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Dr. ANSHUMAN AASHU
1ST YEAR PGT
 GENERAL EPIDEMIOLOGY OF AIDS
 SURGERY IN HIV INFETED PATIENTS
 OCCUPATIONAL RISK OF HIV TRANSMISSION
IN SURGEONS
 PRECAUTIONARY MEASURES
 MANAGEMENT STRATEGY IN EVENT OF
EXPOSURE.
 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.
Structure of the HIV
 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.
Prodromal flu-like
illness
(1-4 weeks)
Seroconversion
(6 months)
Asymptomatic
phase
(8-10 yrs)
AIDS related
complex
AIDS
defining
illness
 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.
 For diagnosis of AIDS related infection or
neoplasm.
 For surgical complications of AIDS.
 For other indications as in general
population.
 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.
 Abscesses.
 Ano-rectal diseases.
 Acute abdominal emergencies.
 Hepato-biliary and splenic disorders.
 Neoplasms.
 Intracranial SOLs.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 Kaposi’s sarcoma and Non Hodgkin’s
lymphoma common neoplasms associated
with AIDS infection.
 Surgery often required for biopsy purposes or
for other complications.
 In HIV positive patients, toxoplasmosis
causes brain abscess. If medical treatment
fails then CT guided stereotatic needle
aspiration.
 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.
 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.
 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.
 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.
 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.
 Deep injury.
 Visible blood on instrument.
 Prick directly into vein or artery.
 High viral load.
 Hollow needle > solid needle
 Large diameter needles.
 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.
 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.
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.
 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.
 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.
 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
 DOUBLE GLOVES
(reduces risk by 5
fold)
 CAP AND MASK
 EYE GLASSES OR
SHIELDS
 PLASTIC
APRON/GOWN
 FOOTWEAR(wellington
shoes)
 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.
 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.
 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.
 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.
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
 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.
 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.
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
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
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
AIDS and Surgeons
AIDS and Surgeons

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AIDS and Surgeons

  • 2.  GENERAL EPIDEMIOLOGY OF AIDS  SURGERY IN HIV INFETED PATIENTS  OCCUPATIONAL RISK OF HIV TRANSMISSION IN SURGEONS  PRECAUTIONARY MEASURES  MANAGEMENT STRATEGY IN EVENT OF EXPOSURE.
  • 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.
  • 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. Prodromal flu-like illness (1-4 weeks) Seroconversion (6 months) Asymptomatic phase (8-10 yrs) AIDS related complex AIDS defining illness
  • 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.  For diagnosis of AIDS related infection or neoplasm.  For surgical complications of AIDS.  For other indications as in general population.
  • 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.  Abscesses.  Ano-rectal diseases.  Acute abdominal emergencies.  Hepato-biliary and splenic disorders.  Neoplasms.  Intracranial SOLs.
  • 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.  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.  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.
  • 15.
  • 16.
  • 17.  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.
  • 18.  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.
  • 19.  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.
  • 20.  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.
  • 21.  Kaposi’s sarcoma and Non Hodgkin’s lymphoma common neoplasms associated with AIDS infection.  Surgery often required for biopsy purposes or for other complications.
  • 22.  In HIV positive patients, toxoplasmosis causes brain abscess. If medical treatment fails then CT guided stereotatic needle aspiration.
  • 23.  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.
  • 24.  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.
  • 25.  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.
  • 26.  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.
  • 27.  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.
  • 28.  Deep injury.  Visible blood on instrument.  Prick directly into vein or artery.  High viral load.  Hollow needle > solid needle  Large diameter needles.
  • 29.  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.
  • 30.  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.
  • 31. 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.
  • 32.  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.
  • 33.  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.
  • 34.  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
  • 35.  DOUBLE GLOVES (reduces risk by 5 fold)  CAP AND MASK  EYE GLASSES OR SHIELDS  PLASTIC APRON/GOWN  FOOTWEAR(wellington shoes)
  • 36.  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.
  • 37.  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.
  • 38.  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.
  • 39.  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.
  • 40.
  • 41.
  • 42. 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
  • 43.  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.
  • 44.  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.
  • 45. 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
  • 46. 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
  • 47. 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