VIVA 3 22/9/14

 What is anaphylaxis?
 Definition?
 Pathogenesis?
o

 Mediators?
o Immunologic
 IgE mediated reactions
 IgG mediated reactions
 Immune complex/complement mediated reactions
o Non Immunologic
 Mast cell/basophil degranulation in the absence of
immunoglobulins
 What is released?
o Histamine, tryptase, chymase, heparin
o Cytokines (TNFα, IL4, IL13)
o Lipid derived mediators (prostaglandin D2, leukotriene B4,
PAF)
 Clinical manifestations?
o Impending doom
o Increase in HR
o Flushing, headache
o Increase in pulse pressure
o Bronchospasm
o GI irritation (NV, D, Abdo pain).
 what may an awake patient complain of? 
 Treatment?
o Call for help, cease precipitant
o A – secure airway if necessary
o B – ventilate with 100% O2
o C – ensure venous access, IV fluid
 o Adrenaline
 α 1 effects – vasoconstriction, increased PVR,
decreased mucosal oedema
 β 1 effects – increase inotropy and chronotropy
 β 2 effects – increased bronchodilation, decreased
release of mediators from mast cells and basophils
 Dosing
 Noradrenaline
 Glucagon
 Salbutamol
 What other treatments, not in the algorithm?
o Antihistamines
o Steroids
o Sugammadex (for Roc anaphylaxis)

 What is a time constant?
o Mathematical device used to describe the rate of change of an
exponential process
 Definitions?
o Time at which the process would have been complete had the
initial rate of change been allowed to continue
o Time required for an exponential process to reach 63% of final
change
o 95% complete after 3 time constants
 How does it relate to respiratory physiology?
o Redistribution of gas may occur in the lung after gas flow has
ceased at the mouth
o τ
 Function of lung compartment resistance and
compliance
 Expresses how quickly a compartment can react to to
an alteration of pressure
 Indication of the filling/emptying velocity of a lung
compartment
 Lung = large number of compartments, variable time
constants.
 Heterogeneity is exaggerated with lung disease.
 Slow / fast alveoli
 Slow – long time constants (high
resistance/compliance
 Fast – low resistance, low compliance
 Inspiration 
o At a given pressure, a compartment with high resistance and
good compliance will fill slowly with a resulting large volume
(asthma
o A compartment with poor compliance and low resistance fills
quickly resulting in smaller volume (e.g. pulmonary fibrosis)
 Expiration
o Pendelluft
 What is the equation for (T = CR)
o Time constant = compliance x resistance
 Given graph (time on x, volume on y) and 2 lung units, one has
increased resistance, what effect on the graph, one has half
compliance, what effect on graph?

o If an airway has higher resistance, movement into/out of lung
 will be slower
o If lower compliance the flow of air into that unit will cease
sooner than other units.
 Then really wanted to know about how it affects inspiration and
expiration - spoke about bronchospasm but she didn’t seem to want
this
 What is the layout of the pulmonary circulation?
o Pulmonary trunk arises from right ventricle and branches into
left and right arteries.
o Pass posterolaterally to the main bronchi and follow them into
the lungs
o Branch with the bronchi
o Pulmonary capillaries line alveolar walls
o Pulmonary veins drain oxygenated blood from the pulmonary
capillaries
 Upper and lower veins on both sides (4 veins in total)
 Pulmonary arteries
 Pulmonary veins
 What affects pulmonary vascular resistance?
o General
 Blood viscosity
 Vessel radius
o Specific to the lung
 Pulmonary blood flow (cardiac output is related)
 Distension – capillaries; flattened  circular
 Recruitment – previeously closed  conduct
blood
 Lung volume

 Hypoxic pulmonary vasoconstriction
 Reduced PAO2
 Reduces VQ mismatch
 Others
 Smooth muscle contraction
o Acidosis
o SNS
o Serotonin
o Histamine
o NA
o Arachidonic acid
o Thromboxane A2
 Smooth muscle relaxation
o Ach
o Isoproterenol
o Histamine
o Prostacycline
 Recruitment
 Distention
 Global factors
 Hypoxic pulmonary vasoconstriction
 What are the treatments of pulmonary hypertension
o Calcium channel blockers
o Prostanoids
o Endothelin receptor antagonists
o PDE5 inhibitors (sildenafil)
o Guanylate cyclase stimulants
 How does nitric oxide work?
o Endogenous vasodilators (Ach, bradykinin) activate NO
synthesis in the luminal endothelial cells)
o Calcium efflux from ER into cytoplasm
o Calcium binds calmodulin which activates endothelial NO
synthase resulting in NO synthesis from L-arginine
o NO diffuses into smooth muscle cells where it activates
soluble guanylyl cyclase and cGMP synthesis from GTP.
o cGMP binds and activates protein kinase G  reduction in Ca
influx and inhibition of Ca dependant muscle contraction
 Oxygen supply and safety feature 
o Piped / Cylinders
o Piped
 Reserve bank on cylinders if primary supply fails
 Low pressure alarms
 Pressure reducing valves from VIE/cylinders to PMGV
 VIE – over/under use features
 From wall – anaesthetists
 Behind wall – pharmacy, supplies, engineering
o Cylinders
 Free of water vapour (blocks entry port)
 Pin index system on outlet valve – correct yoke
 Colour coded
 Pressure gauge – assessment of content
 Stored in dry, well ventilated, away from flammable
substances
 Testing every 5 years –
 internal endoscopic,
 flattening/bend/impact testing 1 in 100 cylinders,
 pressure >50% above working pressure
(22000kPa),
 tensile testing 1 in 100 cylinders
 Valves
 Cracking
 Bodok seal

 Sats probe 
 what are the main things that can cause irregularity in the reading
o Accurate +/- 2% in the 70-100% range (<70% readings are
extrapolated)
o Hypoperfusion / peripheral vasoconstriction – reduction in the
AC component.
o COHB – false high reading
o metHB – may cause false low reading
o Coloured nail dye
o No direct information regarding oxygen delivery to tissues
o Average readings every 10-20s
o Movement
o Venous pulsation (high airway pressures, Valsalva)
 Then asked to explain how a sats probe works
o Application of the Beer Lambert law (Beer law
– the amount of light absorbed is directly
proportional to the concentration of the
chromatophore, Lambert law – the amount of
light absorbed is indirectly proportional to the
distance from the light source).
o 2 LEDs, one emits red, one infrared. They blink
in succession, red, infrared, neither (to
compensate for ambient light).
o The detector on the probe absorbs light and
deducts non-pulsatile information.
o
o The ratio of absorption