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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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Presentation Transcript
slide2
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
i pre operative workup
I Pre-Operative workup:
  • Pre-op analysis should help determine risk for post op complications.
  • Detailed history – Opportunistic infection:

- Prophylactic antibiotics

- ARV therapy regimen

following risk factors should be addressed
Following risk factors should be addressed
  • STD
  • Cardiovascular status
  • Viral hepatitis
  • TB
  • Drug and Alcohol abuse
  • Nutrition
  • Disease status (CD4 count and viral load)
slide6
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
slide7
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

cd4 counts and viral loads
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.
predictors of post op complications
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.
in summary risk for complications
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)
question
QUESTION:

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

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

data evaluating immune function after traumatic injury
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

rahl et al
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

slide15
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)

peri operative consideration
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
slide17
ii.) Local factors:

Foreign body

Electrocautery

Epinephrine injection

Wounds drains

Hair removal with razor

Post irradiation to site

post operative management
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.

post op infections
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.

pulmonary complications
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.
hypo adrenalism
HYPO ADRENALISM:

- Stress of surgery – unmask previously unsuspected hypo adrenalism.

  • Non specific Sx:

- Electrolyte changes (↓Na ↓Ka)

- Hypotension

conclusion
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.