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IgG Immunity, defense against infection IgA‐ Secretions, topical defense IgM‐ Lysis of bacterial cell walls IgE‐ Mast cells, Anaphylaxis and allergy Vasoactive mediators Histamine, leukotrienes, prostaglandins, eosinophil & neutrophil chemotactic factor, plt activating factor Histamine effects Capillary permeability Vasodilation Bronchoconstriction Leukotriene effects Capillary permeability Bronchoconstriction Negative inotropy Coronary artery vasoconstriction Prostaglandins effects Bronchoconstriction Platelet activating factor effects Release of vasoactive amines Complement disorders Hereditary angioedema Hereditary angioedema Airway emergency C1 esterase inhibitor->poorly regulated compliment activation->release of vasoactive mediators (bradykinin)->episodic airway edema What triggers angioedema Emotional stress triggers 30-40% of attacks Treatment for hereditary angioedema Antihistamines & epinephrine doesn't work FFP C1 esterase inhibitor Antifibrinolytics Allergic reactions Anaphylaxis‐ IgE mediated reaction Rhinitis‐ IgE mediated Asthma Food & drug allergies Anaphylaxis‐ Life threatening manifestation of antigen‐antibody reaction Anaphylaxis primary exposure Sensitization via antigen specific IgE antibodies Anaphylaxis secondary exposure Massive degranulation of mast cells & basophils Effects of anaphylaxis Mast cell/basophil degranulation->release of histamine, prostaglandins, & leukotrienes->vasodilation & ↑d capillary permeability->hypotension, bronchoconstriction & CV collapse Treatment for anaphylaxis O2, IV fluids, epinephrine, H1 antagonists, steroids Dosing for epinephrine 1 mg 1:1000 0.01 mg/kg IM Max 0.5 mg in adult Max 0.3 mg in child Dosing for epinephrine for shock but w/ pressure 0.01 mg - 0.1 mg IV. Do not give 1 mg! Dosing for full shock with cardiopulmonary arrest may need 1 mg IV Anaphylactoid reactions Not IgE mediated, similar clinical presentation, don't need prior sensitization S/S of anaphylactoid reactions Degranulations & release of vasoactive mediators->hypotension & CV collapse Treatment of anaphylactoid reactions Similar to anaphylaxis Type 2 hypersensitivity reaction cytotoxic hypersensitivity Antigens are normally endogenous, although exogenous chemicals (haptens) which can attach to cell membranes Drug-induced hemolytic anemia, granulocytopenia & thrombocytopenia IgM & IgG mediated Phagocytes & K cells play a role Amyloidosis Accumulation of insoluble fibrillar proteins  amyloid in heart, vascular smooth muscle, kidneys, adrenals, GI, nerves, and skin Clinical manifestations of amyloidosis Airway‐ macroglossia CV‐ conduction disturbance, RHF Renal‐ nephrotic syndrome Nerves‐ autonomic neuropathy, nerve compression Drug allergy Antigen-antibody, hypotension, bronchospasm, urticaria, unpredictable severity, prior exposure, rapid onset, not dose related, low incidence Drug toxicity Manifestations dependent upon drug Fairly predictable No prior exposure needed Dose related Onset may be delayed Common Drug allergy: Muscle relaxants Account for 60% of periop drug induced allergic reactions High incidence (50%) of cross sensitivity Quaternary ammonium groups (nondepolarizers) Drug allergy: Induction drugs Barbs‐ rare, severe Propofol- egg lecithin emulsion, most common, high incidence of bronchospasm Drug allergy: LAs Rare, accounts for 1% of adverse reactions to locals Ester based->PABA Preservatives (methylparaben, propylparaben) similar to PABA No proven cross-reactivity between ester & amides Drug allergy: Opioids Rare MSO4->histamine release->possible anaphylactoid reaction Drug allergy: VAs Halothane hepatitis- trifluoroacetyl halide metabolites + hepatic microsomal proteins->neoantigens Sevo doesn't produce oxidative halide metabolites Drug allergy: protamine Derived from salmon semen ↑d incidence in pts allergic to seafood, diabetics, vasectomized males) Protamine induced compliment activation->thromboxane->bronchoconstriction & pulm HTN (↑d PAP) Peripheral vasodilation Drug allergy: abx Vanco‐ life threatening anaphylactic & anaphylactoid (red man syndrome) reactions PCN‐ most common cause of fatal anaphylaxis (structurally r/t cephalosporins-> theoretical ↑d risk of allergy Drug allergy: crossmatched blood 3% incidence of allergic reactionst Drug allergy: dextran & hydroxyethyl starch Allergy‐ dextran may react w/ antibodies to viral or bacterial polysaccharides Anaphylactoid‐ dextran may activate compliment Drug allergy: latex ↑d incidence in medical personnel (15% in anesthesiologists) Patients w/ multiple surgeries, fruit (banana) allergies & spina bifida Potential for delayed reaction (>30 minutes) Precautions and prophylaxis for latex allergies Latex free OR environment H1, H2 blockers, corticosteroids may be considered Resistance to infection Reversible, transient, minor immunodepression (N2O & locals inhibit PMN chemotaxis) Stress response to surgical trauma is much more important to immunocompetence Type 1 allergic reaction-hypersensitivity reaction Itching, conjunctivits, rhinitis, laryneal & angioedema, urticaria, bronchospasm (asthma), dysrhythmias, hypotension, GI cramps & malabsorption Disorders of immunoglobulins Deficiencies: X-linked agammaglobulinemia Acquired hypoimmunoglobulinemia Selective immunoglobulin A deficiency Cold autoimmune diseases Multiple myeloma Waldenstrom's macroglobulinemia X‐linked agammaglobulinemia‐ Inability to form any class of antibodies (absent mature B‐lymphocytes)->recurrent bacterial infections Selective immunoglobulin A deficiency 1-600 adults, sinus & pulm infections, risk during blood transfusion (anti-IgA antibodies) Cold autoimmune diseases Abnormal proteins agglutinate in response to cold Cryoglobulinemia Cold hemagglutinin disease Cryoglobulinemia‐ Cold agglutinins->activation of compliment & plts, hyper‐viscosity, renal failure Cold hemagglutinin disease‐ IgM binds erythrocytes when cold->hemolysis, compliment activation, acrocyanosis, Raynaud's, purpura, gangrene, nephritis Multiple myeloma Proliferation of single clone B‐ lymphocytes->immune complex deposition Waldenstrom's macroglobulinemia Neoplastic proliferation of IgM secreting plasma cell->hyper‐ viscosity, infiltration of liver, spleen, lungs, & bone marrow