AIDS and Surgeons


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AIDS and Surgeons

  3. 3.  AIDS is a viral disease caused by a retrovirus of lentivirus family called HIV.  Contains a core containing two single stranded RNA, Reverse Transcriptase enzyme, and core proteins.  The envelope contains a glycoprotien (gp120) – affinity for CD4 antigens.  CD4+ cells are the target for HIV infection, most commonly being the T-helper cells.  Also involves macrophages, dendritic cells etc.
  4. 4. Structure of the HIV
  5. 5.  After infecting the CD4+ cells, leads to the rapid destruction of such cells leading to different manifestations.  Most common cell involved being T-helper cells, leads to immunodeficiency and hence several opportunistic infections.  Some neoplasms (Kaposi’s sarcoma and Lymphoma) also associated with HIV infection.
  6. 6. Prodromal flu-like illness (1-4 weeks) Seroconversion (6 months) Asymptomatic phase (8-10 yrs) AIDS related complex AIDS defining illness
  7. 7.  Sexual.  Body fluids. ◦ Blood and blood products. ◦ Semen, vaginal secretions. ◦ Saliva. ◦ Milk. ◦ Peritoneal, pleural and pericardial fluids. ◦ Synovial fluids. ◦ CSF. ◦ Urine, vomit, tears, sweat, feces (lower risk).  Perinatal transmission.
  8. 8.  For diagnosis of AIDS related infection or neoplasm.  For surgical complications of AIDS.  For other indications as in general population.
  9. 9.  Lymph nodes almost always show follicular hyperplasia, so not reliable for diagnosis.  Excision/Incision biopsy of lymph node or soft tissues required for diagnosis of lymphoma, sarcoma, tuberculosis etc.  Due to the risk of transmission, FNAC should be considered first and surgical biopsy be reserved for inconclusive FNAC reports.
  10. 10.  Abscesses.  Ano-rectal diseases.  Acute abdominal emergencies.  Hepato-biliary and splenic disorders.  Neoplasms.  Intracranial SOLs.
  11. 11.  With profound immunodeficiency, abscesses are common presentations in HIV+ patients.  Young adult patients of either sex with pyomyositis are particulary likely to have AIDS.  Treatment consists of simple Incision & Drainage as in normal conditions.
  12. 12.  Most frequent reason for surgical interventions in HIV+ patients.  HIV+ male homosexuals have higher incidence of such disorders than other HIV+ patients.  Perianal sepsis, Fissures, Fistula, Warts, Squamous cell carcinoma commonly seen.  Large perianal incisions and division of internal anal sphincter should be avoided. Setons are ideal for fistulas.
  13. 13.  Anal warts are mostly resistant to medical therapy with podophyllin. So electrocautery or laser should be used.  Other conditions may mimic perianal sepsis like:- ◦ Massive ulceration following Herpes simplex. ◦ Kaposi’s sarcoma presenting as bleeding hemorrhoids. ◦ Lymphoma as perianal abscess. ◦ Chronic indolent ulcer caused by M. avium intracellulare.
  14. 14.  Acute abdomen may be a presentation in about 12-45% of AIDS patients but surgery is required in only upto 5% cases mainly for appendicitis, obstruction or perforation.  CMV infection, Kaposi’s sarcoma, Lymphoma all may present with bowel obstruction or perforation or even obstructive appendicitis.  Requires laparotomy for perforations and acute obstructions.  30% of all acute appendicitis are related to AIDS related illness. Requires appendectomy.
  15. 15.  Appendicitis carries higher risk of perforation and abscess formation.  Typhlitis common presentation in AIDS patients.  Other opportunistic infections of GIT may also present as acute abdominal emergencies.
  16. 16.  Chronic hepatits B and C infections are common co-infections with AIDS.  Small liver abscesses secondary to infections with cryptococcus, histoplasma, candida etc are common.  Acute acalculous cholecystitis more common in AIDS patients. Require cholecysectomy.  Biliary obstruction due to compression by enlarged portal lymph node or due to infection with cryptosporidium, CMV or mirosporidium may be seen.
  17. 17.  Multiple splenic abscesses leading to splenomegaly is common.  Splenectomy may be required for traumatic or spontaneous rupture of spleen found to be more common in patients with AIDS.  May also be required for associated thrombocytopenia.
  18. 18.  Kaposi’s sarcoma and Non Hodgkin’s lymphoma common neoplasms associated with AIDS infection.  Surgery often required for biopsy purposes or for other complications.
  19. 19.  In HIV positive patients, toxoplasmosis causes brain abscess. If medical treatment fails then CT guided stereotatic needle aspiration.
  20. 20.  Necrotizing arteriopathy leading to aneurysm formation common in HIV infected patients.  Salmonella arteritis especially common leading to pseudoaneurysm.  Infected pseudoaneurysms also common in IV drug abusers (high risk group for HIV infection).  Vascular reconstructions usually helpful.
  21. 21.  Studies show same rate of post-operative complications in HIV positive as with asymptomatic HIV negative patients.  Incidence of infection after anorectal surgery in HIV positive patients is independent of CD4 cell counts.  Relation between viral load and post operative infection is still under trial.
  22. 22.  The surgeon is regularly exposed to blood, which is the most infective medium for HIV transmission. Incidence of accidental exposure to infected patients blood is 6.4%.  Risk is greater when there are more HIV particles in blood i.e. during the earliest and later stages of the disease.  Risk with needle stick injury is 0.3%  Risk of transmission in surgery is 1 in 28000-50000 per hour of operations.
  23. 23.  Extent of risk of infection to the surgeons depends on: ◦ Prevalence of HIV in patient population. ◦ Number of procedures carried out by the surgeon. ◦ Length of the period of risk.  Risk is more when ◦ When surgery lasted for > 3 hours. ◦ > 300ml blood loss present during surgery. ◦ In major vascular, intra-abdominal and gynaecological surgeries.
  24. 24.  Most common mode  Risk of HIV:- 0.3%  1ml of infected blood has 50 HIV RNA compared with 109 HBV particles  Hollow needles 10 times more dangerous than solid needles  Most of needle injuries(27%) occurs from improper disposal.
  25. 25.  Deep injury.  Visible blood on instrument.  Prick directly into vein or artery.  High viral load.  Hollow needle > solid needle  Large diameter needles.
  26. 26.  Recommended by CDC (USA) in 1987.  Every patient to be treated and precautions observed as if he/she has the infection.  Use of protective barriers while dealing with body fluids like blood, semen, vaginal secretions, CSF, synovial fluid, pleural, pericardial, peritoneal and amniotic fluids.  Feces, sweat, tear, saliva, urine, vomitus, nasal secretions not included.
  27. 27.  Corner stone of any precautionary program.  All HCWs should be trained and educated about different aspects of the infection that include: ◦ Mode of transmission. ◦ Standard precutionary guidelines. ◦ Method of disposal. ◦ Social stigma and discrimination issues. ◦ Posting of warning signs for others.
  28. 28. Screening of patients  Screening of patients for HIV, HBV, HCV is very important  Even if HIV test is negative, it is not 100% sure that patient is not infected.  Patient may be in window period when HIV antibodies have not yet formed in the patient (detected by the HIV test kits)  So precautionary measures are very important.
  29. 29.  Revised CDC reommendations (2006) for HIV testing in health care settings and screening pregnant women: ◦ HIV screenings is recommended for patients in all health care settings including pregnant women after the patient is notified that the testing will be performed unless the patient declines (opt-out testing). ◦ Persons at high risk for HIV infection should be screened for HIV at least annually. ◦ Written informed consent from the individual should not be required; general consent for medical care is sufficient and encompasses consent for HIV testing. ◦ HIV screening should be included in the routine panel of prenatal screening for pregnant women. ◦ HIV diagnostic testing as part of prevention counseling associated with controlling HIV transmission or as part of HIV screening program is not required.
  30. 30.  Noncompliance with recommendations on universal precautions amounts to upto 84% in emergency conditions.  Hence, certain basic standard precautions must be observed like wearing gloved while drawing blood or inserting cannula.  Routine wearing of gloves for examination of AIDS patients are not recommended unless for open wounds.
  31. 31.  Needles and sharps must always be disposed in puncture-proof containers.  Such containers should be present as near as practically possible.  Proper waste disposal.  Additional precautions are to be observed while performing on HIV+ patients: ◦ Barrier method ◦ Methodical approach
  32. 32.  DOUBLE GLOVES (reduces risk by 5 fold)  CAP AND MASK  EYE GLASSES OR SHIELDS  PLASTIC APRON/GOWN  FOOTWEAR(wellington shoes)
  33. 33.  Undue haste should be avoided.  Assistants and other staffs should be minimum.  Incisions should be large so as to have minimal requirement of retraction by assistants.  Surgery should be done in orderly manner with meticulous attention to avoid as much blood loss as possible.  Clumsy transfer of instruments should be avoided. Sharps preferably be transferred in kidney dishes.
  34. 34.  TREATMENT OF EXPOSED LOCAL SITE: ◦ Skin: thorough cleaning with soap water. Never put fingers reflexly into mouth. ◦ Eyes: Irrigation with fresh water. ◦ Oral cavity: spit out immediately and rinse with water several times.  Prompt exposure report regarding the time, nature etc of exposure should be reported.
  35. 35.  Source ◦ HIV testing after proper consent. If known to be HIV positive then assess the health status and the possibility of drug resistance if on anti retro-viral therapy  Recipient ◦ Baseline serological testing for HIV, HBV and HCV.  Nature of exposure.
  36. 36.  Depending upon the risk and toxicity balance.  Decision to start PEP depends on: ◦ Severity of exposure (Exposure Code, EC) ◦ HIV status of source (Status Code, SC).  If required, should be started within 2-24 hours of exposure and not later than 72 hours.  Effectivity decreases with increasing duration since exposure.
  37. 37. EC SC. PEP recommendation 1 1 PEP may not be warranted. NO known risk 1 2 Basic regimen. Negligible risk 2 1 Basic Regimen. Negligible risk 2 2 Expanded Regimen. Increased transmission risk. 2/3 Unknown Basic Regimen
  38. 38.  Consists of two NRTIs for 1 month.  Zidovudine 300mg BD+Lamivudine 150mg BD.  Zidovudine 300mg BD+Stavudine 40mg BD.  Didanosine 200mg BD+Stavudine 40mg BD.
  39. 39.  Consists of 2 NRTIs+ 1 PI for 1 month.  Any of the basic regimen+ any one of the following: ◦ Indinavir 800mg TDS. ◦ Ritonavir 100mg BD. ◦ Saquinavir 1000mg BD. ◦ Lopinavir 400mg BD.
  40. 40. Side effects  PEP is very toxic so its use is weighed against toxicity  Should not be used for exposure that poses negligible risk  Don’t use three drug regimen for all HIV exposure  Most common is nausea and diarrhea  Mild and reversible may be relieved by domperidone and loperamide  PIs cause peripheral neuropathy  Indinavir:- Nephrolithiasis, Hyperbilirubinemia  NRTI Abacavir causes hypersensitivity reaction  NNRTI not used causes acute fulminant liver failure  Efavirenz is teratogenic, Steven Johnson Syndrome, dizziness, insomnia, psychiatric illness
  41. 41. Investigations before prescribing PEP  Full medical history  Risk of pregnancy  CBC  LFT  RFT  Zidovudine + Lamivudine + Ritonavir are safe in pregnancy  Alone Zidovudine gives 80% protection. Combinations provide extra protection
  42. 42. Follow up  Perform baseline HIV test of HCW at the time of exposure which will be negative then repeat at 6 wk, 12wk and 6 month interval to see any seroconversion  Follow up every 1-2 wk to check side effects, toxicity and adherence to regimen  Instruct to seek medical advice immediately if experiences acute viral symptoms  Advise to:- have safe sex  Use barrier methods during intercourse  Don’t donate blood or organs during follow up period  Safe to continue performing exposure prone procedure as risk of seroconversion is low and the risk of onward transmission is remote