Exam 1

Question 1

_______ is an immediate severe systemic hypersensitivity reaction c/b the rapid IgE mediated immune release of potent mediators from tissue mast cells and peripheral blood basophils.

Answer 1

anaphylaxis

Question 2

_______ responses are those clinical events c/b mediator release from mast cells and basophils by non-IgE mediated triggering events. They can be potentially life threatening reactions like anaphylaxis, although typically are self limiting.

Answer 2

anaphylactoid

Question 3

90% of allergic reactions of IV drugs occur within _______.

Answer 3

3 minutes

Question 4

The specific immune system is aka _______. Immune responses are directed against a particular antigen. Responses can be _______ involving B lymphocytes, or _______ involving T lymphocytes. B lymphocytes arise from _______ or _______. They use _______ and combat primarily _______.T lymphocytes arise from the _______.

Answer 4

acquired immunity; humoral; cell-mediated; plasma cells; bone marrow; antibodies; bacterial infections; thymus

Question 5

Nonspecific immunity, aka _______, includes _______ and _______. Leukocytes perform _______. A foreign body can activate the _______, in which a cascade of plasma proteins is activated.

Answer 5

innate immunity; physical barriers; leukocytes; phagocytosis; complement system

Question 6

A vaccination provides what type of immunity?

Answer 6

acquired

Question 7

_______ is when antibodies and/or activated T cells are administered to provide protection from an invasive agent. The effect is ______, from hours to weeks.

Answer 7

passive immunity; temporary

Question 8

The _______ is a system of 20 different plasma proteins. The principal proteins are _______ and are normally inactive but can be activated by 2 pathways: _______ or _______. It’s major function is to _______.

Answer 8

complement system; C1-C9, B & D; initiated by IgG or IgM (antibody) binding to antigen; an alternative path by endotoxic or drug reaction; recognize bacteria directly and indirectly

Question 9

Angioneurotic edema (hereditary or acquired) is the result of _______ and causes _______.

Answer 9

deficiency of C1 complement system inhibitor; excess C1 release

Question 10

_______ are molecules capable of stimulating an immune response when injected. This response is specific and produces antibodies against the _______. _______ are low molecular weight substances (_______MW), and must combine with a protein or macromolecule to elicit and immune response. This complex becomes an _______ and causes an allergic response. Haptens are not antigenic by themselves, only _______.

Answer 10

Antigens; chemical structure; Haptens; <8,000; antigen; in combination with macromolecules

Question 11

Examples of haptens include:

Answer 11

drugs or their metabolites
chemicals in dust
animal dander
poison ivy

Question 12

_______ are protein immunoglobulin that can recognize and bind to a specific antigen. They function as specific receptor molecules are are located _______. They consist of 2 portions: the _______ which binds antigen and attaches specifically to a particular type of antigen, and the _______ responsible for unique binding.

Answer 12

antibodies; on different immune cells; Fab (Ab fixing); Fc (complement fixing)

Question 13

Effector cells and proteins of the nonspecific immune response include:

Answer 13

monocytes and macrophages
neutrophils
eosinophils
basophils
mast cells

Question 14

_______ are involved in processing and presenting antigens to T cell lymphocytes. They are predominant cells at sites of _______. They perform _______ and digest invading microorganisms. _______ arise from ________ or may be confined to specific organs such as the _______, _______, _______.

Answer 14

monocytes and macrophages; chronic inflammation; phagocytosis; macrophages; monocytes; lung; lymph nodes; spleen

Question 15

_______ are the first cells to appear in an acute inflammatory reaction and contain substances that aid in microbial killing such as enzymes, proteases, acids, hydroxyl radicals, hydrogen peroxide, and superoxide.

Answer 15

neutrophils

Question 16

_______ are associated with parasitic infections. They secrete enzymes that _______ to try to balance things out (negative feedback). One such enzyme is _______ that breaks down histamine. Other cells such as _______ & _______ secrete eosinophilic chemotactic factors to recruit eosinophils to accumulate at sites of _______, _______ & _______.

Answer 16

Eosinophils; limit the response of other inflammatory cells; histaminase; mast cells; basophils; infections; tumors; allergic reactions

Question 17

On the surface of _______ are IgE receptors that release mediators when activated. A type of _______. Function similarly to mast cells, but have the capacity for _______.

Answer 17

basophils; granulocyte; chemotactic migration in response to other stimuli

Question 18

_______ are important mediators of immediate hypersensitivity reactions. They are located in the tissue of perivascular spaces of the skin, lung and intestine. On the surface there are _______ that bind to specific antigens and once activated these cells release physiologically active mediators important to immediate hypersensitivity responses such as _______, _______ & _______. A central step in anaphylactic syndrome is the activation of _______ and _______. Mediators released from mast cells and basophils cause _______.

Answer 18

mast cells; IgE receptors; histamine; Heparin; proteases; mast cells; basophils; severe and abrupt physiologic alterations (what we see)

Question 19

A _______ is an immediate hypersensitivity reaction caused by foreign protein (antigen) binding to IgE antibody on the surface of mast cells, triggering the release of intracellular granules. Examples include _______, _______ & _______.

Answer 19

Type I hypersensitivity response; anaphylaxis; extrinsic asthma; allergic rhinitis

Question 20

A _______ is a cytotoxic hypersensitivity reaction caused by foreign protein binding with IgG or IgM, causing cytolysis or phagocytosis. AN example is _______.

Answer 20

Type II hypersensitivity response; hemolytic reaction

Question 21

A _______ is an immune complex disease caused by external or internal antigens binding with IgG, IgM or IgA which results in an inflammatory reaction. Examples include_______, _______, _______, & _______.

Answer 21

Type III hypersensitivity reaction; snake venom reaction; SLE; post strep; nephritis

Question 22

A _______ is a delayed response involving sensitized T lymphocytes to specific antigens. It does not require _______ for reaction. Examples include _______ and _______.

Answer 22

Type IV hypersensitivity reaction; antibodies; contact dermatitis; tissue rejection

Question 23

Antigen binding to IgE antibodies initiates _______. _______ to the antigen or to a substance of similar structure is required to produce sensitization. On _______, binding of the antigen to bridge two immunospecific IgE antibodies located on the surfaces of mast cells and basophils releases histamine and chemotactic factors of anaphylaxis. This can occur _______.

Answer 23

anaphylaxis; prior exposure; re-exposure; the first time

Question 24

_______ stimulates H1 and H2 receptors which causes _______ and _______. It also causes tachycardia, decreased SVR, & _______ which can be detrimental in those that are cardiac compromised. It is rapidly metabolized by _______ and you would need samples immediately (unrealistic).

Answer 24

Histamine; vasodilation; increased capillary permeability; coronary vasoconstriction; endothelial enzymes

Question 25

_______ released from mast cells and basophils cause granulocyte migration (_______). Granulocyte acitvation may be responsible for _______.

Answer 25

Chemotactic factors of anaphylaxis; chemotaxis; recurrent manifestations of anaphylaxis

Question 26

Chemical mediators of anaphylaxis include:

Answer 26

``` histamine chemotactic factors of anaphylaxis leukotrienes prostaglandins kinins platelet-activating factor tryptase ```

Question 27

_______ are a slow reacting substance of anaphylaxis. They are a product of breakdown of _______. They produce _______, _______, _______ & _______.

Answer 27

leukotrienes; arachidonic acid; bronchoconstriction; capillary permeability; vasodilation; myocardial depression

Question 28

_______ are products of arachidonic acid metabolism by way of the cyclooxygenase pathway. They are potent _______ and produce _______, _______, _______, & _______. _______ is the major metabolite of mast cells and produces _______ and _______. _______ is a potent vasoconstrictor.

Answer 28

prostaglandins; mast cell mediators; vasodilation; bronchospasm; pulmonary hypertension; increased capillary permeability; prostaglandin D2; bronchospasm; vasodilation; PGE2

Question 29

_______ are small peptides synthesized in mast cells and basophils that produce _______, _______ and _______.

Answer 29

Kinins; vasodilation; increased capillary permeability; bronchospasm

Question 30

``` _______ is a potent material producing aggregation of platelets and possibly leukocytes for inflammatory products. Produces clinical manifestations of anaphylaxis such as: - - - - ```

Answer 30

platelet-activating factor (PAF); decreased myocardial force; coronary vasoconstriction; pulmonary edema; increased pulmonary vascular resistance

Question 31

_______ is released with histamine. It also increases vascular permeability and may be a cause of _______. It has _______ and therefore is a good marker of histamine liberation. ___ hours max.

Answer 31

tryptase; airway edema; longer half life (hours); 2.5

Question 32

Non-IgE mediated reactions/anaphylactoid reactions include _______ and _______. It is different from antigen or anti-IgE mediated histamine release because _______. These types of reactions include the reactions to _______ and _______.

Answer 32

complement activation; non-immunologic histamine release; histamine alone is released; opiates; NDMRs

Question 33

Physiologic alterations of mediator release include:

Answer 33

``` urticaria laryngeal edema nausea vomiting abdominal pain diarrhea bronchospasm (increased PIP's, decreased breath sounds, wheezing) CV collapse ```

Question 34

With clinical manifestations of anaphylaxis individuals will vary in onset of symptoms. It is usually soon after introduction of the causative agent (may be delayed _______). Some patients describe a _______. _______, _______, _______, & _______ systems are affected. _______ predominate during anesthesia.

Answer 34

2-20 minutes; a sense of impending doom; cutaneous; GI; CV; respiratory; CV signs

Question 35

Respiratory manifestations include:

Answer 35

rhinitis laryngeal edema bronchospasm

Question 36

CV manifestations include:

Answer 36

``` circulatory collapse (lightheadedness, syncope, ischemic heart symptoms, tachycardia, hypotension, shock) dysrhythmias (palpitations, EKG changes, PACs, PVCs, A fib) ```

Question 37

Hematological manifestations include:

Answer 37

fibrinolysis | DIC

Question 38

CNS manifestations include: | They are secondary to _______ and _______.

Answer 38

``` headache confusion apprehension anxiety seizures coma (late) cerebral hypoxia; hypoperfusion ```

Question 39

You may not see _______ symptoms when the patient is asleep.

Answer 39

CNS

Question 40

GI manifestations include:

Answer 40

``` dysphagia cramping/abdominal pain (d/t smooth muscle contraction) increased mucus secretion N&V diarrhea ```

Question 41

GU manifestations include:

Answer 41

pelvic pain | urinary incontinence

Question 42

Cutaneous manifestations include:

Answer 42

urticaria pruritis angioedema

Question 43

Eye manifestations include:

Answer 43

conjunctivitis increased tearing ocular itching

Question 44

Reactions may mimic: (differential diagnosis)

Answer 44

MI PE irritant induced bronchospasm aspiration

Question 45

Diagnostic tests include:

Answer 45

RAST (radioallergosorbent test, which has a lot of false negatives); ELISA (enzyme linked immunosorbent assay); and skin testing

Question 46

Initial treatment of anaphylaxis includes:

Answer 46

stop administration or reduce absorption of offending agent maintain airway and administer 100% O2 D/C all anesthetic agents ASAP consider SQ or aerosolized epi for laryngeal edema intubation or cricothyrotomy (not an LMA) **rapid IV volume expansion (25-50ml/kg:2-4L) of crystalloid or colloid for hypotension due to increased vascular permeability

Question 47

IV epi dose:

Answer 47

1-3ml of 1:10,000 aqueous solution (0.1mg/ml) given over 10 minutes OR 1-4mcg/min (0.25-1ml/min of a solution of 4mcg/ml made with 1ml of 1:1,000 epi in 250ml fluid)

Question 48

SQ epi dose:

Answer 48

0.01-0.03ml/kg increments of 1:1,000

Question 49

ETT epi dose:

Answer 49

10ml of 1:10,000

Question 50

Dose of epi should be _______. _______ reduces sympathetic response (_______).

Answer 50

titrated to effect; anesthesia; may have to give more epi

Question 51

Epi is a _______. Alpha effects include: _______. Beta effects include _______, _______ & _______.

Answer 51

alpha and beta agonist; increased PVR which reverses peripheral vascular permeability; bronchodilation; positive inotropic/chronotropic effects; increased production of cAMP

Question 52

Secondary therapy for treatment of anaphylaxis includes:

Answer 52

- antihistamine (Benadryl 1mg/kg, max dose 50mg) - ranitidine 1mg/kg (max dose 50mg) - glucocorticoid (hydrocortisone 0.25-1gm or methylprednisone 30-35mg/kg) - aminophylline (loading dose 5mg/kg followed by continuous infusion 0.5-1mg/kg/hr & check level) - inhaled beta 2 agonists - continuous catecholamine infusion (epi, NE, dopamine) - sodium bicarb 0.5-1mg/kg; titrate to ABGs

Question 53

One of the primary causes of anaphylaxis and allergic reactions under anesthesia is _______. There is _______ between muscle relaxants as they have similar chemical structures, especially _______. IgE mechanism directly against the _______ present in muscle relaxants. There is cross sensitivity with other compounds (_______, _______, _______, _______, _______) as they have similar structures. 90-95% occur in females possibly due to _______.

Answer 53

muscle relaxants; cross-sensitivity; quaternary ammonium groups; quaternary or tertiary ammonium ions; drugs; foods; cosmetics; disinfectants; industrial materials; ion epitopes in cosmetics

Question 54

Induction agents, _______, may cause allergic reactions. Those that experience a reaction often have allergies to food, and reported _______ or ______. Another induction agent, _______, has cause severe anaphylaxis. Those that have had a reaction are allergic to _______ and _______ and are also allergic to _______, _______ & _______. Patients allergic to eggs can be allergic to propofol because of the _______. Etomidate allergic reaction differs from other drugs in that it causes _______ and _______.

Answer 54

barbiturates; asthma; rhinitis; propofol; group phenyl nucleus; isopropyl side chain; muscle relaxants; LAs; antibiotics; protein base; GI; cutaneous symptoms

Question 55

_______ allergy is rare. It is often confused with vasovagal changes, IV injection, epi, psychomotor responses. May see cross sensitivity _____ classes, not _____ classes. IgE sensitivity reported to _______.

Answer 55

LA; among; across; parabens

Question 56

Opioids have _______, therefore reactions are rare. Morphine and Demerol cause _______ and most reactions are _______.

Answer 56

close chemical structures to body endorphins; non-immunologic mediated histamine release; self limiting

Question 57

_______ is the most common antibiotic to cause anaphylaxis. It is a _______, and must combine with tissue macromolecules. _______ have a cross sensitivity to PCN. Patient with a _______ should not receive cephalosporins. If a patient has a PCN allergy ask what happens, if it is severe _____. Newer beta-lactim antibiotics, carbapenems and monobactans _______.

Answer 57

PCN; hapten; cephalosporins; + skin test to PCN; do not give a cephalosporin; also have a cross sensitivity to PCN

Question 58

_______ creates a non-immunologic mediated histamine release that is not necessarily an allergic reaction. It occurs when _______ or ______. AKA _______.

Answer 58

Vancomycin; given rapidly; as a concentrated solution; red man syndrome

Question 59

_______ produces skin eruptions and fever that appear ______ (delayed reactions). Incidence of reaction is 10-15 times higher among patients with _____. _______ is required to convert the native sulfonamide into its immunogenic metabolite. IgE antibody.

Answer 59

sulfonamide; between 7-10 days of treatment; AIDS; hepatic metabolism

Question 60

Reactions to contrast dye are not likely _______. Most reactions occur in the first ______. _______ is activated. _______ due to hypertonicity of solution.

Answer 60

IgE mediated; complement system; non-immunologic histamine release from mast cells and basophils

Question 61

Protamine is derived from_______. _______ have an increased risk for life threatening reactions when given protamine IV. _______ patients develop and antibody against protamine. Patient with _______ may develop antibodies. Symptoms include ______, ______, ______ & ______. Has to be given _____.

Answer 61

salmon testis; diabetics receiving insulin containing protamine; vasectomy; fish allergies; rash; urticaria; bronchospasm; hypotension; slow

Question 62

Latex allergy is seen in _______ and _______. Other populations at risk include_______, _______, _______, _______. Each subsequent systemic reaction occurs with ______ and _______. In most severe cases contact occurs between latex and _______, but in some exposure through _______ has caused severe reactions. The problem with lab tests/skin tests is that _______. Management is through _______.

Answer 62

pediatric pathology-spina bifida; healthcare workers; patients experiencing multiple surgeries; chronic bladder catheterizations; atopic individuals; fruit allergies; less provocation; greater magnitude; mucous membranes; aerosolized latex; there is not one universal protein/latex allergen; avoidance and symptomatic therapy

Question 63

Managing the patient with a known latex allergy includes:

Answer 63

- making it the first case of the day - minimize exposure in preop - remove all latex from the OR - use only latex free IV ports - remove stoppers from multidose vials - communicate allergy to all other caregivers

Question 64

Latex reaction symptoms usually manifest within _____. Symptoms in the awake patient include:

Answer 64

30 minutes but can occur from 10-290 minutes post exposure; itchy eyes, pruritis, SOB, wheezing, faintness, impending doom, restlessness, agitation, N&V, abdominal cramping and diarrhea; *hoarseness and laryngeal edema are common

Question 65

Latex allergy symptoms in the anesthetized patient include:

Answer 65

``` tachycardia hypotension wheezing bronchospasm cardio/RR arrest flushing facial edema laryngeal edema urticaria ```