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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

HIV Takes Control of T Cells


Cd4 values

Normal: 600 -1200 cells per cubic mm of blood replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Viral load1
Viral Load replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.Antiretroviral Drugs (ARVs)

  • 1. Mitochondrial dysfunction

  • 2. Metabolic abnormalities

  • 3. Bone marrow suppression

  • 4. Allergic reactions


Interaction of arvs with other drugs
Interaction of replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Saquiniar (PI) can inhibit midazolam’s metabolism

  • Combination of PI and NNRTIs – excessive sedation


Other drugs
Other Drugs replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Blood transfusions
Blood Transfusions replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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


Pain replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Respiratory1
Respiratory replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Dilated cardiomyopathy

  • Pericardial effusions

  • Endocarditis and valvular lesions

  • Acute coronary syndrome

  • Vasculitis

  • Pulmonary hypertension


Recommendations
Recommendations replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Assess for CAD preoperatively

  • Perform a careful review of preoperative ECG results


Gastrointestinal
Gastrointestinal replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Risks recommendations1
Risks/Recommendations replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Increased prevalence of renal dysfunction from HIV-associated nephropathy

    - Acute and chronic disease

  • Drug-induced nephrotoxicity, HTN, & diabetes

  • HIV-associated nephropathy


Recommendations1
Recommendations replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Neurological
Neurological replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Neurocognitive impairment

  • Encephalopathy

  • Autonomic neuropathy

  • Seizures


Endocrine metabolic
Endocrine & Metabolic replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Anemia

  • Neutropeniawith severe immunosuppession

  • Thrombocytopenia

  • Persistent generalized lymphadenopathy

  • Hematological malignancies

  • Coagulation abnormalities


Recommendations2
Recommendations replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


MRSA replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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


Recommendations3
Recommendations replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • Percutaneous exposure – approx 0.3%

  • Mucous membrane exposure – approx 0.09%


Occupational exposure to hiv
Occupational Exposure replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA. 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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 replication process. Reverse transcriptase allows the RNA to borrow material from the cell and to "write backwards" a chain of viral DNA.

  • 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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