HIV Aids and Anesthesia

Consideration
lecture note prepared for ORT
Students

By: Nigusse Tebeje(Anesthetist)

Introduction
Human immunodeficiency virus (HIV) is a member of
the lentivirus subgroup of retroviruses,and has been
shown to be the cause of acquired immunodeficiency
syndrome (AIDS).
It is believed that HIV-1 evolved with chimpanzees
and crossed over to human beings. Another type of
the HIV virus, HIV-2, originated from the simian
immunodeficiency virus (SIV) of Cercocebus atys in
West
Africa, where the virus is endemic. HIV entered the
United States in the late 1970s and was first
described in 19813.
Epidemiology
Currently there are close to 1 million people
infected with HIV in the United States, and
there has been a steady increase in the
number of infected individuals since 20014.
In 2003, there were an estimated 43,171 new
cases of AIDS diagnosed in this country.
Additionally, there was an estimated 18,017
deaths in 2003 due to AIDS, resulting in a
cumulative estimated number of deaths in
the United States AIDS population of 524,060.
In 2006 the worldwide number of deaths was
2.9 million and the total number of individuals
living with HIV/AIDS is 39.5 million. The number
of AIDS related deaths is decreasing in the
United States due to antiretroviral therapy.
HIV transmission is mediated by sexual contact
or through infected blood. Neonates may be
exposed directly at the time of delivery, by
breast-feeding, or by transplacental spread.
Currently,the 3 most common routes of
transmission are male-to-male sexual contact,
heterosexual contact, and intravenous drug
use.
 Clinical features with
Anaesthetic importance
 HIV disease is a complex medical disorder with widespread
systemic involvement in effect to become a medical sub
specialty.
 The neurological, pulmonary,cardiovascular and
haematological abnormalities are of particular concern to
anaesthesiologists.
 In the early stages of HIV infection, headache,photophobia,
meningoencephalitis, depression, cranial and peripheral
neuropathies have been documented.
 The late phase may be associated dementia,
encephalopathy,
myelopathy, myopathy and peripheral neuropathy. Even
though meningitis is frequent with cryptococcal
infection,tuberculous and syphilitic etiologies have been
reported.
The infectious nature of CSF in HIV must be considered.The
incidence of peripheral neuropathy is 35 % in early HIV
infections which rose to 55% in late stages.
Distal symmetric polyneuropathy, Inflammatory
demyelinating disease, progressive polyradiculopathy have
been reported.
HIV associated neoplasms can cause increased ICP and
cerebral edema which deserves anaesthetic consideration.
An autonomic dysfunction is also reported in HIV infections.
Pericardial effusion, myocarditis, endocarditis (in
intravenous drug abusers) dilated cardiomyopathy (DCM)
and pulmonary hypertension (PH) are reported.
 There is an increased incidence of coronary artery disease
in HIV infections.
HAART (Highly active antiretroviral therapy)
decreased the incidence of pericardial disease at
the cost of increased coronary artery disease due to
the dyslipidemia associated with some antiretroviral
drugs.
Bacterial pneumonia with special reference to
Pneumocystis carini, and tuberculosis may be
present.
 Kaposi’s sarcoma,lymphomas and nocardiosis may
also affect the lungs.
Bone marrow involvement may lead on to
pancytopenia. Coagulation problems may vary from
a hypercoagulable state to a thrombocytopenic
bleeding state.
Treatment
Treatment of HIV infection include the
following
1. Antiretroviral drugs
2. Treatment of opportunistic infections.
3. Avoidance of alcohol and smoking.
4. Psychosocial counseling.
5. Nutritious diet.
Drugs and Anaesthetic importance
HIV infected patients may be on drugs which
include four types of antiretrovirals,
antituberculous drugs, pentamidine and
steroids.
The side effects with relevance to
anaesthesiologists of some commonly used
drugs are listed.
 Nucleoside analogues
1 . Zidovidine: Marrow
supression,myopathy,Inhibits cytochrome
p450.
2 . Lamividine:Well tolerated. Diarhoea,
headache:Peripheral neuropathy
3 . Stavudine:Peripheral neuropathy
4 . Tenofovir: Renal toxicity
5 . Didanosine: Diarhoea, peripheral neuropathy
Protease inhibitors
1 . Indinavir: Nephrolithiasis, Inhibits
cytochrome p450.
2 . Saquinavir: Diarhoea,headache, Inhibits
cytochrome p450.
3 . Ritonavir Inhibits cytochrome p450, elevated
triglycerides
4 . Atazanavir: Diarhoea,jaundice
 Nonnucleosides
1 . Efavirenz: Dizziness,teratogenicity
2 . Nevirapine: Rash, induces cytochrome p450.
Fusion inhibitors
1 . Enfuvirtide: Injection site reactions,
headache ,bacterial pneumonia
2.Pentamidine: Bronchospasm, arrhythmias,
electrolyte imbalance
3.Anti TB drugs: Hepatic renal dysfunction,
thrombocytopenia.
Anaesthetic considerations
Patients with HIV infection can report for HIV
related problems or unrelated problems like
trauma.
The common surgical interventions are
opening of abscesses, Caesarean section,
abdominal emergencies like bleeding and
perforations, lymph node biopsy,
splenectomy, colectomy,sepsis of the genital
tract, perianal ulceration, fistulation or
lymphomas, placement of venous lines and
nasogastric tubes.
 A preoperative check up should include
Careful history to know the diseases like
cardiomyopathy, pulmonary complications,
peripheral neuropathy, drugs and bleeding
episodes and the findings should be
documented.
Any other systemic involvement either due to
HIV or drugs should be noted.
 Investigations
 1. Routine laboratory evaluation like total and differential count, Hb%,
platelet count, clotting function evaluation, electrolytes, blood
grouping and tests for renal and hepatic function should be done.
Anemia with undue tachycardia is usually associated with HIV
infections.
 2. Electrocardiogram, Echo heart.
 3. Pulmonary function test and arterial blood gases. Around 2/3rd of
HIV patients suffer from some respiratory illness during their disease
and hence investigation to diagnose hidden lung disease assumes
significance.
 4. X-Ray chest and CT chest if warranted.
 5. MRI spine or brain if demyelination is suspected. Opportunistic
cerebral infections like asperigellosis can be detected by MRI and CT
findings may be nonspecific.
 6. Preoperative consent should be proper if there is dementia.
 7. CD 4 count (count>500 is better). Increased postoperative
infective complications were found in patients whose CD 4 count is
less than 200/mm3
 8. IV access may be difficult in drug abusers.
 9. Substance abuse and anaesthetic interactions should be borne in
mind.
There is little specific information on overall
risk of anaesthesia and surgery in HIV positive
patient and no surgery should be deferred on
the basis of HIV positivity alone.
 ASA(American society of Anesthesiologists)
risk class is more important than HIV status in
the possibility of perioperative complications.
General anaesthesia is acceptable but drug
interactions and multisystem disease caused
by HIV should be considered preoperatively.
Regional anaesthesia is safe but one must
take into consideration the presence of local
infections,bleeding problems and
neuropathies.
 Anaesthesia and surgery decrease cell
mediated immunity and the effects are more
pronounced after General than Regional
anaesthesia. Antiretroviral drugs affect
cytochrome p 450.
Etomidate, atracurium, remifentanyl and
desflurane are independent of cytochrome p
450 and are preferred.
The metabolism of midazolam and fentanyl are
affected by cytochrome p 450 and are better
avoided.
 Succinyl choline should be used with caution in
renal dysfunction and in the presence of myopathy.
 CMV (Cytomegalovirus) adrenalitis may affect
intraoperative haemodynamics and some patients
need steroid supplementation.
HIV associated anaemia, fever,dehydration,
hypoproteinemia tachycardia and electrolyte
imbalance may compel us to make scientific use of
anaesthetics and relaxants.
Oropharyngeal and oesophageal pathology may
make some patients prone for difficult intubation,
regurgitation and aspiration.
Subtle or overt lung pathology may need intraoperative
increase in FiO2.
The presence of neuropathy may necessitate careful
positioning during anaesthesia.
Tachycardia was more frequent during anaesthesia
while fever, anemia and tachycardia were more
frequent in the postoperative period in HIV infected
individuals.
Ayers J and Smirnov GG(researchers) in their respective
studies concluded that HIV per se does not increase
post procedure complications and surgery should not
be withheld on the basis of HIV status alone.
Perioperative continuation of ART is essential. The use
of erythropoietin in selected cases and immunotherapy
in the future may form important tools in the
perioperative management.
Obstetrics and HIV

The risk of transmission from the HIV infected

mother to child is around 25%. Zidovidine
monotherapy has reduced the incidence to
8% a combination of ART and elective
caesarean section has reduced the
transmission to 2%. Hence as
anaesthesiologists we may encounter a
number of patients posted for elective
caesarean section.
There is little evidence to suggest that HIV
increases complications of pregnancy or
pregnancy alter the clinical profile of HIV
infection.
 In developing countries, with increased post caesarean
section morbidity, mortality and resource crunch,
 Vaginal delivery with suitable precautions can be used
in selected cases.
 In the postoperative period, narcotics and drug
interactions should be kept in mind.
 The use of epidural blood patch (EBP) for postdural
puncture headache is safe.
 EBP is acceptable provided no other viral or bacterial
infections are active.
 There was no increase in morbidity after EBP for two
years in HIV positive patients.
 The era of HAART (highly active antiretroviral therapy)
has
decreased the incidence of perinatal HIV transmission.
HIV and pain

There are various causes of pain in HIV

infection.Acetaminophen, Codeine, Morphine,
Topical Capsaicin,Viscous xylocaine,
Amitriptyline, Carbamazepine, Mexilitene and
Prednisone have been used with variable
success.
The key points are:
Pain is a common and debilitating symptom of
HIV disease; it is seriously under treated.
The multicentre study shows that pain is present
in 62% of HIV inpatients, that its severity
decreases their quality of life, and that over half
with significant pain do not receive any analgesic
treatment.
Under treatment of pain in HIV disease is
related to doctors both underestimating pain
and under prescribing analgesics.
The more severe the pain, the more often
doctors underestimate it.
Doctors are reluctant to prescribe potent
analgesics.
Likelihood of analgesic prescription increases
when doctors estimate pain to be more severe
and regard patients as sicker.
HIV and critical care
 Acute respiratory failure is the commonest cause of ICU
admissions in HIV patients.
 Pneumocystis is identified as the responsible pathogen in 25-
50% of cases.
 Pneumatoceles and pneumothorax may manifest.
 Trimethoprim – sulfamethaxozole or pentamidine IV are
suggested effective therapies.
 Noninvasive ventilation techniques may be associated with
less incidences of pneumothorax.
 Bacterial pneumonia with Pseudomonas and Staphylococcus
may also cause acute respiratory failure for which routine
guidelines for management of acute lung injury will apply.
 Intractable seizures with the cause being either a mass
lesion or infection like Cryptococcus may present in the ICU.
Gastrointestinal bleeding due to infectious
ulceration or Kaposi s sarcoma may present with
shock.
This may be complicated by an associate
thrombocytopenia.
Bowel perforation, AIDS cholangiopathy and
pancreatitis are the other causes of ICU
admissions.
 Life threatening situations and emergencies may
present a situation to the anaesthesiologist in such
a way that universal precautions may be forgotten.
 In severe sepsis patients with HIV infections
patients were less likely to be admitted in ICU but
with a greater mortality rates.
Safe blood

Anaesthesiologists use blood transfusion more

commonly than any other faculty personnel
universally.
 Paid donation and plasma trades are unrecognized
forces that drive an AIDS epidemic in developing
countries.
Volkow etal(who study on blood donation) suggested
to avoid paid donors and this route of transmission can
be combated by a safe blood programme.
A safe blood programme needs a safe donor.
After a study of prevalence of markers of transfusion
transmissible diseases, it was concluded that
voluntary blood donor service with students as major
donors is the answer to counter this problem.
Risk of cross infection
Inhospital transmission of HIV in anaesthetic
practice may occur in three ways.
1. Patient to Anaesthetist
HIV can be transmitted through sharp injuries,
broken skin with body fluids and splashing of a
mucosal surface.
The risk of transmission by needle stick injury
varies from 0.3 – 0.03%. Factors which
increase transmission are Hollow needle
injuries, Volume of inoculated blood and
Depth of injuries.
20 % of anaesthesiologists had at least a
needle injury in a 3 month period.
This implies a cumulative risk of 4.5% in a 30
year anaesthesia career.
Poor infection control practices put
anaesthesiologists at risk. 8% of
anaesthesiologists wore gloves for peripheral
venous cannulation and 90% for central
venous cannulation.
Its ideal that we should wear in 100% of
cases. The following details with regard to
contact of body fluids and blood are tabled:
 Table : Showing the probability
of blood contact.
Procedure % of blood contact
Peripheral venous 18%
catheterization
Central venous 87%
catheterization
Arterial puncture 38%
Lumbar puncture 23%
Epidural catheter 34%
Endotracheal intubation 4%
Extubation 9%
Suction –oral cavity, 13%
trachea.
Intramuscular injection 8%
2. Patient to patient
 Reuse of syringes, airway devices should be condemned. Either
a disposable respiratory circuit or hydrophobic filter is
warranted. Laryngoscopes should be properly sterilized before
reuse.
3. Anaesthetist to patient
 The risk appears low. It is estimated around 2.4-24 per million
procedures.
 The adoption of universal precautions is mandatory to decrease
the in hospital transmission.
 Blood contamination and contact was more in emergency ward
than in operation room and was decreased by 98% on wearing
gloves.
 In a study of following universal precautions, 65% of Thai
Anaesthesia personnel don’t follow universal precautions and at
least one third admitted that they recap needles before
disposal.
In a study of gloving practices it was observed
to be deficient in paediatric cases and in
Anaesthesiologists aged 55 or more.
 It was noted that anaesthesiologists were
aware of the precautions and hygienic
practices but performance falls below
expectations.
Universal precautions
Universal precautions as defined by CDC
(Centers for disease control and prevention)
are a set of precautions designed to prevent
transmission of HIV to health workers while
providing health care.
They apply to blood, body fluids containing blood,
semen, vaginal secretions, tissues,CSF, pleural,
peritoneal, pericardial and amniotic fluids.
They do not apply to faeces, sputum, sweat, tears,
urine and vomitus unless they contain blood.
1. Washing Hands - One of the most important
requirements and the one that is most commonly
ignored is washing hands, before and after seeing
a patient.
 Strict adherence to washing hands with ordinary
soap clearly reduces the risk of transmission of HIV
and many other infectious agents.
2. Wearing Gloves - A pair of disposable plastic gloves
have to be worn whenever the potential for a contact
with the patient’s body fluid exists. At surgery, where
there is a risk of injury from sharp objects, double gloving
with good quality latex gloves is recommended.
 Fortified gloves that reduce chances of injury from sharps
are not universally available and are also expensive.

3. Eye Glasses/Cap/Mask - The eyes are to be protected

from split secretions by wearing goggles; the
conventional glasses worn for correction of eyesight
defects are open in the sides; but nevertheless give
acceptable protection.
 The cap and mask protect the head and face from being
exposed to spillage.
4.Foot Wear - The feet are notorious for little
cuts and abrasions that may be contaminated
by body fluids.
Gumboot types of footwear are to be worn to
avoid this.
5. Impervious Gown - While disposable
impervious gowns are available, the cost may
not be justifiable.
In our conditions, use of a plastic apron under
the conventional operating gown will serve
the purpose.
6.Needles and Sharps - Manipulation of
needles like bending and re-sheathing should
be avoided. The used needles are to be
deposited in thick walled puncture resistant
containers for later incineration.
Thick cardboard boxes discarded in the
pharmacy can be for this purpose. A small
square hole is made in the top for deposition
of the needles.
 It is sent for incineration when two thirds full.
7.Surgical technique - Risk from needle prick
injuries are greatest when working in depths like
pelvis, the diaphragmatic hiatus or the chest.
The use of the hand to direct the passage of
needles is to be avoided.
While blunt needles have been shown to
drastically reduce injuries, they are expensive and
are not universally available.
8. Soiled linen - Soaking soiled linen for 30
minutes in 1:100 bleach solution (hypochlorite
solution) kills the HIV virus completely.
These can then be processed normally with
washing and autoclaving as usual.
9. Metal Instruments - Metal instruments are
washed with soap and water. They are then soaked
in 2% Glutaraldehyde solution for 30 minutes to kill
the virus.
The sharp instruments are transferred to another
container with fresh glutaraldehyde and soaked for
a further six hours. The other instruments are
autoclaved.
10. Plastic tubings - The anaesthetic tubings,
tubings used for suction and those used in rotary
pumps are all soaked in 2% Glutaraldehyde for six
hours after cleaning with soap and water.
Where available, these can also be subjected to
ethylene oxide sterilization.
Post exposure prophylaxis (PEP)
Once the health worker is exposed, it is ideal to test
the patient and asses the nature of injury by a
team and the necessity of drugs as prophylaxis
should be ascertained.
Depending on the nature of the inoculum
(percutaneous or mucosal splash, large or small
blood volume, hollow needle or closed needle
injuries) and the patient’s viremic status (HIV
positive, unknown or negative.) a two or three drug
regimen can be started as early as possible,
preferably 1- 2 hours with a maximum of four
weeks after the exposure.
Post exposure counseling is to be done by a team
of experts to ascertain the necessity of PEP.
PEP should be initiated as soon as possible. The
interval within which PEP should be initiated for
optimal efficacy is not known. If questions exist
about which antiretroviral drugs to use or whether
to use a basic or expanded regimen, starting the
basic regimen immediately rather than delaying
PEP administration is probably better.
If appropriate for the exposure, PEP should be
started even when the interval since exposure
exceeds 36 hours.
 Initiating therapy after a longer interval (e.g., 1
week) might be considered for exposures that
represent an increased risk for transmission.
The optimal duration of PEP is unknown. Because 4
weeks of ZDV appeared protective in occupational and
animal studies, PEP probably should be administered for
4 weeks, if tolerated.
Use of PEP when HIV Infection Status of Source Person is
Unknown.
The following are recommendations regarding HIV
postexposure prophylaxis : If indicated, starts PEP as
soon as possible after an exposure.
Reevaluation of the exposed person should be
considered within 72 hours postexposure, especially as
additional information about the exposure or source
person becomes available.
Administer PEP for 4 weeks, if tolerated. If a source
person is determined to be HIV-negative, PEP should be
discontinued.
PEP for Pregnant Health Care Personnel : If the
exposed person is pregnant, the evaluation of risk
of infection and need for PEP should be
approached as with any other person who has had
an HIV exposure.
 However, the decision to use any antiretroviral
drug during pregnancy should involve discussion
between the woman and her health-care
provider(s) regarding the potential benefits and
risks to mother and fetus.
Certain drugs should be avoided in pregnant
women. Because teratogenic effects were
observed in primate studies, Efavirenz is not
recommended during pregnancy.
Reports of fatal lactic acidosis in pregnant
women treated with a combination of
Stavudine and Didanosine have prompted
warnings about these drugs during pregnancy.
Because of the risk of hyperbilirubinemia in
newborns, Indinavir should not be
administered to pregnant women shortly
before delivery.
 Recommendations for the Selection of Drugs for HIV PEP:
Two regimens for PEP are provided:
1) a “basic” two-drug regimen that should be appropriate for
most HIV exposures Zidovudine (ZDV) 600mg perday +
Lamivudine (3TC); 150 mg bid
Alternate basic regimens
 3TC + Stavudine (d4T) 3TC: 150 mg twice daily, and d4T: 40
mg (if body weight is <60 kg, 30 mg twice daily) twice daily.
 Didanosine (ddI) + d4T ddI: 400 mg (if body weight is <60
kg, 125 mg twice daily) daily, on an empty stomach. d4T: 40
mg (if body weight is 60kg, 30 mg twice daily) twice daily. 2)
An “expanded” three-drug regimen that should be used for
exposures those pose an increased risk for transmission. It
includes a basic regimen plus one of the following:
 Indinavir (IDV)800 mg every 8 hours, on an empty stomach.
Nelfinavir (NFV) 750 mg three times daily,
with meals or snack, or1250 mg twice daily,
with meals or snack
Efavirenz (EFV)600 mg daily, at bedtime.
Abacavir (ABC) 300 mg twice daily.
Antiretroviral agent generally not
recommended for use as pep:
 Nevirapine.
Conclusion
It should be emphasized that all practicing
anaesthesiologists should be familiar with the disease its
widespread ramifications, and use preoperative
consultation with a team approach.
The type of anaesthesia does not matter. Routine
preoperative testing for HIV is acceptable but the
concept of mandatory testing should be avoided and a
HIV test should always be along with a pre and post test
counseling.
The problem of window period in HIV and the threat of
occupational exposure to other transmissible diseases
make strict adherence to universal precautions
mandatory.
We will see more innovative therapies and necessarily
be informed about them as we provide anaesthesia care.
 Thank
you