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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

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
slide26
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
slide43
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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