PHARM ANESTHESIA INFECTION Flashcards
nitroprusside complication and treatment
The patient is exhibiting symptoms of cyanide toxicity secondary to the nitroprusside medication. These patients can have weakness and confusion and develop pulmonary edema. Thiocyanate (choice C) levels can be checked to ensure the patient does not have a toxic level of cyanide.
Antidotes for cyanide toxicity include amyl nitrite (choice A), sodium nitrite, and sodium thiosulfate.
Bottom Line: The treatment for cyanide toxicity is amyl nitrite.
Propofol
metabolism
hepatic metabolism by conjugation to glucuronide and sulfate
excreted by the kidneys in this water soluble form.
Propofol has an antiemetic effect at low doses possibly by acting on GABA receptors which causes decreased serotonin levels in the area postrema.
Propofol DECREASES intracranial pressure (ICP) in patients with normal or elevated ICP (choice D) while maintaining normal cerebral CO2 reactivity and autoregulation. Propofol also DECREASES intraocular pressure by 30- 40%.
Propofol infusion syndrome is rare and potentially lethal
Clinical features include refractory bradycardia, asystole, metabolic acidosis, rhabdomyolysis, hyperlipidemia, cardiomyopathy, skeletal myopathy, and enlarged liver.
A 48-year-old male presents to the emergency department with complaints of shortness of breath and dyspnea on exertion. A chest x-ray shows a small calcified lesion in the right upper lobe that is new from previous films. The patient reports that he was recently on a hiking trip in Ohio prior to the onset of his symptoms.
The patient is presenting with a Histoplasmosis infection.
Ohio and Mississippi river valleys and are identified on chest x-rays as calcified lesions.
Tx of histoplasmosis
self limiting
do not require any further intervention if the patient’s condition is uncomplicated.
These patients can have bulky mediastinal nodes that can cause compressive symptoms. (and still no tx?)
Bottom Line: The majority of infections with Histoplasmosis are self-limiting and do not warrant treatment.
Steps in Rapid Sequence Intubation:
- Preoxygenation - Administration of 100% oxygen for 3 minutes of normal, tidal volume breathing in a normal, healthy adult establishes an adequate oxygen reservoir to permit 8 minutes of apnea before oxygen desaturation to less than 90% occurs.
- Pretreatment - Patients with significant cardiovascular disease (e.g., ischemic coronary disease) who are being intubated in the ED may benefit from the administration of the synthetic opioid, fentanyl, in a dose of 3 !g/kg to mitigate the release of catecholamines in response to airway manipulation.
- Paralysis with induction - In this phase, a potent sedative agent (Etomidate) is administered by rapid IV push in a dose capable of rapidly producing unconsciousness. This is immediately followed by rapid administration of an intubating dose of an NMBA, usually succinylcholine.
It is usual to wait 45 seconds from the time the succinylcholine is given to allow sufficient paralysis to occur.
- Positioning - The patient should be positioned for intubation as consciousness is lost. Usually, positioning involves head extension, often with flexion of the neck on the body, but there is evidence that simple extension of the head alone, or extension of both the head and neck (the extension-extension position) are equivalent or superior.
Sellick’s maneuver (application of firm backward-directed pressure over the cricoid cartilage) has long been recommended to minimize the risk of passive regurgitation and, hence, aspiration.
- Tube placement and confirmation of placement – End-tidal CO2 detector
Bottom Line: The order for rapid sequence intubation is preoxygenation, pretreatment with fentanyl as needed for cardiovascular disease, paralysis with a potent sedative agent, succinylcholine for paralysis, positioning and tube placement.
Succinylcholine is degraded by
plasma pseudocholinesterase and has a very short half-life.
Succinylcholine is a DEpolarizing neuromuscular blocking agent.
Patients with renal or hepatic dysfunction may have a prolonged response to what non-depolarizing paralytic
vecuronium,
because it is cleared by both the kidney and liver.
pancuronium is eliminated by
both the kidney and liver
and
requires dose adjustments in the setting of renal or hepatic dysfunction.
Cisatracurium elimination is by
elimination is by ester hydrolysis and Hoffman elimination.
and both liver and kidney get “poly” cyst
an isomer of atracurium,
with fewer tendencies to induce release of histamine.
Rocuronium onset
rapid onset of action
and
intermediate duration of action,
which makes it useful for short procedures, and is eliminated by the liver.
Patients with absolute indications for an IVC filter
have thromboembolic disease with a contraindication to anticoagulation or a complication or failure of anticoagulation.
thrombolysis is indicated for
treatment of
acute myocardial infarction,
acute ischemic stroke,
most cases of massive pulmonary embolism.
CAREFUL- “acute” is 24h catheter therapy
Currently approved fibrinolytic agents and their mechanisms
streptokinase, acylated plasminogen streptokinase activator complex (anistreplase),
urokinase, recombinant tissue-type plasminogen activator (rt-PA) (Alteplase; Activase),
and
two recombinant derivatives of rt-PA, tenecteplase (TNKase) and reteplase (Retaplase). All of these agents act by converting the proenzyme, plasminogen, to plasmin, the active enzyme
Heparin acts as
an anticoagulant by
activating antithrombin III a
nd accelerating the rate at which antithrombin inhibits enzymes involved in blood coagulation, particularly thrombin and factor Xa
Mycobacterium avium complex (MAC)
Mycobacterium avium
and
Mycobacterium intracellulare.
aerobic, non-spore forming, and non-motile bacilli.
These organisms produce pulmonary disease in patients with normal immune function
and may lead to
disseminated disease in patients with immunodeficiency.
Disseminated MAC is diagnosed with positive cultures from blood or other normally sterile sites including bone marrow, liver, and spleen (choice A). Blood cultures are the best test for disseminated infection. Sending two separate blood samples will achieve a diagnosis in 99% of cases of disseminated MAC. In cases of early disease, bone marrow biopsy with culture may be the most sensitive test.
MAC cultured from lymph nodes may indicate local disease alone (choice B).
Sputum cultures, bronchial washings, and stool samples can test positive for MAC and represent colonization or local disease (choice C, D and E). Positive cultures from more than one of these sites indicates disseminated disease.
Bottom Line: Disseminated MAC infection occurs in immunocompromised patients. Diagnosis is confirmed with positive cultures from blood, bone marrow, spleen, or liver.