HIV AND ITS ANAESTHETIC IMPLICATIONS

DR.DEEPAK SOLANKI M.D. ANAESTHESIOLOGY dr.dsolanki@gmail.com

Introduction

 Acquired Immune Deficiency Syndrome, first recognized in 1981 More than 50 million people have been infected with HIV and 20 million have died. World wide two third of 36 million are known carriers of HIV Young women are the fastest growing population with HIV in US Overall Risk of Anaesthesia and Surgery in HIV Positive Patient needs further study. 20-25% of HIV positive patients will require surgery for their Illness

Diagnosis

 As the Viral envelope is composed of different glycoprotein or the p24 antigenic core, these can be detected by diagnostic techniques like

Serologic test Viral Culture Genomic Detection

Standard Screening Test for HIV is ELISA. The most Commonly used test is Western Blot Test . PCR & p24 NOW AVAILABLE & MORE RELIABLE TEST

Epidemiology and General Consideration

 HIV belongs to lentivirus group of retroviruses HIV 1 and 2 have been identified HIV 2 predominantly found in Africa Retroviruses contain the enzyme Reverse Transcriptase It allow viral DNA to be transcribed to DNA The Virus preferentially infects T Helper Lymphocytes (CD4 T Cells) This lead to increased susceptibility to opportunistic infections and
malignancies

Clinical features with Anaesthetic Importance

 HIV is a complex medical disorder In early stage of infection

Headache Photophobia Meningoencephalitis Depression Cranial and Peripheral neuropathies

 In late stage of infection Dementia Encephalopathy Myelopathy Peripheral Neuropathy Meningitis TB Cardiac Autonomic Neuropathy Pericardial Effusion Myocarditis & endocarditis Increased incidence of CAD Kaposis Sarcoma

Treatment

Antiretroviral drugs Treatment of Opportunistic Infections Avoidance of alcohol and smoking Psychosocial Counseling Nutritious diet

Drugs and Anaesthetic Importance

Drugs Nucleoside Analogues Zidovidine Lamividine Stavudine

Side effects Marrow Suppression, Myopathy Inhibits Cytochrome P450 Well Tolerated , Diarrhea , Headache Peripheral Neuropathy Peripheral Neuropathy Renal Toxicity Diarrhea Nephrolithiasis , Inhibits Cytochrome P450 Diarrhea , Headache Elevated triglycerides Diarrhea , Jaundice Injection site reaction , Headache , Brochial pneumonia Bronchospasm , Arrhythmia , Electrolyte Imbalance Hepatic, renal dysfunction , Thrombocytopenia

Tenofovir Diadanosine Indinavir Saquinavir Ritonavir Atazarivir

Protease Inhibitors

Fusion Inhibitors

Enfrevitrate Pentamidine Anti Tubercular drugs

Anaesthetic Consideration

 Patients with HIV infection can report for HIV related problems or unrelated problems like trauma Common surgical Interventions are
Opening of abscesses Caesarian section Abdominal emergencies like bleeding , perforation , lymph node biopsy , spleenectomy , Colectomy Sepsis of Genital tract Perianal Ulceration

Preoperative Check Up

 Careful History H/O drug intake Bleeding episode Any other Systemic involvement due to HIV or due to drugs Intra venous asses may be difficult Drug abuse and anesthetic interaction should be born in mind. Pre operative consent should be proper if patient is having dementia.

Investigations
Routine Investigations ECG & ECHO Pulmonary function test ABG X-ray chest & CT chest MRI Spine or Brain CD4 Count

Risk of Anesthesia & Surgery

 There is a little Specific information on overall risk of anaesthesia Risk of Anaesthesia depend upon other associated diseases ASA grading is more important Anaesthesia is acceptable in all cases Regional anaesthesia is safe

Patients with HIV infection can report for HIV related or unrelated problems. General anaesthesia decreases cell mediated immunity. Anaesthetic drugs like etomidate , Atracurium , Remifantanyl and Desflurane can be used. Metabolism of fentanyl and Midazolam are affected by Cytochrome P450

Succinylcholine should be used with caution oropharyngeal and esophageal pathology Adrenalitis may affect intra operative haemodynamics HIV patient compel us to make scientific use of anesthetic and relaxants

Post Operative Management

Post operative infection is more in these patients We should use minimal invasive procedure Use meticulous aseptic procedure Use appropriate Prophylactic antibiotic

Obstetric & HIV

Perinatal Transmission
Typ e s o f in t e rve n t io n % o f t ra n s m is s io n No in t e rve n t io n Zid o vid in e m o n o t h e ra p y LSCS Alo n e Zid o vid in e + LSCS 20 % 17 % 8 % 0 %

 In the post operative period, narcotics and drug interaction should be kept in mind. The use of epidural patch for post dural puncture headache is safe provided no other viral or bacterial infection is active.

HIV and Pain

Types of pain associated with HIV infection may be due to Headache Herpes Simplex Post Herpetic neuralgia Back pain Abdominal pain Painful peripheral neuropathy HIV related arthralgia

 A specialist in pain management should be consulted when necessary Current pain management includes -Non narcotic and narcotic analgesics -Tricyclic Antidepressants -Anticonvulsant -Therapy should be adequate -Physical therapy and psychological techniques

Safe blood

Anesthesiologists use blood transfusion more frequently Do not accept paid donation Avoid paid donations This root of transmission can be combated by safe blood programme Safe blood programme needs a safe blood donor

Answer to this problem is Voluntary blood donor Service with students Relative blood donor service

HIV and Anesthesiologist

Anesthesiologist should be familiar with disease Understanding of pathogenesis Possible Drug interaction Vigorous Infection control policies

Risk of Cross infection

Patient to Anesthetist

Transmitted through Sharp injuries Broken Skin With body fluids Splashing of mucosal surface

Factors which increase transmission areHollow needle injuries Volume of inoculated blood Depth of Injuries Poor infection control practice 90% Anaesthesiologists are not wearing gloves for cannulation

Sh o win g p ro b a b ilit y o f b lo o d c o n t a c t
Procedure % probability

Peripheral Venous catheterization Central Venous catheterization Arterial puncture Lumbar Puncture Epidural catheter Endotracheal Intubation Extubation Suction Oral cavity , Trachea Intramuscular injection Connection and Disconnection of Blood Drip

18% 87% 38% 23% 34% 4% 9% 13% 8% 43%

Patient to Patient

Re use of Syringes Airway devices Respiratory circuit Reuse of Laryngoscopes without sterilization Use of Multi dose vials

Anesthetist to Patient

Risk appears low around 2.242.40 /million Adaptation of universal Precautions are mandatory to decrease hospital transmission

4. Other Modes of Spread

Mode % Sexual contact Blood Transfusion Mother to child Injecting drug Users 60 % - 70 % 3%- 5% 20 % - 30 % 2 % -3 %

Needle Stick

1%

Exposure Route

Risk /10,000 exposures

Blood Transfusion Child Birth Needle sharing Infection Anal and Vaginal Intercourse Needle stick

9000 2500 67 60 30

Table showing the risk of acquisition of contact

Universal Precautions

As Defined by CDC there are set precautions to prevent transmissions of HIV

Washing Hands Wearing Gloves Eye Glasses / Cap & Mask Foot Wear Impervious Gown

Contd. Needles and Sharp Surgical Technique Soiled linen Metal Instruments Plastic Tubing

New Devices Which Reduces Needle Stick Injuries

Retractable lancets used for blood sampling by heel stabs and finger sampling. Retractable Needles Shields added to Needles Protected disposable scalpels with shield Blunt suture needles IV cannula with blunting or guarding of needle

POST EXPOSURE PROPHYLAXIS

Once the health worker is exposedTest the patient Asses the nature of injury Necessity of drugs as prophylaxis should be ascertained Nature of inoculum Patients viremic status Two or Three drug regimen can be

Showing Guidelines for PEP

Exposure type HIV +VE (1) HIV +VE (2) Unknown HIVUnknown status source HIV -ve

Small volume

Consider Basic 2 drug PEP

Recommend Generally no Generally no No PEP Basic 2 drug PEP PEP PEP needed.For needed.Basic source with 2 drug PEP in HIVrisk likely settings. factors.Basic 2 drug PEP

Large volume

Recommen Recommend Generally no Generally no No PEP d Basic 2 advance 3 PEP PEP drug PEP drug PEP needed.For needed.Basic source with 2 drug PEP in HIVrisk likely settings. factors.Basic 2 drug PEP

(1) Low viral load

(2) High viral load

PEP should be initiated as soon as possible Peep should be administered for 4 weeks

SELECTION OF DRUGS

Basic two drug regimen for HIV exposures

Zidovudine (ZDV) 600 mg/day + Lamivudine(3TC) 150 mg BD

Alternative basic regimens

3TC+ Stavudine (d4T): 3 TC (150 mg twice daily & d4T 40 mg twice daily Didanosine + d4T- 400 mg , on empty stomach d4T 40 mg BD Indinavir (IDV) 800mg 8 hourly on an empty stomach Nelfinavir (NFV) 750 mg TDS with meals Efavirenz (EFV) 600 mg at bed time Abacavir (ABC) 300 mg BD daily Navirapine Antiretroviral agent generally not recommended for use as PEP

THANKS