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NURA-620 Co-Existing > Lecture 1: Immunity and Infection CO > Flashcards

Lecture 1: Immunity and Infection CO Flashcards

1
Q

SURGICAL SITE INFECTIONS

- 14-16% of ?

A
  • 14-16% of nosocomial infections
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2
Q

SURGICAL SITE INFECTIONS

- Highest rates in ?

A
  • Highest rates in intra-abdominal cases
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3
Q

SURGICAL SITE INFECTIONS

- Patient, microbial, & wound related factors: review table 26.1 (slide 3)***

A
  • Patient, microbial, & wound related factors: review table 26.1 (slide 3)***
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4
Q

SURGICAL SITE INFECTIONS

- _______, including _____, is predominant cause

A
  • S. aureus, including MRSA, is predominant cause
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5
Q

SURGICAL SITE INFECTIONS

- Presentation usually w/i __ days of surgery (Local inflammation, poor wound healing, sx of systemic infection)

A
  • Presentation usually w/i 30 days of surgery (Local inflammation, poor wound healing, sx of systemic infection)
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6
Q

SURGICAL SITE INFECTIONS

- Gold standard dx ?

A
  • Gold standard dx: aseptically obtained wound culture
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7
Q

SURGICAL SITE INFECTIONS

- Widespread use of broad-spectrum abx are contributing to ?

A
  • Widespread use of broad-spectrum abx are contributing to resistant infections
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8
Q

SSI PREVENTION #1

A

Frequent handwashing

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9
Q

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)

A
  • Usually within 1 hour prior to incision (within 2 hours for vancomycin and fluoroquinolones)
  • Redose in prolonged surgery (>4 hours)
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10
Q

SSI PREVENTION
Appropriate administration of prophylactic antibiotics (abx):
- Most common abx is a first-generation ?

A
  • Most common abx is a first-generation cephalosporin (broad spectrum, low side effects, high tolerability)
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11
Q

SSI PREVENTION
Appropriate administration of prophylactic antibiotics (abx):
- Small bowel also needs ___________ coverage; large bowel and female genital tract surgery need ___________ coverage

A
  • Small bowel also needs gram-negative coverage; large bowel and female genital tract surgery need anaerobic coverage
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12
Q

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 ?

A

4-8 weeks

immunocompromise, one month

A1C

nutritional optimization

active infection at intended surgical site

ID source of infection prior to surgery

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13
Q

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***

A

Tissue hypoxia
- Optimize oxygenation with titration of inspired O2

hypothermia

analgesia

Hypocapnia

leukocyte

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14
Q

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!!!

A

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

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15
Q

TRANSFUSION

_________ contamination is the greatest risk of transfusion-transmitted disease (NOT complication)

1: 5,000 for ________ (stored at room temp) &
1: 50,000 for ________

A

Bacterial

platelets

PRBCs

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16
Q

TRANSFUSION

Viral contamination very high or low due to ?
Risk of HIV-1 and hepatitis C virus transmission: 1 in __________ blood transfusions

A

low, vigorous screening (minipool nucleic acid amplification)

2 million

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17
Q

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

A

bacterial contamination of product & immunosuppression

NK cell inhibition

decreases risk

one

Room temp storage

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18
Q

SEPSIS: Septic shock

defined by ?

Sepsis: SIRS w/ ?

*Surgery and anesthesia should be postponed to at least initiate treatment

A

defined by hypotension not reversed with IVF’s

Sepsis: SIRS w/ infectious source.....
Bacteremia
Fungemia
Parasitemia
Viremia
Other
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19
Q

SEPSIS: SIRS

  • SIRS response can lead to ?
  • Surgery & anesthesia should be postponed to at least initiate treatment
A

systemic vasodilation, altered capillary permeability, & MSOF

Pancreatitis
Burns
Trauma
Other

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20
Q

SEPSIS: Classic distributive shock

defined by?

*Surgery & anesthesia should be postponed to at least initiate treatment

A

high output cardiac failure with hypotension, bounding pulses, & wide pulse pressure

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21
Q

Source control surgery:

4-Ds of Source Control:

A

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)
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22
Q

SEPSIS: Dx

A

Dx:

via culture; important to culture all likely sources (blood, urine, sputum minimum)

narrow abx coverage ASAP

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23
Q

SEPSIS: Tx

A

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%

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24
Q

SEPSIS: Anesthetic

Note limited reserve; prone to ? Will need?
Adequate vascular access for ?
Prioritize ?
Anticipate ?

A

hypoxemia & hypotension; invasive monitoring (ABP)

resuscitation

antibiotic administration

ICU admission

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25
Q

SEPSIS: Anesthetic

Concern with use of _________.
_______ insufficiency may already be present & may be worsened even with single dose.

A

etomidate

adrenal

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26
Q

SEPSIS: Anesthetic

Substantial _________ release may accompany surgical manipulation of infectious source. Can lead to ?

A

cytokine

decompensation

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27
Q

SEPSIS : Resuscitation and Tx

Review slide 12!

A

Resuscitation and Tx: Review slide 12!

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28
Q

SEPSIS: Four pillars of severe sepsis management

A

immediate resuscitation
empiric therapy
source control
prevention of further complications

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29
Q

What is the pressor of choice in the fluid resuscitated patient with sepsis?

A

Norepinephrine

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30
Q

Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***

Epi:
Alpha1 =
Beta1 =
Beta2 =
HR =
Target Organs =
A 
Epi:
Alpha1 = ++++
Beta1 = ++++
Beta2 = ++++
HR = ++++
Target Organs = Skin, muscle
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31
Q

Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***

NE:
Alpha1 =
Beta1 =
Beta2 =
HR =
Target Organs =
A 
NE:
Alpha1 = ++++
Beta1 = ++++
Beta2 = ++
HR = ++
Target Organs = Central organs
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32
Q

Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***

Dopa:
Alpha1 =
Beta1 =
Beta2 =
HR =
Target Organs =
A 
Dopa:
Alpha1 = ++
Beta1 = ++
Beta2 = ++++
HR = ++++
Target Organs = Skin, muscle
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33
Q

Table 12.1/Slide 13: Pharmacologic support of circulation in sepsis***

Phenylephrine:
Alpha1 =
Beta1 =
Beta2 =
HR =
Target Organs =
A 
Phenylephrine:
Alpha1 = ++
Beta1 = 0
Beta2 = 0
HR = - ?
Target Organs = No real change
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34
Q

SEPSIS : Resuscitation and Tx

***Review slide 13!

A

Resuscitation and Tx

***Review slide 13!

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35
Q

Underfilled/under resuscitated:
CVP =
SVO2 =
SV =

A

CVP = 8 cmH2O
SVO2 = 55%
SV = 45mL
*give volume!

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36
Q

Filled/resuscitated:
CVP =
SVO2 =
SV =

A

CVP = 12 cmH2O
SVO2 = 70%
SV = 79mL
*volume status adequate

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37
Q

Overfilled/over resuscitated:
CVP =
SVO2 =
SV =

A

CVP = 18 cmH2O
SVO2 = 80%
SV = 110mL
*remove volume!

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38
Q

AHA 2017 Guidelines: INFECTIVE ENDOCARDITIS (IE)
***
Antibiotic prophylaxis with dental procedures is reasonable for patients with ?

A

cardiac conditions associated with the highest risk of adverse outcomes from endocarditis

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39
Q

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:

A
  • 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
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40
Q

AHA 2017 Guidelines: INFECTIVE ENDOCARDITIS (IE)
***
Conclusive or no conclusive evidence that links GI or GU tract procedures with the development of IE ?

A

no conclusive

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41
Q

GI INFECTIONS

C. difficile:

aerobic or anaerobic?
gram-positive or gram-negative
spore forming?

A

anaerobic
gram-positive
spore forming (resistant to heat, acid, and antibiotics)

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42
Q

GI INFECTIONS

Most common cause of in-hospital diarrhea (frequency increasing due to widespread use of broad spectrum abx)?

A

C. difficile

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43
Q

GI INFECTIONS

Risk doubles after X days of antibiotics

A

3 days

*minimize post op prophylactic abx usage

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44
Q

GI INFECTIONS

C. diff to OR for acute abdomen will be very ?

Anticipate ?

Plan for ?

A

ill

dehydration, acid base abnormalities, and electrolyte imbalances

invasive monitoring to guide fluid resuscitation and vasopressor administration

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45
Q

GI INFECTIONS

Alcohol-based hand sanitizer will not kill spores; best tx is ?

A

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
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46
Q

GI INFECTIONS

C. difficile: Tx

A

oral metronidazole or oral vancomycin

newer therapy: fidaxomicin; success with fecal transplant

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47
Q

NECROTIZING SOFT TISSUE INFECTION

Variety:

A

Fournier’s, gas gangrene, “flesh eating” bacteria

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48
Q

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.

A

severity

symptoms

SIRS

genital; crepitus

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49
Q

NECROTIZING SOFT TISSUE INFECTION

Surgical __________ with very high mortality (up to X%)

DO NOT ?

Definitive treatment is ?

A

Surgical emergencies with very high mortality (up to 75%)

DO NOT POSTPONE

Definitive treatment is surgical debridement along with abx

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50
Q

NECROTIZING SOFT TISSUE INFECTION

Anesthetic:

tx like severe ______ =

anticipate _______ release intraoperatively; ensure vascular access for resuscitation

A

sepsis
aggressive fluid resuscitation & goal directed therapy; avoid etomidate (adrenal suppression)
*have vasopressin ready!

cytokine

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51
Q

TETANUS

Gram + or - ?

occurs with ______ contamination of wound

A

Gram-negative; occurs with spore contamination of wound

52
Q

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 ?
A

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

53
Q

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 ?

A

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

54
Q

TETANUS

Anesthesia: anticipate SNS ______activity
titration of ?
administration of ?

A

Anesthesia: anticipate SNS hyperactivity
titration of volatile anesthetic

lidocaine, esmolol, metoprolol, magnesium, nicardipine & nitroprusside

55
Q

PNEUMONIA

Variety of causes:

A 
community-acquired 
atypical (more common in younger adults) 
aspiration 
postoperative 
ventilator-acquired 
legionnaires (hotels and whirlpools) 
fungal (immunocompromised) 
Chlamydia psittaci (exposure to birds)
56
Q

PNEUMONIA

Aspiration:

Risk in patients with ?

Increased risk = ?

Poor _____________ and ___________ disease increase pneumonia risk following aspiration

A

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

57
Q

PNEUMONIA

Chest xray:
Diffuse infiltrates suggestive of ______ pneumonia
Lobar opacification suggestive of ______ pneumonia

A

Chest xray:

Diffuse infiltrates suggestive of “atypical” pneumonia Lobar opacification suggestive of “typical” pneumonia

58
Q

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

A

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

59
Q

TUBERCULOSIS

Primary spread is from ?

MDR & XDR strains have emerged. These are more or less virulent & lethal ?

A

Primary spread is from aerosolized droplets

Multi-drug resistant & extremely drug resistant (XDR) strains have emerged; these are more virulent & lethal

60
Q

TUBERCULOSIS

Sx =

Increased incidence =

A

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

61
Q

TUBERCULOSIS

Dx =

A

Dx: Mantoux, interferon release assays, chest x-ray, sputum culture for acid-fast bacilli

62
Q

TUBERCULOSIS

First-line drugs =

TB treatment must continue for X months to be curative; X% will have negative sputum within 3 months with treatment

A

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

63
Q

TUBERCULOSIS

**Isoniazid toxicity:

Neurotoxicity prevented with daily __________

A

Isoniazid toxicity: peripheral nervous system & liver; hepatotoxicity worsened in rapid acetylators

Neurotoxicity prevented with daily pyridoxine

64
Q

TUBERCULOSIS

**Rifampicin:

A

Rifampicin: thrombocytopenia, leukopenia, anemia, renal failure; hepatitis in 10%

65
Q

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

A

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

66
Q

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 ?

A

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)

67
Q

S/P TRANSPLANT ANESTHESIA

Pre-op:

A

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

68
Q

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) = ?

A

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!

69
Q

HIV & AIDS

Retrovirus leading to ?

Seroconversion X weeks following inoculation: X-like sx’s; positive ____ 4-8 weeks after inoculation

A

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)

70
Q

HIV & AIDS

Phases =

A

Acute, latent, & end-stage phases

71
Q

HIV & AIDS

______ detects antibodies to HIV

A

ELISA detects antibodies to HIV

72
Q

HIV & AIDS

Most specific and sensitive test for HIV?

A

Nucleic acid testing of HIV RNA is the most specific and sensitive test for HIV

73
Q

HIV & AIDS

Hallmark sx until HAART initiated?

A

Generalized lymphadenopathy is a hallmark sx until HAART initiated

74
Q

HIV & AIDS

Hallmark of progression from chronic latent phase HIV to AIDS are?

A

Hallmark of progression from chronic latent phase HIV to AIDS are weight loss & FTT

75
Q

Subclinical and clinical multiple organ system involvement is a hallmark of ?

  1. 2 million in US w/ ?
    1: X unaware
A

Subclinical and clinical multiple organ system involvement is a hallmark of HIV infection

1.2 million in US w/ HIV/ AIDS; 1:8 unaware

76
Q

HIV & AIDS

Tx =

A

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

77
Q

HIV & AIDS

________ involvement common; often subclinical

Virus has high affinity for the ___________ & has trophic effects on ________ structures

Manifestations:

Protease inhibitors (HAART):

A

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 &amp; aortic dissections

Protease inhibitors (HAART): premature atherosclerosis / PVD and diastolic dysfunction

78
Q

HIV & AIDS

? involvement common;
? is a reservoir for infection;
variety of infectious & _________ diseases;
AIDS ________

A

CNS involvement common;
CNS is a reservoir for infection;
variety of infectious & neoplastic diseases;
AIDS dementia

79
Q

HIV & AIDS

What is the most frequent neurologic complication in HIV ?

A

Peripheral neuropathy is the most frequent neurologic complication in HIV

80
Q

HIV & AIDS

Pulmonary: prone to ?
PCP pneumonia: less common now with ______; risk increases w/ CD4

A

Pulmonary: prone to opportunistic infections

PCP pneumonia: less common now with HAART; risk increases w/ CD4 <200; c-xray shows bilateral ground-glass opacities

81
Q

HIV & AIDS

Endocrine: prone to ______________; _______ levels should be monitored
______________: glucose intolerance; altered lipid metabolism; fat redistribution

A

Endocrine: prone to adrenal insufficiency; cortisol levels should be monitored
Protease inhibitors: glucose intolerance; altered lipid metabolism; fat redistribution

82
Q

HIV & AIDS

Hematological: _____ is most common early finding of HIV; bone marrow suppression w/ _________; thrombocytopenia worsens with CD4

A

Hematological: anemia is most common early finding of HIV; bone marrow suppression w/ zidovudine; thrombocytopenia worsens with CD4 <250; coagulopathies (hypercoaguable vs. bleeding)

83
Q

HIV & AIDS

Renal:
protease inhibitors can cause ?
HIV-associated nephropathy can lead to ?

A

Renal: protease inhibitors can cause ATN & kidney stones; HIV-associated nephropathy can lead to renal failure

84
Q

HAART

Combo of at least X drugs

Commitment = ?

Longterm metabolic effects = ?

HAART does or does not offer protective effects for anesthesia?

Variable effects on ?

A

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

85
Q

HAART

***Table 26.11 (slide 30)

A

***Table 26.11 (slide 30)

86
Q

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?

A

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!!!

87
Q

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

A

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

88
Q

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?

A

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

89
Q

IMMUNITY

Two pathways = ?

_________: rapid & nonspecific

_________: delayed onset of activation; capable of memory; humoral (B lymphocytes) & cellular component (T lymphocytes)

A

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)

90
Q

INADEQUATE INNATE IMMUNITY

Neutropenia: Neutrophil granulocyte count

A

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
91
Q

INADEQUATE INNATE IMMUNITY

______ is the primary organ of complement protein synthesis: advanced ______ disease increases risk of infection

A

Liver is the primary organ of complement protein synthesis: advanced liver disease increases risk of infection

92
Q

INADEQUATE INNATE IMMUNITY

____________: most common cause is autoinfarction from vasoocclusive crises in ?

A

Hyposplenism: most common cause is autoinfarction from vasoocclusive crises in sickle cell anemia

93
Q

ANGIOEDEMA

Hereditary or ?

Episodic subcutaneous and submucosal edema formation, can compromise ?

A

Hereditary or acquired

Episodic subcutaneous and submucosal edema formation, can compromise airway

94
Q

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
A

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
95
Q

ANGIOEDEMA

Acquired:
Lymphoproliferative disease
- ______________ (0.5% of patients taking)
- Due to increased __________; may develop unexpectedly after prolonged drug use with ?

A

ACE inhibitors

bradykinin; ACE inhibitor

96
Q

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?

A

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)

97
Q

ANGIOEDEMA

Acute attack of angioedema:

A

**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

98
Q

ANGIOEDEMA

Prior to anesthesia: require prophylaxis before _____ procedures or any procedure requiring?

A

Prior to anesthesia: require prophylaxis before dental procedures or any procedure requiring intubation

99
Q

ANGIOEDEMA

___________ should be available

A

C1 inhibitor concentrates

100
Q

ANGIOEDEMA

Minimize trauma to ?

A

Minimize trauma to oropharynx (eg: suctioning)

101
Q

ANGIOEDEMA

Regional anesthesia is/is not well tolerated?

A

Regional anesthesia is well tolerated

102
Q

ALLERGIC REACTIONS

What allergy should be in the differential diagnosis of any cardiovascular collapse in the OR?

A

Drug

103
Q

ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!

Classified by mechanism:
Type I (anaphylaxis): 
Type II: 
Type III:
Type IV:
A

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

104
Q

ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!

Classified by mechanism:
Type ?: mediate cytotoxicity with IgG, IgM, and complement

A

Classified by mechanism:

Type II: mediate cytotoxicity with IgG, IgM, and complement

105
Q

ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!

Classified by mechanism:
Type ?: (anaphylaxis) IgE mediated and involve mast cells and basophils

A

Type I: (anaphylaxis): IgE mediated and involve mast cells and basophils

106
Q

ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!

Classified by mechanism:
Type ?: T lymphocyte–mediated delayed hypersensitivity

A

Type IV: T lymphocyte–mediated delayed hypersensitivity

107
Q

ALLERGIC REACTIONS
***ON EXAM! Review slide 40 too!

Classified by mechanism:
Type ?: tissue damage via immune complex formation or deposition

A

Type III: tissue damage via immune complex formation or deposition

108
Q

ALLERGIC REACTIONS

Anaphylactoid reaction = ?

A

mediator release from mast

cells and basophils through a non-immune mechanism

109
Q

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

A

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

110
Q

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

A

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

111
Q

TRIGGERS (MULTI EXAM ?s)
Slide 42 &
Stoelting p. 575-580***

A

TRIGGERS (MULTI EXAM ?s)
Slide 42 &
Stoelting p. 575-580***

112
Q

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

A

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

113
Q

TRANSFUSION REACTION

Anaphylactic reactions to blood are/arnt rare;
tx = ?

A

Anaphylactic reactions to blood are rare; tx: STOP transfusion, fluids, epi, pressors

114
Q

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

A

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
115
Q

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

A

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

116
Q

SLIDE 45***

A

SLIDE 45***

117
Q

SLIDE 46***

A

SLIDE 46***

118
Q

AUTOIMMUNE

Anesthetic implications of autoimmune disorders:

  • ? with RA
  • ? with SLE
  • ? failure with chronic autoimmune hepatitis
  • ? crisis in patients treated long term with corticosteroids
A

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
119
Q

AUTOIMMUNE

Newer therapies for autoimmune disorders inhibit immune response: increased/decrease risk of perioperative infection

A

Newer therapies for autoimmune disorders inhibit immune response: increased risk of perioperative infection

120
Q

AUTOIMMUNE

Risk of accelerated ?

  • autoimmune disease may increase CV morbidity/ mortality X-fold
  • long-term steroid therapy is associated with ?
A

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
121
Q

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

A

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

122
Q

MISCELLANEOUS

Selective IgA deficiency (1:600-800 adults)
- recurrent pulmonary/ sinus infections; must get blood transfusion from IgA _________ donor or will have anaphylaxis

A

deficient

123
Q

MISCELLANEOUS

Cryoglobulinemia & cold hemagglutinin disease: microvascular ___________ w/ end organ damage from hypothermia (<33°C); must maintain normothermia

A

thrombosis

124
Q

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
A

Amyloidosis

125
Q

MISCELLANEOUS

____________ syndrome: gene deletion; absent or diminished thymus development, other congenital abn (cardiac; facial dysmorphisms); immunocompromised

A

DiGeorge

NURA-620 Co-Existing (11 decks)

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