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HIV AND ANAESTHESIA

HIV AND ANAESTHESIA. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software based statistics ,PhD ( physio ) Mahatma Gandhi Medical college and research institute , puducherry , India. We are leading as Indians in ???????.

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HIV AND ANAESTHESIA

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  1. HIV AND ANAESTHESIA • Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software based statistics ,PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry , India .

  2. We are leading as Indians in • ???????

  3. NUMBER OF HIV INFECTIONS(5.7 MILLION)

  4. FROM 1981---NOW 40 MILLIONS • 5.7 IN INDIA. • Come down from 2.2 lakhs to 1.3 lakhs / year • 25 % OF HIV PATIENTS NEED SURGERY AT SOME POINT OF LIFE.

  5. HIV--LENTIVIRUS GROUP OF RETRO VIRUSES. • HIV COINTAIN REVERSE TRANSCRITASE • VIRAL RNA TO DNA –INCORPORATES INTO HOST CELL GENOME. • AFFECTS CD4 LYMPHOCYTES-DESTROYS THEM. • HENCE OPPURTUNISTIC INFECTIONS AND MALIGNANCIES.

  6. MODES OF SPREAD Chance

  7. CLINICAL COURSE • SEROCONVERSION 2-10 WEEKS. • CHRONIC PHASE—2-10 YEARS. • SYMPTOMATIC AIDS. • DIAGNOSIS ---ANTIBODIES BY ELISA OR WESTERN BLOT. • SEROCONVERSION 2-10 WEEKS—TESTS NEGATIVE BUT PATIENT IS INFECTIVE –WINDOW PERIOD.

  8. CLINICAL FEATURES –ANAESTH. IMPORTANCE. • In 2016 • DIPLOMA IN HIV or MD in HIV • NEUROLOGICAL. • PULMONARY. • CARDIOVASCULAR. • HAEMATOLOGICAL

  9. NEUROLOGICAL • EARLY: HEADACHE,PHOTOPHOBIA,CRANIAL AND PERIPHERAL NEUROPATHY. • 35 – 55 % • LATE:--DEMENTIA, MENINGOENCEPHALITIS, • MYOPATHY,AUTONOMIC DYSFUNCTION(15%).

  10. CARDIAC • PERICARDIAL EFFUSION. • MYOCARDITIS, • ENDOCARDITIS(IV DRUG ABUSE), • DILATED CARDIOMYOPATHY.30 – 40% • PULMONARY HYPERTENSION.(1 in 200) • ↑ CORONARY ART. DISEASE.(dyslipidemia due to drugs )

  11. RESPIRATORY: • PNEUMOCYSTIS CARINI PNEUMONIA. • Tuberculosis. • Asperigilloses • Kaposi’s sarcoma, lymphomas and nocardiosis may also affect the lungs. 2/3rd of HIV patients suffer from some respiratory illness during their disease

  12. HEMATOLOGIC: • PANCYTOPENIA. • BLEEDING. • HYPERCOAGULABLE STATE.

  13. Others • Glomerulosclerosis may progress to CRF. • Chronic diarhoea and electrolyte problems, oropharyngeal candidiasis, esophagitis, acalculous cholecystitis, liver diseases. • Adrenal insuffiency, SIADH, hypothyroidism

  14. Treatment of HIV infection include the following • 1. Treatment of opportunistic infections. • 2. Nutritious diet, • 3. Avoidance of alcohol and smoking. • 4. Psychosocial counseling. • 5. Antiretroviral drugs.

  15. Drugs • ART (4 TYPES), 1.NUCLEOSIDE ANALOGUE 2.PROTEASE INHIBTORS. 3.NONNUCLEOSIDES 4.FUSION INHIBITORS • ATT, • PENTAMIDINE, • STEROIDS.

  16. Drugs –

  17. Anaesthetic considerations

  18. PATIENT CAN COME FOR • HIV RELATED--- NODE BIOPSY, SPLENECTOMY,PLACEMENT OF VENOUS LINES OR NASOGASTRIC TUBES. • HIV UNRELATED--- TRAUMA. LSCS etc

  19. Other than routine preop • PREOP: H/O DRUGS, • CARDIO PULMONARY DISEASES, PERIPHERAL NEUROPATHY, AUTONOMIC NEUROPATHY, • BLEEDING EPISODES, • DOCUMENT ALL.

  20. INVESTIGATIONS. • ROUTINE– HB, TC, DC, BLEEDING PROFILE, • TESTS FOR RENAL & HEPATIC FUNCTION.ELECTROLYTES. • ECG, ECHO HEART. • PFT, XRAY CHEST AND CT SOS. • Normal CxR with abnormal CT is common in HIV patients

  21. MRI SPINE IF DEMYELINATION SUSPECTED. • CONSENT!! • DEMENTIA BEWARE. • CD 4 (> 500 BETTER). • DRUG ABUSE AND IMPLICATIONS.

  22. ANAESTHESIA: • NO SURGERY DEFERRED DUE TO HIV.

  23. Risks – for us or for the patient ?? • OVERALL RISK -? INCREASED • RISKS INCREASE WITH ASA STATUS • IV ACCESS ? IN DRUG ABUSERS.

  24. REGIONAL ANAESTHESIA • SAFE– BUT CONSIDER LOCAL INFECTIONS, BLEEDING PROBLEMS, NEUROPATHIES.

  25. Are we introducing the virus in CNS • No • HIV virus is already in CSF and • proved safety of neuraxial blocks per se does not increase virus load in CNS.

  26. GA --ACCEPTABLE • ART AFFECT CYTOCHROME P450. ETOMIDATE, ATRACURIUM, DESFLURANE REMIFENTANYL -OK- INDEPENDENT OF CYTOCHROME P450. MIDAZOLAM , FENTANYL NOT PREFERRED. SCOLINE ? ? MYOPATHY , RENAL DYSFUNCTION

  27. ANAESTHESIA- CONT. • HIV ASSOC. FEVER, • DEHYDRATION, • HYPOPROTENIMIA, • TACHYCARDIA, • ELECTROLYTE IMBALANCE – • BE SCIENTIFIC IN USE OF RELAXANTS.

  28. ANAESTHESIA- CONT • CMV ADRENALITIS→ INTRAOP. HEMODYNAMIC IMBALANCE →SUPPLEMENT STEROIDS. • OESOPHAGEAL,OROPHARYNGEAL PATHOLOGY– PRONE FOR ASPIRATION.

  29. ANAESTHESIA- CONT • SUBTLE OR OVERT LUNG PATHOLOGY- INCREASED FiO2. • NEUROPATHY –CAREFUL POSITIONING • . POST OP NARCOTICS & DRUG INTERACTIONS- KEPT IN MIND • EPIDURAL BLOOD PATCH - SAFE.

  30. OBSTETRICS • ELECTIVE LSCS + ART = LESS TRANSMISSION. • BUT COUNTRIES LIKE INDIA –UNIVERSAL PRECAUTIONS AND ART FOR THE MOTHER AND BABY – ACCEPTABLE.

  31. CROSS INFECTIONS 1.PATIENT TO PATIENT, 2.PATIENT TO ANAESTHETIST, 3. ANAESTHETIST TO PATIENT.

  32. PATIENT TO PATIENT. • NO REUSE OF SYRINGES AND AIRWAY DEVICES. • DISPOSABLE RESPIRATORY CIRCUIT. • ANAESTH. TO PATIENT: • RISK LOW. • 2.4 – 24 / MILLION. • APPLY UNIVERSAL PRECAUTIONS.

  33. PATIENT TO ANAESTH: • NEEDLE INJURY TRANSMISSION 0.3% • HOLLOW NEEDLE INJURIES,MORE BLOOD,MORE DEPTH—INCREASED RISK.

  34. Oh!! what a pity anaesthetist !! • 20 % OF ANAESTH – ONE NEEDLE INJ. – 3 MONTH PERIOD. • MEANS- 4.5 OF 100 ANAESTHETISTS WILL BECOME HIV +VE IN 30 YEAR ANAESTH CAREER.

  35. UNIVERSAL PRECAUTIONS. • SET OF PRECAUTIONS TO ↓ HIV TRANSMISSION TO HEALTH CARE WORKERS. • APPLY TO BLOOD, SEMEN,VAGINAL SECRETIONS, TISSUES,CSF,PLEURAL, PERICARDIAL PERITONEAL AND AMNIOTIC FLUIDS. • DON’T APPLY-FECES,SPUTUM,URINE,TEARS AND SWEAT.

  36. 1.WASH HANDS— BEFORE AND AFTER. 2.GLOVES- PREFER TWO. 3. GOGGLES- NORMAL OK BUT PREFER WITH SIDES.

  37. 4.FOOT WEAR- CHANCES OF CUTS ↑ 5.IMPERVIOUS GOWN. 6.NEEDLES.CONTAINER IS PUNCTURE RESISTANT.NO RESHEATHING OR BENDING.

  38. USE OF HAND TO GUIDE NEEDLES –NO

  39. Universal precautions • SOILED LINEN → • SOAK 30 MINUTES IN 1: 100 BLEACH SOLUTION →WASH →AUTOCLAVE. METALS →WASH WITH SOAP & WATER → CIDEX 30 MIN. → AUTOCLAVED. SHARPS→ WASH WITH SOAP & WATER → CIDEX → 6 HOURS.

  40. ANAESTH TUBINGS, SUCTION TUBINGS → WASH WITH SOAP & WATER →CIDEX → 6 HOURS • UNIVERSAL PRECAUTIONS –SHOULD BE UNIVERSAL

  41. POST EXPOSURE PROPHYLAXIS • SUPPOSE A NEEDLE PRICK OCCURS →HIV FOR PATIENT → NATURE OF INJURY AND INOCULUM → TEAM APPROACH → TWO OR THREE DRUGS FOR FOUR WEEKS DEPENDING ON THE RISK. • LAMIVIDINE 150 BD + ZIDOVIDINE 300 BD • THIRD DRUG –INDINAVIR 800 TID

  42. CONCLUSION • BE FAMILIAR WITH HIV, SYSTEMS AFFECTED, DRUGS USED & UPDATE • PREOP CONSULTATION AS A TEAM. • NO MANDATORY TEST (PRE & POST COUNSELLING IS A MUST) • TYPE OF ANAESTHESIA DOES NOT MATTER. • UNIVERSAL PRECAUTIONS MANDATORY.

  43. Questions ?? • On the night before surgery, the wife of a patient phones the ward sister that her husband is HIV positive • What should be done ??

  44. Questions ?? • Suppose the patient is not willing for the test and undergoes a surgical procedure ??

  45. Questions ?? • This is an HIV positive cholecystecytomy • Can we do it Saturday last case ??

  46. OUR DAYS,TEACHING IN ANAESTHESIA IS JUST SAFE ANAESTHESIA COMING DAYSIT IS SAFE ANAESTHESIA AND ………..

  47. SAFE ANAESTHESIOLOGIST

  48. THANK YOU ALL

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