Anesthetic considerations for the hiv patient
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Anesthetic Considerations for the HIV+ Patient. Veronica Y. Amos PhD CRNA October 2014. Prevalence. In 2011, an estimated 1.1 million persons in the U.S. were living with HIV infection 1 in 6 (15.8%) are unaware they are HIV positive. Incidence.

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Anesthetic Considerations for the HIV+ Patient

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Anesthetic considerations for the hiv patient

Anesthetic Considerations for the HIV+ Patient

Veronica Y. Amos PhD CRNA

October 2014


Prevalence

Prevalence

  • In 2011, an estimated 1.1 million persons in the U.S. were living with HIV infection

  • 1 in 6 (15.8%) are unaware they are HIV positive


Incidence

Incidence

  • Centers for Disease Control (CDC) estimated that approximately 50,000 people are newly infected with HIV


Hiv versus aids

HIV versus AIDS

  • HIV: Human Immunodeficiency Virus - a retrovirus that specifically infects several kinds of cells in the human body, the most important is the CD4 T-Lymphocyte


Hiv versus aids1

HIV versus AIDS

  • AIDS: Acquired Immunodeficiency Syndrome - When an individual’s CD4 T-Lymphocyte cell count has fallen below 200, and/or the individual has developed some specific and opportune infections.


Hiv targets t cells

HIV Targets T Cells

  • T cells act as the host that the HIV virus needs in order to replicate


Cd4 receptor site

CD4 Receptor Site

  • CD4 is a protein on the surface of the T cell. HIV’s gp120 antigen is a mirror image of the CD4 protein.


Hiv takes control of t cells

  • Viral RNA needs to become DNA in order to start the replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

HIV Takes Control of T Cells


Cd4 values

Normal: 600 -1200 cells per cubic mm of blood

Meds not needed: 600-350

Increased risk: 350-200 (meds may be started)

Risk for opportunistic infections: less than 200

CD4 Values


Viral load

Viral Load

  • This test detects and/or measures the amount (viral load) of RNA of the HIV in the blood


Viral load1

Viral Load

  • Untreated and uncontrolled HIV viral loads can range as high as one million or more copies/mL. A low viral load is usually between 40 to 200 copies/mL, depending on the type of test used.


Viral load2

Viral Load

  • A viral load result that reads “undetectable” does not mean that one is cured.


Adverse drug effects from antiretroviral drugs arvs

Adverse Drug Effects from Antiretroviral Drugs (ARVs)

  • 1. Mitochondrial dysfunction

  • 2. Metabolic abnormalities

  • 3. Bone marrow suppression

  • 4. Allergic reactions


Interaction of arvs with other drugs

Interaction of ARVs with Other Drugs

  • Propofol and NRTIs may both potentially promote mitochondrial toxicity and lactic acidosis and it may be best to avoid propofol “infusions” in patients receiving ARVs


Pharmacokinetic interactions

Pharmacokinetic Interactions

  • Primarily due to liver enzyme induction or inhibition, particularly the CYP450 3A4 enzyme

  • PIs and NNRTIs are the most commonly implicated group of ARVs in drug interactions. Enzyme induction or inhibition can affect the action of several classes of anesthetic drugs


Opioids

Opioids

  • The effects of fentanyl may be enhanced by ritonavir (protease inhibitor) due to both liver enzyme inhibition and induction

  • Enzyme inhibition reduces fentanyl clearance and enzyme induction increases metabolism to active metabolites such as normeperidine


Benzodiazepines

Benzodiazepines

  • Saquiniar (PI) can inhibit midazolam’s metabolism

  • Combination of PI and NNRTIs – excessive sedation


Other drugs

Other Drugs

  • Calcium Channel Blockers may have enhanced hypotensive effects due to enzyme inhibition

  • Local anesthetics such as lidocaine may have increased plasma levels due to enzyme inhibition

  • Neuromuscular blocker effects may be prolonged, even from a single dose of vecuronium


Other drugs1

Other Drugs

  • Proton Pump Inhibitors, and to a lesser extent antacids and H2 blockers, may adversely affect the absorption of the PI atazanavir

  • PIs impair the metabolism of the cardiac drugs amiodarone and quinidine


Preferable

Preferable

  • Etomidate, atracurium, remifentanil and desflurane are not dependent on CYP450 hepatic metabolism, and therefore, may be preferable drugs


Blood transfusions

Blood Transfusions

  • There is evidence that allogenic blood transfusion in the HIV infected patient can lead to transfusion-related immunomodulation (TRIM) and can result in an increase in HIV viral load


Anesthetic considerations for the hiv patient

Pain

  • Pain is common in advanced HIV disease and can be very difficult to treat. The etiology of this pain can be multi-factorial, including opportunistic infections such as herpes simples, peripheral neuropathy and drug-related pain


Organ involvement

Organ Involvement

  • Organ involvement in HIV infection may be a direct consequence of HIV infection because of an opportunistic infection or neoplasm, or related to other causes such as side effects of the medications


Respiratory

Respiratory

  • Prevalence of underlying pulmonary disease is increased due to the increased risk for bacterial pneumonia and the high prevalence of smoking


Respiratory1

Respiratory

  • Both upper and lower airway may be involved with HIV infection:

    - Bronchitis, sinusitis, pneumonia (PCP)

    - TB, myobacteria and fungal infections

    - Airway obstruction (Kaposi’s sarcoma)


Risks recommendations

Risks/Recommendations

  • Risk for postoperative pneumonia is increased

  • Carefully evaluate for respiratory complications in the peri-operative period: HIV+ patients with active PCP or a history of PCP are at increased risk for a spontaneous pneumothorax


Cardiovascular

Cardiovascular

  • Increased prevalence of CAD from metabolic dysfunction due to HIV infection and/or ART

  • QT prolongation or other cardiac abnormalities may occur in advanced HIV and/or ART (methadone, anti-arrhythmics, PI, antipsychotics)


Cardiovascular1

Cardiovascular

  • Dilated cardiomyopathy

  • Pericardial effusions

  • Endocarditis and valvular lesions

  • Acute coronary syndrome

  • Vasculitis

  • Pulmonary hypertension


Recommendations

Recommendations

  • Assess for CAD preoperatively

  • Perform a careful review of preoperative ECG results


Gastrointestinal

Gastrointestinal

  • Difficulty or pain on swallowing

  • Increased gastric emptying times

  • Bleeding tendency on airway instrumentation/NGT placement

  • Diarrhea with associated electrolyte dysfunction & dehydration

  • Hepatobiliary impairment

  • Pancreatitis


Hepatic

Hepatic

  • Increased prevalence of hepatic dysfunction from ART or from preexisting liver disease


Risks recommendations1

Risks/Recommendations

  • Co-infection with HBV or HCV may predispose to increased bleeding due to coagulopathy or thrombocytopenia

  • Assess preoperatively and dose anesthetics, antibiotics, and other medications accordingly


Renal

Renal

  • Increased prevalence of renal dysfunction from HIV-associated nephropathy

    - Acute and chronic disease

  • Drug-induced nephrotoxicity, HTN, & diabetes

  • HIV-associated nephropathy


Recommendations1

Recommendations

  • Assess for renal dysfunction preoperatively due to possible impact on dosing, selection of anesthetics, and peri-operative antibiotics


Neurological

Neurological

  • Neurocognitive impairment

  • Encephalopathy

  • Autonomic neuropathy

  • Seizures


Endocrine metabolic

Endocrine & Metabolic

  • Lipodystrophy (truncal obesity, buffalo hump)

  • Raised plasma triglycerides, cholesterol, glucose

  • Disorders of the hypothalamic-pituitary-adrenal axis (Cushings/Addisons)

  • Hyponatremia due to syndrome of inappropriate antidiuretic hormone or adrenal failure

  • Hypo/hyperthyroidism

  • Lactic acidosis


Hematological

Hematological

  • Anemia

  • Neutropeniawith severe immunosuppession

  • Thrombocytopenia

  • Persistent generalized lymphadenopathy

  • Hematological malignancies

  • Coagulation abnormalities


Recommendations2

Recommendations

  • Consult with hematologist prior to procedure when platelet count approaches 50,000


Anesthetic considerations for the hiv patient

MRSA

  • Community-acquired is more common in MSM than in the general population


Recommendations3

Recommendations

  • Good history of previous MRSA infections

  • Use vancomycin instead of cefazolin for prophylaxis with a positive history of MRSA


Hiv infected parturient

HIV Infected Parturient

  • The advances in HIV treatment have also brought down the rate of mother-to-child HIV transmission significantly. If the mother takes appropriate medical precautions, including taking HIV drugs, the rate of transmission can be reduced from about 25 percent to below 2 percent. In addition, studies have shown that being pregnant will not make HIV progress faster in the mother


Hiv infected parturient1

HIV Infected Parturient

  • HIV infection does not contraindicate the administration of neuraxial anesthesia analgesia during labor and/or for a cesarean section). HIV is a neurotropic virus, and the CNS is infected early in the course of the disease.


Hiv infected parturient2

HIV Infected Parturient

  • Vertical transmission is increased when CD4 (T-cell counts) decrease below 400 mL and viral load increases over 1000 copies/mL

  • Elective C-Sections combined with antiretroviral therapy has reduced vertical transmission to <5%


Hiv infected parturient3

HIV Infected Parturient

Risk factors for vertical transmission include prolonged preterm rupture of membranes (>4 hrs), chorioamnionitis, presence of STD, lack of maternal antiviral therapy, and obstetrical invasive procedures such as cervical cerclage and amniocentesis


Key points to remember

Key Points to Remember

  • If the HIV patient is on a cocktail and they are told to hold a HIV med before surgery….they need to discontinue them all and restart them all together


Key points to remember1

Key Points to Remember

  • Occasionally with surgical intervention there may be a temporary or transient increase, also called a blip, in viral load. In people whose viral load is less than 50 copies, blips are a frequent occurrence and is not associated with a sustained increase in viral load.


Risk for occupational transmission of hiv

Risk for Occupational Transmission of HIV

  • Percutaneous exposure – approx 0.3%

  • Mucous membrane exposure – approx 0.09%


Occupational exposure to hiv

Occupational Exposure to HIV

  • Places you at risk:

    • Percutaneous injury (needlestick or cut with a sharp object)

    • Contact of mucous membrane or non-intact skin

    • Blood, tissue, or other body fluids (cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluid)


Remember

Remember

  • Just because a source patient has an undetectable serum viral load – it does not eliminate the possibility of HIV transmission or the need for post-exposure prophylaxis (PEP ) & follow-up testing


Recommendations4

Recommendations

  • PEP is recommended

  • Start PEP medication regimens as soon as possible (within 72 hrs) after occupational exposure & continue for a 4-week duration

  • PEP should contain 3 (or more) ART drugs that have the fewest side-effects & are best tolerated


Follow up testing

Follow-up Testing

  • HIV testing at baseline, 6 weeks, 12 weeks, 6 months post-exposure

  • Complete blood count, renal and hepatic function tests at baseline and 2 weeks

  • HIV test results should preferable be given to the exposed healthcare provider at face to face appointments


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