSIS: Dx
Dx:
via culture; important to culture all likely sources (blood, urine, sputum minimum)
narrow abx coverage ASAP
SEPSIS: Tx
Tx:
Time sensitive
empiric antibiotics then tailored to cultured organism ASAP
goal directed therapy with end organ perfusion as a goal - MAP >65, CVP 8-12, adequate UOP, correction of metabolic acidosis, mixed venous O2 sat >70%
SEPSIS: Anesthetic
Note limited reserve; prone to ? Will need?
Adequate vascular access for ?
Prioritize ?
Anticipate ?
hypoxemia & hypotension; invasive monitoring (ABP)
resuscitation
antibiotic administration
ICU admission
SEPSIS: Anesthetic
Concern with use of _________.
_______ insufficiency may already be present & may be worsened even with single dose.
etomidate
adrenal
SEPSIS: Anesthetic
Substantial _________ release may accompany surgical manipulation of infectious source. Can lead to ?
cytokine
decompensation
SEPSIS : Resuscitation and Tx
Review slide 12!
Resuscitation and Tx: Review slide 12!
SEPSIS: Four pillars of severe sepsis management
immediate resuscitation
empiric therapy
source control
prevention of further complications
What is the pressor of choice in the fluid resuscitated patient with sepsis?
Norepinephrine
Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***
Epi: Alpha1 = Beta1 = Beta2 = HR = Target Organs =
Epi: Alpha1 = ++++ Beta1 = ++++ Beta2 = ++++ HR = ++++ Target Organs = Skin, muscle
Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***
NE: Alpha1 = Beta1 = Beta2 = HR = Target Organs =
NE: Alpha1 = ++++ Beta1 = ++++ Beta2 = ++ HR = ++ Target Organs = Central organs
Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***
Dopa: Alpha1 = Beta1 = Beta2 = HR = Target Organs =
Dopa: Alpha1 = ++ Beta1 = ++ Beta2 = ++++ HR = ++++ Target Organs = Skin, muscle
Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***
Phenylephrine: Alpha1 = Beta1 = Beta2 = HR = Target Organs =
Phenylephrine: Alpha1 = ++ Beta1 = 0 Beta2 = 0 HR = - ? Target Organs = No real change
SEPSIS : Resuscitation and Tx
***Review slide 13!
Resuscitation and Tx
***Review slide 13!
Underfilled/under resuscitated:
CVP =
SVO2 =
SV =
CVP = 8 cmH2O
SVO2 = 55%
SV = 45mL
*give volume!
Filled/resuscitated:
CVP =
SVO2 =
SV =
CVP = 12 cmH2O
SVO2 = 70%
SV = 79mL
*volume status adequate
Overfilled/over resuscitated:
CVP =
SVO2 =
SV =
CVP = 18 cmH2O
SVO2 = 80%
SV = 110mL
*remove volume!
AHA 2017 Guidelines: INFECTIVE ENDOCARDITIS (IE)
***
Antibiotic prophylaxis with dental procedures is reasonable for patients with ?
cardiac conditions associated with the highest risk of adverse outcomes from endocarditis
AHA 2017 Guidelines: INFECTIVE ENDOCARDITIS (IE)
***
Antibiotic prophylaxis with dental procedures is reasonable for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including:
- Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
- Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
- Previous endocarditis
- Congenital heart disease (CHD) ONLY in the following categories:
• Unrepaired cyanotic CHD, including those with palliative shunts and conduits
• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure
• Repaired CHD with residual shunts or valvular regurgitation at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients with valve regurgitation due to a structurally abnormal valve
AHA 2017 Guidelines: INFECTIVE ENDOCARDITIS (IE)
***
Conclusive or no conclusive evidence that links GI or GU tract procedures with the development of IE ?
no conclusive
GI INFECTIONS
C. difficile:
aerobic or anaerobic?
gram-positive or gram-negative
spore forming?
anaerobic
gram-positive
spore forming (resistant to heat, acid, and antibiotics)
GI INFECTIONS
Most common cause of in-hospital diarrhea (frequency increasing due to widespread use of broad spectrum abx)?
C. difficile
GI INFECTIONS
Risk doubles after X days of antibiotics
3 days
*minimize post op prophylactic abx usage
GI INFECTIONS
C. diff to OR for acute abdomen will be very ?
Anticipate ?
Plan for ?
ill
dehydration, acid base abnormalities, and electrolyte imbalances
invasive monitoring to guide fluid resuscitation and vasopressor administration
GI INFECTIONS
Alcohol-based hand sanitizer will not kill spores; best tx is ?
prevention with vigorous hand washing with soap & water and use of contact isolation precautions
- Spores that are resistant to heat, acid, and antibiotics
- Extremely hardy & resistant to common disinfectant
GI INFECTIONS
C. difficile: Tx
oral metronidazole or oral vancomycin
newer therapy: fidaxomicin; success with fecal transplant
NECROTIZING SOFT TISSUE INFECTION
Variety:
Fournier’s, gas gangrene, “flesh eating” bacteria
NECROTIZING SOFT TISSUE INFECTION
Presentation may not reveal ?
Pain is often out of proportion to ?
_____ symptoms likely!
Often occur in the ______ area; ______ at site may be present.
severity
symptoms
SIRS
genital; crepitus
NECROTIZING SOFT TISSUE INFECTION
Surgical __________ with very high mortality (up to X%)
DO NOT ?
Definitive treatment is ?
Surgical emergencies with very high mortality (up to 75%)
DO NOT POSTPONE
Definitive treatment is surgical debridement along with abx
NECROTIZING SOFT TISSUE INFECTION
Anesthetic:
tx like severe ______ =
anticipate _______ release intraoperatively; ensure vascular access for resuscitation
sepsis
aggressive fluid resuscitation & goal directed therapy; avoid etomidate (adrenal suppression)
*have vasopressin ready!
cytokine
TETANUS
Gram + or - ?
occurs with ______ contamination of wound
Gram-negative; occurs with spore contamination of wound
TETANUS
Symptoms are from the neurotoxin “___________”
- CNS effects
_______ is often the presenting sx
- may initially present as ?
SNS responses are labile & exaggerated
- expect ?
Laryngeal, pharyngeal, intercostal, & diaphragmatic spasms
- all can affect ?
- may need ?
Symptoms are from the neurotoxin “tetanospasmin”
- CNS effects
Trismus is often the presenting sx***
- may initially present as dental
SNS responses are labile & exaggerated
- expect tachycardia & htn; prone to skeletal muscle spasms that can lead to increased 02 consumption, hyperthermia, & death
Laryngeal, pharyngeal, intercostal, & diaphragmatic spasms
- all can affect adequate ventilation; may need early airway protection
TETANUS
Tx =
? for muscle spasms
? & vent support may be needed
? to mitigate SNS overactivity
Exotoxin neutralized by intrathecal or intramuscular administration of ?
Surgical debridement delayed until a few hours after ?
Tx: controlling muscle spasms, preventing SNS hyperactivity, supporting ventilation, neutralizing toxin, & surgical debridement
Diazepam or lorazepam for muscle spasms
NDNMB & vent support may be needed
Beta-blockers to mitigate SNS overactivity
Exotoxin neutralized by intrathecal or intramuscular administration of human antitetanus immunoglobulin
Surgical debridement delayed until a few hours after antitoxin
TETANUS
Anesthesia: anticipate SNS ______activity
titration of ?
administration of ?
Anesthesia: anticipate SNS hyperactivity
titration of volatile anesthetic
lidocaine, esmolol, metoprolol, magnesium, nicardipine & nitroprusside
PNEUMONIA
Variety of causes:
community-acquired atypical (more common in younger adults) aspiration postoperative ventilator-acquired legionnaires (hotels and whirlpools) fungal (immunocompromised) Chlamydia psittaci (exposure to birds)
PNEUMONIA
Aspiration:
Risk in patients with ?
Increased risk = ?
Poor _____________ and ___________ disease increase pneumonia risk following aspiration
Risk in patients with depressed consciousness & abn swallowing or esophageal motility; induction of anesthesia increases risk
Increased risk: nasogastric tubes, esophageal cancer, bowel obstruction, or repeated vomiting
Poor oral hygiene and periodontal disease increase pneumonia risk following aspiration
PNEUMONIA
Chest xray:
Diffuse infiltrates suggestive of ______ pneumonia
Lobar opacification suggestive of ______ pneumonia
Chest xray:
Diffuse infiltrates suggestive of “atypical” pneumonia Lobar opacification suggestive of “typical” pneumonia
PNEUMONIA
Anesthetic:
Defer surgery if possible in ___________;
expect ________ despite oxygenation in severe cases
Carefully titrate fluids: may present ___________ but ____________ may lead to worsening
Use lung-protective strategies of X mL/kg _____ body mass and mean airway pressures
Defer surgery if possible in acute pneumonia;
expect hypoxemia despite oxygenation in severe cases
Carefully titrate fluids: may present dehydrated but overhydration may lead to worsening
Use lung-protective strategies of 6–8 mL/kg ideal body mass and mean airway pressures <30 cm H2O); use vent setting as similar to ICU as possible; meticulous pulmonary hygiene with suctioning
Use a PEEP valve for transport to minimize de-recruitment in PEEP dependent patient
TUBERCULOSIS
Primary spread is from ?
MDR & XDR strains have emerged. These are more or less virulent & lethal ?
Primary spread is from aerosolized droplets
Multi-drug resistant & extremely drug resistant (XDR) strains have emerged; these are more virulent & lethal
TUBERCULOSIS
Sx =
Increased incidence =
Sx: persistent nonproductive cough, anorexia, weight loss, chest pain, hemoptysis, and night sweats
Increased incidence: minority racial and ethnic groups, people from areas where TB is endemic (Asia, Africa), IV drug abusers, HIV/ AIDS
TUBERCULOSIS
Dx =
Dx: Mantoux, interferon release assays, chest x-ray, sputum culture for acid-fast bacilli
TUBERCULOSIS
First-line drugs =
TB treatment must continue for X months to be curative; X% will have negative sputum within 3 months with treatment
First-line drugs: isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol
TB treatment must continue for 6 months to be curative; 90% will have negative sputum within 3 months with treatment
TUBERCULOSIS
**Isoniazid toxicity:
Neurotoxicity prevented with daily __________
Isoniazid toxicity: peripheral nervous system & liver; hepatotoxicity worsened in rapid acetylators
Neurotoxicity prevented with daily pyridoxine
TUBERCULOSIS
**Rifampicin:
Rifampicin: thrombocytopenia, leukopenia, anemia, renal failure; hepatitis in 10%
TUBERCULOSIS: ANESTHETIC
Increased risk of provider exposure especially during ?
Postpone elective procedures until X negative sputum cultures
Perform high-risk procedures (bronchoscopy, tracheal intubation, and suctioning) in ___________ rooms; N95 on ________ for transport; N95 on ________
High-efficiency particulate air filter should be placed in the anesthesia delivery circuit between what and what?
Bacterial filters should be placed on the ________ limb of the anesthesia delivery circuit to decrease the discharge of tubercle bacilli into the ambient air
Sterilize anesthesia equipment with _________ methods, using a disinfectant that destroys tubercle bacilli
Use of a dedicated anesthesia machine and ventilator if possible *try to schedule at end of day
PACU in a negative-pressure isolation room if possible
Increased risk of provider exposure especially during bronchoscopy
Postpone elective procedures until 3 negative sputum cultures
Perform high-risk procedures (bronchoscopy, tracheal intubation, and suctioning) in negative pressure rooms; N95 on patient for transport; N95 on staff
High-efficiency particulate air filter should be placed in the anesthesia delivery circuit between the Y connector and the mask, LMA, or ETT
Bacterial filters should be placed on the exhalation limb of the anesthesia delivery circuit to decrease the discharge of tubercle bacilli into the ambient air
Sterilize anesthesia equipment with standard methods, using a disinfectant that destroys tubercle bacilli
Use of a dedicated anesthesia machine and ventilator if possible *try to schedule at end of day
PACU in a negative-pressure isolation room if possible
INFECTION S/P TRANSPLANT
_______________ therapy
Infections within 1 month- likely source is ?
2nd to 6 months: __________ infections; reactivation disease syndromes (Ex = ?)
- Trimethoprim-sulfamethoxazole (Septra) prophylaxis for Pneumocystis pneumonia for at least X mo’s
- Inflammatory response blunted = ?
> 6 months: Many do well & infection risk (increases/decreases); some deal with chronic or progressive ?
Immunosuppressive therapy
Infections within 1 month- likely source is allograft
2nd to 6 months: Opportunistic infections; reactivation disease syndromes (TB)
- Trimethoprim-sulfamethoxazole (Septra) prophylaxis for Pneumocystis pneumonia for at least 6 mo’s
- Inflammatory response blunted; sometimes difficult to identify source of infection
> 6 months: Many do well & infection risk decreases; some deal with chronic or progressive viral infections (hepatitis B virus, hepatitis C virus, CMV, EBV, herpes zoster)
S/P TRANSPLANT ANESTHESIA
Pre-op:
focus on determining the degree of immunosuppression and transplanted organ function, evaluating for any co-existing infection, reviewing co-morbidities
Minimum: CBC, CMP, LFT’s, viral panels/ viral loads PRN, chest x-ray, ECG
S/P TRANSPLANT ANESTHESIA
Strict _______ technique with all invasive procedures
Active rejection requiring explantation = ?
Elective or non-urgent cases should be postponed in ?
Continue what drugs throughout the perioperative period?
__________ anesthesia is controversial post-transplant
Avoid what due to immunocompromised state?
__________ anesthesia thought to have increased immunosuppressant effects over regional
Cyclosporine: delayed metabolism of NMB’s (esp. ____ronium/ ____ronium) = ?
Strict aseptic technique with all invasive procedures
Active rejection requiring explantation: emergent case
Elective or non-urgent cases should be postponed in active rejection or in patients with evidence of active infection
Continue antimicrobial and anti rejection drugs throughout the perioperative period
Regional anesthesia is controversial post-transplant
Avoid nasal intubation due to immunocompromised state
General anesthesia thought to have increased immunosuppressant effects over regional
Cyclosporine: delayed metabolism of NMB’s (esp. pancuronium/ vecuronium) = increased DOA!
HIV & AIDS
Retrovirus leading to ?
Seroconversion X weeks following inoculation: X-like sx’s; positive ____ 4-8 weeks after inoculation
Retrovirus leading to severe immune dysfunction; lymphotrophic; affinity for CD4 cells
Seroconversion 2-3 weeks following inoculation: flu-like sx’s; positive ELISA 4-8 weeks after inoculation (ELISA detects antibodies to HIV)
HIV & AIDS
Phases =
Acute, latent, & end-stage phases
HIV & AIDS
______ detects antibodies to HIV
ELISA detects antibodies to HIV
HIV & AIDS
Most specific and sensitive test for HIV?
Nucleic acid testing of HIV RNA is the most specific and sensitive test for HIV
HIV & AIDS
Hallmark sx until HAART initiated?
Generalized lymphadenopathy is a hallmark sx until HAART initiated
HIV & AIDS
Hallmark of progression from chronic latent phase HIV to AIDS are?
Hallmark of progression from chronic latent phase HIV to AIDS are weight loss & FTT
Subclinical and clinical multiple organ system involvement is a hallmark of ?
- 2 million in US w/ ?
1: X unaware
Subclinical and clinical multiple organ system involvement is a hallmark of HIV infection
1.2 million in US w/ HIV/ AIDS; 1:8 unaware
HIV & AIDS
Tx =
Tx: highly active antiretroviral therapy (HAART)
Halts viral replication & delays progression
HAART is tailored to individual patients based on viral genotype/ phenotype sensitivity and resistance to drug regimens
HIV & AIDS
________ involvement common; often subclinical
Virus has high affinity for the ___________ & has trophic effects on ________ structures
Manifestations:
Protease inhibitors (HAART):
Cardiac involvement common; often subclinical
Virus has high affinity for the myocardium & has trophic effects on vascular structures
Manifestations: Left ventricular dilatation; cardiac dysfunction may result; pulmonary htn in ~1%, pericardial effusion (25% ), myocarditis in advanced disease; increased risk aneurysms & aortic dissections
Protease inhibitors (HAART): premature atherosclerosis / PVD and diastolic dysfunction
HIV & AIDS
? involvement common;
? is a reservoir for infection;
variety of infectious & _________ diseases;
AIDS ________
CNS involvement common;
CNS is a reservoir for infection;
variety of infectious & neoplastic diseases;
AIDS dementia
HIV & AIDS
What is the most frequent neurologic complication in HIV ?
Peripheral neuropathy is the most frequent neurologic complication in HIV
HIV & AIDS
Pulmonary: prone to ?
PCP pneumonia: less common now with ______; risk increases w/ CD4
Pulmonary: prone to opportunistic infections
PCP pneumonia: less common now with HAART; risk increases w/ CD4 <200; c-xray shows bilateral ground-glass opacities
HIV & AIDS
Endocrine: prone to ______________; _______ levels should be monitored
______________: glucose intolerance; altered lipid metabolism; fat redistribution
Endocrine: prone to adrenal insufficiency; cortisol levels should be monitored
Protease inhibitors: glucose intolerance; altered lipid metabolism; fat redistribution
HIV & AIDS
Hematological: _____ is most common early finding of HIV; bone marrow suppression w/ _________; thrombocytopenia worsens with CD4
Hematological: anemia is most common early finding of HIV; bone marrow suppression w/ zidovudine; thrombocytopenia worsens with CD4 <250; coagulopathies (hypercoaguable vs. bleeding)
HIV & AIDS
Renal:
protease inhibitors can cause ?
HIV-associated nephropathy can lead to ?
Renal: protease inhibitors can cause ATN & kidney stones; HIV-associated nephropathy can lead to renal failure
HAART
Combo of at least X drugs
Commitment = ?
Longterm metabolic effects = ?
HAART does or does not offer protective effects for anesthesia?
Variable effects on ?
Combo of at least 3 drugs
Life long commitment
Longterm metabolic effects: glucose intolerance; lipid abnormalities; increased risk CAD and CVD; fat redistribution to neck, back of neck, & abdomen
HAART does not offer protective effects for anesthesia
Variable effects on liver enzyme (CYP450) induction/ inhibition depending on the combination
HAART
***Table 26.11 (slide 30)
***Table 26.11 (slide 30)
HIV/ AIDS ANESTHETIC
Perioperative risk correlates with immune function: CD4 + cell count of less than X cells/μL puts the patient at significant risk for opportunistic infections and increased infectious risk associated with surgery.
The presence of X, Y, or Z disease may also lead to perioperative complications. Consequently, the patient with AIDS requires significant preoperative ______ regardless of age.
Thorough multi-system evaluation pre-op (CBC, CMP, LFT’s, Coag’s, CXR, ECG, consider echo/ stress test/ cardiac clearance); viral load & CD4’s are or are not required from our perspective?
Consider ______ difficulties with fat redistribution; consider presence ____ lesions
Be sure to document pre-existing ___________ or _______ loss
No increased risk of __ day post surgical complications and no specific preferred _________
- ___________ involvement can affect choice of anesthetic
No what with myopathy?
Perioperative risk correlates with immune function: CD4 + cell count of less than 200 cells/μL puts the patient at significant risk for opportunistic infections and increased infectious risk associated with surgery.
The presence of pulmonary, cardiac, or renal disease may also lead to perioperative complications. Consequently, the patient with AIDS requires significant preoperative workup regardless of age.
Thorough multi-system evaluation pre-op (CBC, CMP, LFT’s, Coag’s, CXR, ECG, consider echo/ stress test/ cardiac clearance); viral load & CD4’s are not required from our perspective
Consider airway difficulties with fat redistribution; consider presence oral lesions
Be sure to document pre-existing neuropathy or vision loss
No increased risk of 30 day post surgical complications and no specific preferred anesthetic
Neurological involvement can affect choice of anesthetic
**Succs!!!
HIV/ AIDS ANESTHETIC
__________ under anesthesia is frequently seen in HIV+ patients
Potential for ___________ instability due to autonomic dysfunction
May have chronic _________ with resultant hypovolemia and electrolyte imbalances (hypokalemia)
May need _________ supplementation (adrenal insufficiency)
Protease inhibitors: Consider __________ duration of action of hepatically metabolized drugs, such as fentanyl, midazolam, and morphine- judicious dosing and careful titration
Perinatal antiretroviral therapy increases/decreases transmission to fetus; C- section increases/decreases vertical transmission from mother to child
Exposure transmission: Prospective studies have suggested a roughly X% risk percutaneously and X% from mucous membrane exposure
Tachycardia under anesthesia is frequently seen in HIV+ patients
Potential for hemodynamic instability due to autonomic dysfunction
May have chronic diarrhea with resultant hypovolemia and electrolyte imbalances (hypokalemia)
May need steroid supplementation (adrenal insufficiency)
Protease inhibitors: Consider prolonged duration of action of hepatically metabolized drugs, such as fentanyl, midazolam, and morphine- judicious dosing and careful titration
Perinatal antiretroviral therapy decreases transmission to fetus; C- section decreases vertical transmission from mother to child
Exposure transmission: Prospective studies have suggested a roughly 0.3% risk percutaneously and 0.09% from mucous membrane exposure
PRIONS
Prions (proteinaceous infective particles) are infectious ______; many preferentially infect ___________ tissue
ex = ?
Universally ____; highly ________
May come to OR for ?
Prions are / are not destroyed by standard mechanisms of decontamination?
Prions (proteinaceous infective particles) are infectious proteins; many preferentially infect neurological tissue
ex: Creutzfeldt-Jakob disease (CJD), Mad Cow
Universally lethal; highly infectious
Prions are not destroyed by standard mechanisms of decontamination
*Limit OR personnel; remove unnecessary equipment; use disposable instruments; wear full barrier precautions (double glove, eye shield; liquid repellant gown); use TIVA and the ICU/portable vent; do not use the pipeline scavenging; essentially everything gets thrown away and incinerated; special care with tissue specimens
IMMUNITY
Two pathways = ?
_________: rapid & nonspecific
_________: delayed onset of activation; capable of memory; humoral (B lymphocytes) & cellular component (T lymphocytes)
Two pathways: innate immunity & adaptive immunity
Innate: rapid & nonspecific
Adaptive (acquired): delayed onset of activation; capable of memory; humoral (B lymphocytes) & cellular component (T lymphocytes)
INADEQUATE INNATE IMMUNITY
Neutropenia: Neutrophil granulocyte count
Neutropenia: Neutrophil granulocyte count <1500/mm3; Increased risk infection if <500/mm3
- May be drug induced, autoimmune-related
- G-CSF: reduces duration of neutropenia after chemo or bone marrow transplant
INADEQUATE INNATE IMMUNITY
______ is the primary organ of complement protein synthesis: advanced ______ disease increases risk of infection
Liver is the primary organ of complement protein synthesis: advanced liver disease increases risk of infection
INADEQUATE INNATE IMMUNITY
____________: most common cause is autoinfarction from vasoocclusive crises in ?
Hyposplenism: most common cause is autoinfarction from vasoocclusive crises in sickle cell anemia
ANGIOEDEMA
Hereditary or ?
Episodic subcutaneous and submucosal edema formation, can compromise ?
Hereditary or acquired
Episodic subcutaneous and submucosal edema formation, can compromise airway
ANGIOEDEMA
Most common hereditary form: autosomal dominant deficiency or dysfunction of ?
- leads to the release of ________ mediators that increase/decrease vascular permeability and produce _____ via ?
- repeated bouts of _____ and/or ______ edema lasting 24–72 hours
- episodes may be triggered by ?
- ______ surgery can be an important trigger of laryngeal attacks
Most common hereditary form: autosomal dominant deficiency or dysfunction of C1 esterase inhibitor
- leads to the release of vasoactive mediators that increase vascular permeability and produce edema via bradykinin
- repeated bouts of facial and/or laryngeal edema lasting 24–72 hours
- episodes may be triggered by menses, trauma, infection, stress, or estrogencontaining oral contraceptives
- dental surgery can be an important trigger of laryngeal attacks
ANGIOEDEMA
Acquired:
Lymphoproliferative disease
- ______________ (0.5% of patients taking)
- Due to increased __________; may develop unexpectedly after prolonged drug use with ?
ACE inhibitors
bradykinin; ACE inhibitor
ANGIOEDEMA
___________: the mainstay of prophylactic therapy; ___________ therapy is another option
- these prophylactics are NOT helpful in acute episodes nor are drugs usually used to treat allergic reaction….
such as?
Androgens: the mainstay of prophylactic therapy; antifibrinolytic therapy is another option
- these prophylactics are NOT helpful in acute episodes nor are drugs usually used to treat allergic reaction (catecholamines, antihistamines)
ANGIOEDEMA
Acute attack of angioedema:
**C1 inhibitor concentrate (plasma-derived or recombinant);
icatibant, a synthetic bradykinin receptor antagonist;
ecallantide, a recombinant plasma kallikrein inhibitor that blocks the conversion of kininogen to bradykinin;
or
**fresh frozen plasma (2–4 units) to replace the deficient enzyme
ANGIOEDEMA
Prior to anesthesia: require prophylaxis before _____ procedures or any procedure requiring?
Prior to anesthesia: require prophylaxis before dental procedures or any procedure requiring intubation
ANGIOEDEMA
___________ should be available
C1 inhibitor concentrates
ANGIOEDEMA
Minimize trauma to ?
Minimize trauma to oropharynx (eg: suctioning)
ANGIOEDEMA
Regional anesthesia is/is not well tolerated?
Regional anesthesia is well tolerated
ALLERGIC REACTIONS
What allergy should be in the differential diagnosis of any cardiovascular collapse in the OR?
Drug
ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!
Classified by mechanism: Type I (anaphylaxis): Type II: Type III: Type IV:
Classified by mechanism:
Type I: (anaphylaxis): IgE mediated and involve mast cells and basophils
Type II: mediate cytotoxicity with IgG, IgM, and complement
Type III: tissue damage via immune complex formation or deposition
Type IV: T lymphocyte–mediated delayed hypersensitivity
ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!
Classified by mechanism:
Type ?: mediate cytotoxicity with IgG, IgM, and complement
Classified by mechanism:
Type II: mediate cytotoxicity with IgG, IgM, and complement
ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!
Classified by mechanism:
Type ?: (anaphylaxis) IgE mediated and involve mast cells and basophils
Type I: (anaphylaxis): IgE mediated and involve mast cells and basophils
ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!
Classified by mechanism:
Type ?: T lymphocyte–mediated delayed hypersensitivity
Type IV: T lymphocyte–mediated delayed hypersensitivity
ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!
Classified by mechanism:
Type ?: tissue damage via immune complex formation or deposition
Type III: tissue damage via immune complex formation or deposition
ALLERGIC REACTIONS
Anaphylactoid reaction = ?
mediator release from mast
cells and basophils through a non-immune mechanism
ANAPHYLAXIS
Incidence = 1:X to 1:XX anesthetics
? collapse, ? edema, & _______spasm
Risk: not reliably predictable; note patients with hx of ?
_____________ of mast cells & basophils
Sx usually within 5-10 minutes of exposure to antigen
- Tachycardia, bronchospasm, laryngeal edema, cutaneous manifestations
- Initial sx difficult to appreciate under anesthesia; 1st sign may be CV collapse
Confirmation via histamine & tryptase levels: time sensitive
Skin testing post-event must take place >6 weeks afterwards
Incidence = 1:3,500 to 1:20,000 anesthetics
CV collapse, interstitial edema, & bronchospasm
Risk: not reliably predictable; note patients with hx of asthma &/or fruit or drug allergies
Degranulation of mast cells & basophils
ANAPHYLAXIS
Sx (usually within X minutes of exposure to antigen) = ?
- Initial sx difficult to appreciate under anesthesia; 1st sign may be ?
Confirmation via what & what levels: ________ sensitive?
Skin testing post-event must take place >Xweeks afterwards
Sx usually within 5-10 minutes of exposure to antigen
- Tachycardia, bronchospasm, laryngeal edema, cutaneous manifestations
- Initial sx difficult to appreciate under anesthesia; 1st sign may be CV collapse
Confirmation via histamine & tryptase levels: time sensitive
Skin testing post-event must take place >6 weeks afterwards
TRIGGERS (MULTI EXAM ?s)
Slide 42 &
Stoelting p. 575-580***
TRIGGERS (MULTI EXAM ?s)
Slide 42 &
Stoelting p. 575-580***
TRANSFUSION REACTION
Hemolytic reactions occur 1: X blood transfusions
Ig? and Ig?
Acute hemolytic reactions: ? incompatibility; ? failure & ?
Tx: aggressive hydration; heparin for DIC +/-
Delayed reactions are often due to ? or ? antibodies: usually require no treatment
Hemolytic reactions occur 1: 10,000–50,000 blood transfusions
IgM and IgG
Acute hemolytic reactions: ABO incompatibility; renal failure & DIC
Tx: aggressive hydration; heparin for DIC +/-
Delayed reactions are often due to Kidd or Rh antibodies: usually require no treatment
TRANSFUSION REACTION
Anaphylactic reactions to blood are/arnt rare;
tx = ?
Anaphylactic reactions to blood are rare; tx: STOP transfusion, fluids, epi, pressors
TRANSFUSION REACTION
Transfusion-related acute lung injury (TRALI):
leading cause of transfusion-related ?
FFP & PLT most/least commonly ?
- ? and ? that occur within 6 hours of transfusion
- activation of _____________ on the pulmonary vascular endothelium from donor leukocyte antibodies
- supportive tx
Transfusion-related acute lung injury (TRALI): leading cause of transfusion-related M&M; FFP & PLT most commonly
- hypoxia and bilateral pulmonary edema that occur within 6 hours of transfusion
- activation of neutrophils on the pulmonary vascular endothelium from donor leukocyte antibodies
- supportive tx
TRANSFUSION REACTION
Transfusion-related immunomodulatory (TRIM) : increased/decreased susceptibility to infection; promotion of ________ growth
- increased/decreased NK cell and phagocytic function, impaired antigen presentation, suppression of _________ production
Transfusion-related immunomodulatory (TRIM) : increased susceptibility to infection; promotion of tumor growth
- decreased NK cell and phagocytic function, impaired antigen presentation, suppression of lymphocyte production
SLIDE 45***
SLIDE 45***
SLIDE 46***
SLIDE 46***
AUTOIMMUNE
Anesthetic implications of autoimmune disorders:
- ? with RA
- ? with SLE
- ? failure with chronic autoimmune hepatitis
- ? crisis in patients treated long term with corticosteroids
Anesthetic implications of autoimmune disorders:
- cervical instability with RA ~ F.O. bronch!*
- renal injury with SLE
- liver failure with chronic autoimmune hepatitis.
- Addisonian crisis in patients treated long term with corticosteroids
AUTOIMMUNE
Newer therapies for autoimmune disorders inhibit immune response: increased/decrease risk of perioperative infection
Newer therapies for autoimmune disorders inhibit immune response: increased risk of perioperative infection
AUTOIMMUNE
Risk of accelerated ?
- autoimmune disease may increase CV morbidity/ mortality X-fold
- long-term steroid therapy is associated with ?
Risk of accelerated atherosclerosis, heart disease, & stroke
- autoimmune disease may increase CV morbidity/ mortality 50-fold
- long-term steroid therapy is associated with hypertension and diabetes mellitus
IMMUNITY & ANESTHESIA
Table 27.7 too?
Surgical stress has a significant immunosuppressive effect but there is also evidence that __________ plays a role
_________ anesthesia attenuates the neuroendocrine surgical stress response
- **________ and neuraxial anesthesia with local anesthetics may help preserve immune system function
Surgical stress has a significant immunosuppressive effect but there is also evidence that anesthesia plays a role
Regional anesthesia attenuates the neuroendocrine surgical stress response
- **Regional and neuraxial anesthesia with local anesthetics may help preserve immune system function
MISCELLANEOUS
Selective IgA deficiency (1:600-800 adults)
- recurrent pulmonary/ sinus infections; must get blood transfusion from IgA _________ donor or will have anaphylaxis
deficient
MISCELLANEOUS
Cryoglobulinemia & cold hemagglutinin disease: microvascular ___________ w/ end organ damage from hypothermia (<33°C); must maintain normothermia
thrombosis
MISCELLANEOUS
__________: accumulation of insoluble fibrillar proteins in various tissues; can be primary or secondary
- Note macroglossia in 20%: enlarged, stiff tongue; enlargement of salivary glands; overall difficult airway
- Cardiac involvement with conduction defects; also severe renal, GI, & hepatic effects
Amyloidosis
MISCELLANEOUS
____________ syndrome: gene deletion; absent or diminished thymus development, other congenital abn (cardiac; facial dysmorphisms); immunocompromised
DiGeorge
