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SURGERY IN THE HIV POSITIVE PATIENT PowerPoint PPT Presentation

SURGERY IN THE HIV POSITIVE PATIENT Dr A Mouton HIV infection continues to be major cause of morbidity and mortality WHO estimate 40 million people world wide infected AIDS now fourth largest cause of death worldwide Sub-Sahara Africa → most common cause of death

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SURGERY IN THE HIV POSITIVE PATIENT

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Surgery in the hiv positive patient l.jpg

SURGERY IN THE HIV POSITIVE PATIENT

Dr A Mouton


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  • HIV infectioncontinues to be major cause of morbidity and mortality

  • WHO estimate 40 million people world wide infected

  • AIDS now fourth largest cause of death worldwide

  • Sub-Sahara Africa → most common cause of death

  • 15% of HIV (+) patients and 30-50% of patients with AIDS developed cancer


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PERI-OPERATIVE GUIDELINES FOR SURGERY


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IPre-Operative workup:

  • Pre-op analysis should help determine risk for post op complications.

  • Detailed history – Opportunistic infection:

    - Prophylactic antibiotics

    - ARV therapy regimen


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Following risk factors should be addressed

  • STD

  • Cardiovascular status

  • Viral hepatitis

  • TB

  • Drug and Alcohol abuse

  • Nutrition

  • Disease status (CD4 count and viral load)


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  • Fluid-electrolyte and acid-base disturbances are common

    a.)Hyponatremia

    • Common

    • Poor prognosis

    • Due to: - Volume Depletion from GIT losses

    • Renal disease

    • Inappropriate ADH secretion

    • Medication

    • Third spacing of fluid 2° to Nefrotic syndrome

      (↓ albumin)

    • 1°/2° adrenal insufficiency


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B. Hypokalemia - 2° to vomiting, diarrhoea, and

tubular acidosis

C. Hypocalemia - Drugs

- Malignancy, CMV

D. Hypo-uricaemia - Assorted opportunistic

infections like CMV

- Indicates ↑ morbidity and

mortality


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CD4 COUNTS AND VIRAL LOADS:

  • CD4 counts determine staging of HIV disease and need for prophylaxis.

  • Viral Loads determine effectiveness of ARV treatment.

  • Higher complication rate of CD4 <200cell/mm³ and post operative viral load > 10000 copies/ml.

  • Viral load > 10000 copies/ml suggest that ARV is no longer effective.


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PREDICTORS OF POST OP COMPLICATIONS

  • Follow percent CD4 count in addition to absolute CD4 count.

  • Significant change in absolute CD4 count in setting of stable percent CD4, demonstrate immunological stability.

    TRAM et al:

  • Post operative percent CD4 < 18 and pre to post operative change in percent CD4 of 3 independent risk factor for post-op morbidity.

    JONES et al:

  • - Most important risk factor for post-op complications is ASA classification (measure

  • general health status)

  • - HIV (+) not independent risk factor.


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IN SUMMARY:(Risk for Complications)

  • i)ASA risk class.

  • ii)Post-op percent CD4.

  • iii)Pre to post-op change in percent CD4.

  • iv)CD4 <200cell/mm³ (infection risk)


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QUESTION:

-Impaired immunity a consequence of surgery in HIV (+) patient?

-Does surgical intervention impact on the course of HIV infections?


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DATA EVALUATING IMMUNE FUNCTION AFTER TRAUMATIC INJURY:

  • i.)Loss of delayed type hypersensitivity.

  • ii.) Impair Lymphocyte proliferation.

  • iii)Production of an immune suppressive

    factor.

  • iv.)Alteration in number of circulating CD4

    /CD8 lymphocytes


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RAHL et al:

-HIV (+) patient → on HAART

-Surgery - 50% major procedures

- 50% minor procedures

-Surgery - 50% General surgery

- 25% Gyne

- 25 Other

-Parameters - CD4 count before and after operation

- Viral load


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Viral load (within 180 day) - ⅓ had a higher titer post op

- ⅔ unchanged or ↓

  • First study that documents safety of surgery in

    HIV (+) patient in term of Immune suppression in HAART era.

  • Magnitude of surgery and extent of immune

    dysfunction pre-op did not impact on immune system adversely.

    (Determined by CD4 and viral load)


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PERI OPERATIVE CONSIDERATION

  • Continue HAART

    -Gautun et al. (2008) – 43 drug naïve AIDS patients

    - mean baseline CD4 count 112

    - Follow up after 3 months

    - 80% clinical improvement

    - CD4 ↑ by > 50 in 85% of cases

    - Mean CD4 increases from 112 baseline to 196

    Factor associated with ↑ risk for infection

    I.) Systematic factors:

    • DM

    • Corticosteroid use

    • Obesity

    • Extreme of age

    • Recent surgery

    • Massive transfusion

    • ASA class 3-5


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ii.) Local factors:

Foreign body

Electrocautery

Epinephrine injection

Wounds drains

Hair removal with razor

Post irradiation to site


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POST OPERATIVE MANAGEMENT:

Most complication: (1)CD4 < 200 cell/mm³

(2)Poor nutritional status(↓Alb)

(3)± Neutropenia

Clinical adrenal insufficiency occurring in 5%

HIV(+) and 20% AIDS patients post-op.


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POST OP INFECTIONS:

- Approach to patient with fever → determined by presence and nature of surgery and CD4 and viral load.

- Most fevers from common case:

-Pneumonia

-Intravascular catheters

-UTI

-Hepatitis

-Trombophelitis

  • Important to distinguish between post op complications

    and development of opportunistic infections.


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PULMONARY COMPLICATIONS

  • Most frequent complication

  • Initial diagnostic management rely on knowledge of Immune dysfunction.

  • Nosocamial Pneumonia (S Aureus and gram (-)

    - Late in disease (<CD < 100)

  • Dyspnea or cough – careful assessment that is guided by clinical presentation and CD4

  • - FBC, blood culture, CXR.


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HYPO ADRENALISM:

- Stress of surgery – unmask previously unsuspected hypo adrenalism.

  • Non specific Sx:

    - Electrolyte changes (↓Na ↓Ka)

    - Hypotension


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CONCLUSION

  • HIV (+) patients are not at ↑ risk for complications, unless there medical health indices are poor, CD4 <200, their CD4 ratio changing, Viral load > than 10 000 copies/ml.

  • Ethically, it is difficult to refuse an HIV (+) patients services if you provide these services to non HIV positive patients.

  • In era of HAART surgical outcomes HIV (+) patients has been excellent. There is no data to suggest that major surgery influences HIV disease progression.


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