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Advanced Physiology
Exam I-Infectious diseases
109
Physiology
Graduate
05/23/2014

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Cards

Term
TB is most prevalent in what type of patients?
Definition
older population, immigrants, and institutionalized individuals
Term
True or False; bubonic plague has resurfaced?
Definition
true; the black plague was said to have killed 40 Al Qaeda gunmen at an Algerian camp
Term
First line of defense against infection
Definition
skin
Term
SCIP
Definition
surgical improvement project, a CMS initiative to reduce complications through evidenced based care
Term
SCIP sets specific guidlines to reduce the incidence of?
Definition
P/O surg site infections
cardiac events
DVT & VAP
Term
SCIP measures include?
Definition
appropriate antibiotic prophylaxis
appropriate hair removal methods
glucose control (specifically for cardiac procedures)
normothermia
Term
Antibiotics must be given within what time frame?
Definition
30 to 60 minutes of incision
Term
What antibiotic is the exception to the time frame for initial antibiotic prophylaxis?
Definition
Vancomycin- must be given within 120 minutes of incision
Term
Antibiotic infusion must be COMPLETED prior to this, and sufficient time allowed for tissue saturation.
Definition
application of the tourniquet
Term
In cases where incision time has been delayed, what is the recommended time frame that requires redosing?
Definition
> 1 hour since administration will likely require re-dosing/readministration
Term
Responsibilities of the CRNA regarding abx prophylaxis? (part of the assessment & hx)
Definition
determine: if pt is receiving ATC abx; if so, when was the last dose, and when should next dose be given
it is the CRNAs responsiblity to stay on schedule
confirm there is an order in place for abx; if not request an order or have MD document reason abx is not required
Term
True or False, ALL body hair should be removed "clipped" prior to surgery
Definition
False; only remove hair that interferes w/surgery or is excessive. May be done by CRNA for IV/CL insertion
Term
True or false; SCIP initiatives require every pt have a bear hugger applied in the OR
Definition
False; SCIP recommends NORMOTHERMIA, but prescriptive requirements for warming devices has been eliminated
Term
Name 2 disease that have re-emerged?
Definition
TB & Malaria
Term
MIC is?
Definition
Minimal inhibitory concentration: most common in vitro predictor of antimicrobial effect
Term
True or False; every antimicrobial and microbial pair have the same MIC at which the organism is considered susceptible?
Definition
False; each pair has a specific MIC associated with it
Term
General rule that determines the best choice for a targeted bacteria?
Definition
The antibiotic with the lowest MIC is considered the best choice in general
Term
Terms: inhibiting bacterial growth without actually killing the organism itself is?
Definition
bacteriostatic
Term
Killing or rendering bacteria dysfunctional is classified as?
Definition
Bacterialcidal
Term
True or false; all antibiotics have a correlation with dose to killing effect?
Definition
False; some have a dose to killing effect (larger dose- more effective), while others are time dependent- requiring specific tissue concentrations maintained by specific dosing schedule
Term
True/False: Preemptive antibiotic regimen schedules/timing is DIFFERENT than timing regimens in the ICU
Definition
true
Term
What drug accounts for the most FATAL anaphylactic drug reactions? (most reported drug allergy)
Definition
Penicillin
Term
PCN allergy is associated with cross sensitivity to what 3 antibiotic classes?
Definition
Cephalosporins, carbapenems, and monbactims
Term
What structure in PCN/similar abx drives the allergy?
Definition
the beta lactam ring
Term
How long does it typically take for an Allergic reaction to drugs to manifest?
Definition
5-10 minutes after exposure
Term
Latex reactions typically occur within what time frame?
Definition
30+ minutes after exposure
Term
Name the enzyme that bacteria develop that breaks down the beta lactam ring in antibiotics rendering them ineffective?
Definition
Beta-Lactamase
Term
Name a type of beta lactamase bacteria
Definition
MRSA
Term
Classification of cephalosporins?
Definition
Broad spectrum (effective against G + & G- bacteria)
Term
What generations of cephalosporins are effective against MRSA?
Definition
Third gen (cefotaxime/claforan, ceftriaxone/rocephin)
Fourth gen (Cefipime/maxipime)
Fifth gen *best (ceftarolin/teflaro)
Term
Which generation of cephalosporins is most effective against gram negative bacteria?
Definition
second generation: Cefuroxime (ceftin/zinacef), Cefotetan (cefotan)
Term
True or false: Cefazolin (1st Generation) would be the best choice for prophylaxis in a neurosurgical patient?
Definition
False; Cefazolin does NOT penetrate the CNS
Term
Name a cephalosporin that is ideal for prophylaxis in most cases?
Definition
Cefazolin- b/c it is broad spectrum, excellent for skin infections, low incidence of SE's, penetrates most tissue (except CNS)
Term
Dose & Administration time for Cefazolin in the adult pt?
Definition
1gm (>100kg or BMI > 30 requires 2 gm)
given over 3-5 min IVP
redosed @ 3 hours
Term
Cefazolin should be redosed when?
Definition
case is longer than 3 hours and not closed, cases with excessive blood loss (more than 1.5 L) or more than 6 Units PRBCs have been given, if there is a 2nd procedure- prior to 2nd incision or at 3 hours OR time- whichever comes first
Term
Patients scheduled for surgery in which entry into the bowel is expected or a possiblity (ie-appendectomy); prophylaxis should include which abx?
Definition
2nd generation cephalosporins- Cefoxitin & Cefotetan
Term
Adult dosing for Cefoxitin & Cefotetan? (2nd gen)
Definition
1-2gms
Rebolus Cefoxitin (1/2 life 40min) at 2 hours
Rebolus Cefotetan (1/2 life 3-5hr) at 4 hours
Term
Antibiotic most commonly used for MRSA infections?
Definition
Vancomycin
Term
Vancomycin is used against what type of baacteria?
Definition
gram positive bacteria
Term
The action of vancomycin is? (fast/slow)
Definition
slow (works by slowing cell division)
Term
Name a common substitute abx used for pts allergic to cephalosporins?
Definition
Vancomycin
Term
Administration time (relative to incision time) for vancomycin?
Definition
within 60 to 120 minutes
Term
Dose & administration of vancomycin
Definition
Adult: 1 gm (weight based)
Must be given over 60 minutes (give slowly)
redoses at 12 hours
Term
Complications of vancomycin administration caused by giving the drug TOO FAST?
Definition
progression from red man syndrome to hypotension and tachycardia! Should not be given faster than 1gm per hour
Term
Flushing, rash, and itching particularly in the upper torso as a result of histamine release is an adverse effect of what drug?
Definition
Vancomycin
Term
What drug can be given to alleviate the symptoms (d/t the histamine release) associated with vancomycin?
Definition
Benadryl (slowing down the infusion rate may also help decrease symptoms)
Term
What class of antibiotics are most effective when given in large single daily doses?
Definition
Aminoglycosides (gentamicin)
Term
This type of abx are highly polar thus are poorly absorbed via GI tract and should be given IV or IM?
Definition
Aminioglycosides
Term
True or False; Aminoglycosides are effective against gram positive bacteria?
Definition
False; excellent activity against aerobic gram NEGATIVE organisms
Term
What antibiotic would likely be a poor choice for patients with renal failure?
Definition
Aminioglycosides; almost COMPLETELY secreted through the kidney. Close monitoring for balance between effectiveness and renal toxicity is required- thus pharmacy should be dosing this abx based on IBW not actual body weight
Term
Dosing for aminoglycosides? (gentamycin)
Definition
Adult: 1.5mg/kg (MAX 240mg)
Given over 30-60 min
Admin w/in 1 hour of incision
Term
What class of abx are nephrotoxic and ototoxic?
Definition
Aminoglycosides
Term
Risk factors for Gentamycin toxicity include?
Definition
1. Renally compromised patients
2. Elderly (reduced number of functional nephrons)
3. Large dose administration > 5 days (d/t drug accumulation causes damage to nephrons)
Term
What is the first sign of ototoxicity associated with aminoglycosides?
Definition
tinnitis; stop infusion immediatly, ringing may continue for 2 wks (if damage occurs to vestibular or cochlear sensory cells occur hearing loss may be permanent)
Term
Non-depolarizing muscle relaxant effects are prolonged by what abx?
Definition
Gentamycin, tobramycin, and neomycin (aminoglycosides) by inhibiting pre-junctional acetylcholine release and reducing post synaptic senstivity to acetycholine
Term
What two drugs are used to reverse the effects (improve muscle strength)of NDMR?
Definition
Neostigmine & Calcium - improves muscle strength
Term
indications of renal toxicity (associated w/aminioglycoside administration)
Definition
increased creatinine, decreased creatinine clearance, and high trough levels.
Term
True or False; nephrotoxicity associated with gentamycin administration is permanent
Definition
False; if caught early it is usually reversible
Term
definition prodrug? and give an example
Definition
Something (bacteria) has to cleave a portion off before the drug becomes active; Metronidazole (flagyl)
Term
Alcohol insumption must be avoided with this abx?
Definition
metronidazole (flagyl)
Term
Drug used to treat anaerobic bacterial, protozoal and parasitic infections
Definition
Metronidazole
Term
Dose/administration of metronidazole?
Definition
adult dose 500mg, given 60 min before incision and redosed at 6 hours
Term
Most common complaints associated w/ metronidazole?
Definition
GI symptoms
Term
Antibiotic associated w/significant GI side effects specifically the overgrowth of C-diff?
Definition
Clindamycin (cleocin); thus only given when pt is allergic to first line tx like flagyl or other abx will not achieve the goals
Term
Class/mode of action of clindamycin
Definition
Lincosamide, broad spectrum (positive and negative anaerobic activity)
Term
This abx blocks the release of acetycholine at the NMJ pronlonging the effect of NDMRs?
Definition
Clindamycin
Term
dose/schedule for clindamycin
Definition
adult dose 600-900mg given over 30 minutes
within 60 min of incision
redosed @ 3 hours
Term
What operative site is associated with a higher risk for SSI?
Definition
INTRA-abdominal surgery (20% compared to extra-abdominal surgery)
Term
Risk factors for SSIs include?
Definition
1. extremis of age (infant/elderly)
2. chronic ilness
3. DM
4. Corticosteroid therapy
5. Immunocompromised
Term
Scientifically supported strategies to reduce SSIs include?
Definition
1. prophylactic abx w/in 1 hour of incision
2. increased tissue oxygenation (PROVEN for colorectal sx)
3. Pain control (increases oxgyen tension at wound sites)
4. Avoid hypocapnia (hypocapnia occurs frequently in anesthesia, Low PaC02 produces peripheral VASOCONSTRICTION, while hypercapnia produces vasodilation- increasing perfusion to skin)
5. Avoid hypothermia: b/c causes vasoconstriction
6. Avoid hyperglycemia: high BG inhibits leukocyte function, and promotes bacterial growth
7. wound probing: closure w/staples, probing between staples
Term
SIRS:
Definition
cascade of events leading to significant vasodilation, ramping up of inflammatory system and complement cascade, encompasses infection (blood or tissue), sepsis and septic shock
Term
Laboratory/hemodynamic indications of SIRS:
Definition
1. WBC <4K or >11K (or >20% immature forms- babies sent to war)
2. HR >90 bmp
3. Temp <36 or >38
4. RR >20 bmp or PaCO2 <32 mmHg (attempt to compensate for metabolic acidosis)
Term
Intraoperative mgt of sepsis/septic shock includes
Definition
First priority is antibiotics and baseline labs
CL for vasopressors
Arterial lines
CVP
Fluids
Glucose control (important for organ survivial)
Coagulopathy (esp DIC) is common
Term
Treatment goals for Sepsis/septic shock
Definition
1. MAP > 65
2. CVP 8-12
3. urine output 1ml/kg/hour minimally
4. normal pH (without metabolic acidosis)
5. mixed venous oxgyen saturation > 70%
Term
Necrotizing soft tissue infections include?
Definition
Gas gangrene, toxic shock syndromes, severe cellulitis, flesh-eating infections
Term
A subclass of sepsis & are SURGICAL EMERGENCIES?
Definition
necrotizing soft tissue infections
Term
Treatment of necrotizing soft tissue infectons
Definition
gram positive and negative (broad) coverage, natural honey to digest necrotic tissue, hyperbaric (if anaerobic)
Term
Anesthetic challenges associated with necrotizing soft tissue infections
Definition
1. Treatment of hypotension
2. central line placement (art line/cvp)
3. catecholamine/cortisol depletion
4. multiorgan failure-adequate urine output
5. Blood/FFP/Platelets
Term
Patients who develop SIRS driven sepsis are at risk for what?
Definition
coagulapathy or DIC
Term
most powerful poison known to humans second only to botulism
Definition
tetanus
Term
Trismus aka
Definition
lock jaw
Term
Tetanus
Definition
d/t gram negative macillus clostridum tetani, tetanospasm spreads centrally along motor nerves to spinal cord and enters circulation proceeding to the CNS-suppressing inhibitory pathways producing severe muscle spasms (tetany)
Term
What muscles can be effected by tetanus?
Definition
ALL! (laryngeal, pharyngeal, diaphragm)
Term
Stimulus that can precipitate spasms in tetanus?
Definition
light, loud noise, suctioning - anything really. Spasms are tonic/clonic & excrutiatingly painful
Term
Sympathetic nervous system involvement in tetanus presents as?
Definition
tachycardia, arrhythmias, hypertension, labile blood pressure d/t excessive catecholamine release
Term
Anesthetic goals for pts w/tetanus
Definition
1. early intubation/supportive airway measures
2. valium for muscle spasms or NDRMs
3. Beta antagonists (propranolol or esmolol) for tachy-arrythmias and htn
4. penicillin (destroys exotoxin)
5. Arterial line
6. Volatile anesthetics are good (if you have a pressure)
7. Lidocaine, esmolol, magnesium, nicardipine, nitropresside)
Term
Most common nosocomial infection in the ICU
Definition
VAP
Term
Best treatment for VAP is:
Definition
Prevention! 1. meticulous handwashing
2. aspiration of secretions (esp during extubation)
3. Early extubation
4. Choosing approriatness of ventilatory support
Term
Flu Pandemics
Definition
normal flu- typically very young & very old effected
H1N1-children & young adults also affected
SARS (severe acute respiratory distress syndrome)-many deaths included healthcareworkers
new strain H5N1 (bird flu) can jump species
MERS (middle east respiratory syndrome)-many healthcare workers affected
Term
True or False, Flu viruses are highly contageous and spread by droplets
Definition
True
Term
Anesthetic implications for pts with the flu
Definition
Stict iso, contact precaustions, negative pressure roms, N95 pt and provider, full wipe down & circut change for ventilator according to protocols
Term
symptoms of TB include?
Definition
nonproductive cough, night sweats, chest pain, weight loss, hemoptysis
Term
TB is spread via?
Definition
droplets (often pts are asymptomatic initially)
Term
TB is diagnosed by?
Definition
CXR, sputum smears, cultures, direct blood tests, TB skin tests
Term
Treatment of TB?
Definition
continued for 6 months, longer for TB outside of the lungs
Term
Anesthesia related implications for TB
Definition
postpone elective procedures until pt is no longer infectious
negative pressure environment
tight fighting N95
high efficiency air filter in circuit between Y connector and the mask,LMA or ETT.
bacterial filter placed on exhalation limb of circuit
sterilize equipment
isolation p/o
Term
HIV resides in what cells
Definition
CD4+ helper T cells (98% of these cells reside in the lymph nodes)
Term
Hallmark of initial HIV infection
Definition
sore, swollen lymph glands (persist until tx is initiated)
May appear asymptomatic and look healthy
Term
Rapid decline in CD4+ T cell count occurs with?
Definition
HIV conversion to AIDS (T cells are destroyed)
Term
Common features associated with HIV include?
Definition
abnormal echocardiograms (up to 50%), LV dilation, premature CAD, pericardial effusions, aortic aneurysms
Term
neurological manifestions in HIV occur early and can include?
Definition
meningitis and intracranial masses
Term
The most frequent neurological complication of HIV is
Definition
Peripheral neuropathy
Term
True of false; HIV related pulmonary complications are caused by opportunistic infections
Definition
True
Term
In HIV, endobronchial sarcoma may cause?
Definition
massive hemoptysis
Term
Endocrine manifestations of HIV include?
Definition
adrenal insufficiency & glucose intolerance
Term
Renal manifestations of HIV include?
Definition
ATN & kidney stones, ARF r/t disease process & drug regimen
Term
Anesthetic implications r/t HIV
Definition
Drug holidays, drug therapy may increase M &M, CBC, LFTs, RFTs, coagulation studies, CXR and ECG
Meticulous pulmonary care and early extubation if possible
Term
What type of anesthesia should be avoided in pts with AIDS
Definition
NO SAB or Epidural b.c neurological lesions can increase intracerebral pressure
Term
Upregulation of ACH nicotinic receptors may occur in HIV pts (d/t peripheral neurapathy), therefore caution should be taken with use of?
Definition
succinylcholine-autonomic instability, arterial line may be helpful
Also peripheral neuropathy may preclude use of regional
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