ANAESTHETIC CONSIDERATION IN AIDS PATIENTS

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INCIDENCE OF SERO-POSITIVE CASES IN OUR HOSPITAL

YEAR NO OF LSCS /P.S CASES

SERO-POSITIVE CASES

INCIDENCE

2012 3769 22 0.58%

2013 4218 31 0.73%

HIV patients in India –around 5 million(2006)

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Why HIV patients are considered special..?

HIV as disease

affects all the systems of the body

The effect of anti-HIV drugs on the organ system

The spread of infection to the O.T personnel.

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How the disease affects the body system?

CVS:Pericardial

effusion,endocarditis,myocarditis,DC

M,PHT,IHD

RS:Kaposi’s

sarcoma,Lymphoma,Nocar

diosisCNS:

Peripheral and autonomic

neuropathy,increased ICP

Coagulation system:

Thromboembolism,

thrombocytopenia and

hypercoagulable state

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How the disease affects the body system?

GIT:↑Gastric emptying

time, diarrhoea,Hepato-biliary involvement,pancreatitis

RENAL:Nephropathy

ENDOCRINE:SIADH-

Hyponatremia,Hypo/

Hyperthyroidism

Disorders of HPA axis

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REVIEW OF ANTIRETERO VIRAL DRUGS

Drug class Subclass Available drugs

Reverse transcriptase inhibitors

Nucleoside/nucletide analogues

AbacavirDidanosineLamivudineZidovudine

Non-nuleotide analogues

NevirapineDelavirdine

Protease inhibitors

AtazanavirDarunavirIndinavir

Integrase inhibitors

Raltegavir

Entry inhibitors

Fusion inhibitors Enfuviritide

CCR-5 antagonists Maraviroc

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SIDE EFFECTS ASSOCIATED WITH ARV DRUGS

DRUG SIDE EFFECTSZidovidine Marrow

suppression,myopathy

Lamividine Diarrhoea,peripheral neuropathy

Tenofovir Renal toxicityDidanosine Diarrhoea.

P.neuropathyIndinavir Nephrolithiasis,

enzyme inhibitionRitonavir Enzyme inhibitionNevirapine Rash, enzyme

inductionPentamidine Bronchospasm,arry

thmia

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DRUG INTERACTION

Enzyme induction : Fentanyl having prolonged action

Midazolam having prolonged action after saquinavir

Enhanced hypotensive effects after calcium channel blockers

Increased plasma level of lignocaine

Prolonged effect after Non-depolariser

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PRE-ANAESTHETIC EVALUATION

Careful history and examination aboutCardiomyopathy, pulmonary complicationsPeripheral neuropathy. Bleeding episodes

Routine investigationsAnaemia

PFT CD4 count: if more than 500, infective complications

are less

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No surgery should be deferred on the basisof HIV positivity alone…

ASA risk class is more important than HIV status.

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CHOICE OF ANAESTHESIAG.A/R.A – Both are safe

considerations Drug interactions and multisystem involvement

when G.A is chosen

Presence of peripheral neuropathy,local infection and coagulopathyshould be kept in mind if R.A is chosen

Beware of C.S.F infectivity

Depression of Cell mediated Immunity more pronounced after G.A

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ANAESTHETIC CONSIDERATIONS

Etomidate, Desflurane and atracurium are preferred

Midazolam and fentanyl action may be prolonged

Adrenalitis – steroid supplementation

Presence of anaemia, fever, dehydration,Tachycardia, Hypoproteinaemia needs cautious administration of anaesthesia

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ANAESTHETIC CONSIDERATIONS

Oesophageal or oro-pharyngeal lesions – difficult intubation and aspiration

Subtle or overt lung pathology

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ANAESTHETIC CONSIDERATIONS

Use of bacterial filters to protect the machine and circuit

SAB may be preferred for LSCS

Blood transfusion – to be kept minimum

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RISK OF CROSS INFECTION

Transmission of HIV in hospital:

o Exposure to infected body fluids of the patient

o Either because of sharp injury orsplashing of infected secretion to mucous membrane/broken skin

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Most of the injuries occur…

Due to overenthusiastic participationin attending an unscreened patient especially in emergency set up.

Recapping of needles

Wrong method of disposal of contaminated sharps

In foolishly overconfident

In Senior Anaesthesiologists

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Some points about the needle stick injury…

A single needle stick injury is associated with 0.31%risk of HIV transmission

Nearly 20% of the Anaesthesiologists would havehad a needle stick injury in the past 3 months…

Invariably occurs due to recapping especially forSeniors…

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The habit of wearing gloves for various procedures…

Peripheral venous canulation

0 – 5%

Intubation 0 – 10%Extubation 50 – 70%Handling of Blood and Blood products

70 – 80%

Suctioning of tracheal secretions

90 – 95%

Taking venous blood samples

0 – 20%

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Single or Double gloving…?

Single glove: 10 – 100 fold reduction in the dose of inoculam in needle stick injury

Double gloving reduces it further

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Patient to patient transmission:

• Contaminated anaesthetic circuits

• Laryngoscopes

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HOW TO PROTECT THE HOSPITAL PERSONNEL..?

UNIVERSAL PRECAUTIONS:

“Set of precautions designed to prevent transmission of HIV to health workers while providing health care”

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UNIVERSAL PRECAUTIONS:

• Washing Hands : with soap and water

• Wearing Gloves : single for ordinary procedures.Double for procedures involving handlingof sharp objects

• Eye glasses, cap, mask : covered glasses esp during ortho procedures

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UNIVERSAL PRECAUTIONS:

Impervious gowns : water impermeable

Handling of needles and sharps : Re-sheathing to be avoided

Beware of working in the depth during surgery

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UNIVERSAL PRECAUTIONS:

How to deal with the used materials after surgery..?

Soiled linen: Soaking in 1:100 hypochlrite solution for 30 min.

Metal Instruments: Wash with soap and waterSoak in 2% Gluteraldehyde solution for 30 minSharp instruments for 6 hoursThen they are autoclaved

Plastic tubing: soaking in 2% Gluteraldehyde for 6 hours or ETO sterlisation.

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NEW METHODS OF AVOIDING SHARP INJURY

RETRACTABLE SCALPEL SAFETY LANCETS

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SAFETY SYRINGES

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TYES OF SAFETY SYRINGES27/32

SAFTEY CANULAS 28/32

POST-EXPOSURE PROPHYLAXIS

As soon as possible after injury

Ideally within 1-2 hours

A combination of Zidovudine – 250mg b.dLamivudine – 150 mg b.dIndinavir – 800 mg tds for a duration of 4 weeks

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SUMMARY:

• Careful preoperative evaluation of patientsto know about the involvement of various organ systems

• Review of ART drugs and their side effects

• Consider the drug interactions with anaesthesia drugs

• Minimize the interruption of ART therapy

• Strict asepsis

• Tailored anaesthetic plan for individual patients

• Meticulous universal precautions

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“If the Anaesthesiologists serve for 30 years in the theatre,the risk of acquisition of HIV infection is 4.5%...!”

Concluding remarks…

If the universal precautionary methods are scrupulouslyfollowed, we can make this sentence false….

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THANK YOU

dr.r.selvakumar. M.D.D.A.DNB

professor of anaesthesiology,k.a.p.viswanatham govt medical college,trichirapalli.tamilnadu.