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Hiv and surgeons


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Hiv and surgeons

  1. 1. HIV and SURGEONS<br />By<br />Dr NareshKumar<br />M.S.(General Surgeon)<br />
  2. 2. Human Immunodeficiency Virus<br />Two types:-HIV-1 and HIV-2<br />HIV-1 is most common worldwide<br />HIV-2 is most common in west Africa<br />It is a Retrovirus<br />Family:- Retroviridae<br />Sub-family:-Lentivirinae<br />It has Reverse Transcriptase Enzyme<br />It is RNA dependant DNA Polymerase<br />Normally DNA RNA Proteins<br />But in HIV RNADNA mRNA Proteins<br />Here Reverse Transcriptase converts RNA into DNA<br />
  3. 3. Structure of HIV Virus<br />
  4. 4. Life Cycle of HIV Virus<br />
  5. 5. GP-120 recognised by CD4 receptors on CD4 cells<br />Virus fuses with CD4 cell membrane<br />Releases its RNA and RTase into CD4 cell cytoplasm<br />Reverse Transcription occurs<br />dsDNA forms<br />dsDNA enters CD4 cell nucleus<br />Incorporates into CD4 cell DNA by Integrase<br />Provirus forms<br />This has two fates:-<br /><ul><li>GP-120 recognized by CD4 receptors on CD4 cells
  6. 6. Virus fuses with CD4 cell membrane
  7. 7. Releases its RNA and RTase into CD4 cell cytoplasm
  8. 8. Reverse Transcription occurs
  9. 9. dsDNA forms
  10. 10. dsDNA enters CD4 cell nucleus
  11. 11. Incorporates into CD4 cell DNA by Integrase
  12. 12. Provirus forms</li></li></ul><li>Latent infection Productive infection<br />Virus remains latent in the host DNA<br />Divides and multiply with replication of host DNA<br />Viral DNA along with host DNA transcribe into mRNA<br />mRNA translates into proteins<br />GAG protein:-Forms Capsid<br />POL protein:-Forms RTase,Protease,Integrase<br />EVE protein:-Forms envelope glycoprotein(GP120,GP41)<br />All these assemble to form virion along with RNA<br />Virion released from host cell by budding<br />
  13. 13. CD4 cells<br />T-Helper Cells<br />Monocytes<br />Macrophages<br />Dendritic Cells<br />Langerhans Cells<br />
  14. 14. These points of life cycle are important for therapeutic purpose:-<br />RTase inhibitors:-NRTI:- Zidovudine, Lamivudine, Stavudine ect.<br />NNRTI:- Nevirapine, Efavirenz<br />Protease inhibitors:-Ritonavir, Indinavir ect<br />Integrase inhibitors<br />Fusion inhibitors:-inhibits fusion of HIV with CD4 cells:-Enfuvirtide<br />
  15. 15. Modes of Transmission<br />Sexual:-Homosexual, Heterosexual<br />Blood, blood products and other body fluids<br />Mother to foetus<br />Breast Milk<br />
  16. 16. No risk with<br />Casual contact<br />Eating<br />Insects:-Mosquitoes<br />Sharing things<br />
  17. 17. Sexual Transmission<br />Most common and important<br />More risk in Homosexual<br />Virus concentrates in seminal fluid, vaginal and cervical secretions<br />Receptive anal intercourse has more risk because:-<br />Thin fragile rectal mucus membrane<br />Trauma during intercourse<br />
  18. 18. Vaginal intercourse Is also important although vaginal mucosa is several layer thick than anal mucosa and less chances of trauma<br />Chances of infection from male to female are more than female to male because:-<br />Semen remains for longer time in vagina as compare to penis in vaginal secretions<br /> STDs:-Increases the risk due to:-<br />Infection increases the vascularity of mucosa->increases langerhan’s cells<br />Infection->Genital ulcer->increases risk<br />
  19. 19. Lack of circumcision:- increases risk due to:-<br />Increased susceptibility to STDs<br />Increased susceptibility to micro trauma<br />Highly vascular foreskin has more lymphocyte and langerhan cells<br />Moist environment beneath foreskin ->increase micro flora  inflammation increase T cells Increases risk<br />Oral sex less eficient than anal or vaginal but not totally safe<br />
  20. 20. Blood, blood product and body fluids<br />Transfusion related from:-<br />Whole blood<br />Platelets<br />FFP<br />Packed red cell<br />Clotting factors<br />
  21. 21. Previously was very imp. Mode of transmission<br />Now there is screening of blood for HIV,HBV,HCV in all authorized blood banks all over the world<br />Despite best efforts risk can not be completely eliminated since current technology can not detect HIV RNA for first 1-2 wks of inf. Due to very low level of viremia<br />Infection of hemophiliacs has been reduced due to heat treatment of clotting factors<br />HIV can be killed at 30*C for 30 min<br />Hyper immune gamma globulin, HBV Ig, HBV vaccine and Rh immunoglobulin have no risk due to processing which kills HIV<br />
  22. 22. Intravenous Drug Users<br />They have high risk of infection due to:-<br />Sharing injections, needles and syringes<br />Water used to mix the drug<br />Cotton through which drug is filtered<br />I/V puncture is not necessary. S/C or I/m injection can transmit the disease<br />
  23. 23. Risk increases with<br />Duration of drug used<br />Frequency of needle sharing<br />Number of partners<br />I/v > S/c or I/m<br />
  24. 24. Occupational Exposure<br />Small but definite and potential risk<br />Person at risk are:-<br />Health care worker (HCWs)<br />Surgeons<br />Lab Technicians<br />All other who works with HIV infected material<br />
  25. 25. Needle Stick Injury<br />Most common mode<br />Risk of HIV:- 0.3%<br />HBV:- 6-30%<br />HCV:- 1.8%<br />1ml of infected blood has 50 HIV RNA compared with 109 HBV particles<br />There are incidences when patient was positive for HBV and HIV both but the HCW became infected with HBV only<br />Hollow needles 10 times more dangerous than solid needles<br />
  26. 26. Most of needle injuries(27%) occurs from improper disposal<br />Injury occurs most commonly on Index finger and Palm adjacent to thumb of non dominant hand<br />
  27. 27. Factors associated with increased risk of transmission<br />Deep injury<br />Presence of visible blood on instrument<br />Device placed directly in vein or artery<br />Early or terminal illness in patient<br />High viral load<br />Source patient dies within 2 months of exposure<br />Large diameter needle<br />
  28. 28. Mucus membrane contact<br />Due to spillage or splash of infected material on face, mouth, eyes etc.<br />Risk :- 0.09%<br />Intact skin has no risk<br />
  29. 29. Non intact skin<br />If HCW has injury to any body part<br />Abrasion of skin<br />Ulcer of skin<br />Average risk not known<br />Risk is less than mucus membrane contact<br />Risk of infection from body fluids other than blood is less but has not been quantified<br />
  30. 30. Various body fluids causing infection <br />High risk<br />Blood <br />Amniotic fluids<br />CSF<br />Breast milk<br />Pericardial fluid<br />Peritonial fluid<br />Pleural fluid<br />Synovial fluid<br />Unfixed tissue or organ<br />Vaginal sec.<br />Seminal fluid<br />Sliva associated with dental procedure<br />Low risk<br />Urine <br />Vomit <br />Saliva <br />Faeces <br />Sweat <br />Tears <br />
  31. 31. Mother to fetus or infant<br />Can occur during pregnancy, delivery or breast feeding<br />Imp. In developing countries<br />Perinatal most common because:-<br />HIV IgA increases 3-6 months after birth<br />Culture and P24 antigenimia increases wks to months after birth<br />PCR becomes positive many months after birth<br />Cesarean section decreases transmission<br />
  32. 32. In the absence of prophylactic ART probability of transmission is:-<br />15-25% in developed countries<br />25-35% in developing countries<br />This is due to:-<br />Adequate prenatal and natal care<br />Better general health of pregnant female<br />
  33. 33. Factor associated with high transmission<br />Well documented<br />High maternal viremia<br />Low CD4 count <br />Prolonged interval b/w membrane rupture and delivery<br />Potential <br />Chorioamnionitis<br />STDs<br />Preterm delivery<br />Cigarette smoking<br />Vit A deficiency<br />Obstetric procedure like:-<br />Amniocentesis<br />Fetal scalp electrode<br />episiotomy<br />
  34. 34. Breast feeding<br />Imp. In developing countries where it is continued for long time<br />Factor that increase the risk:-<br />Detectable HIV In breast milk<br />Mastitis <br />Low CD4 count<br />Vit. A deficiency<br />
  35. 35. Risk highest in early months of breast feed<br /> avoidance of breast feeding is controversial<br />Although vit. A deficiency increase the risk but its supplementation does’t protects<br />
  36. 36. Clinical Manifestations<br />Spectrum changes from:-<br />Primary infection (with or without acute syndrome) clinical latency symptomatic disease<br />Means HIV +ve patient may not be having AIDS, but an AIDS patient will always be HIV +ve.<br />Acute symptoms:- 50-70% experience acute syndrome 3-6 wks after primary infection<br />It remains for 1 to several wks<br />Due to high viremia n low CD4 count<br />
  37. 37. Symptoms are<br />Fever<br />Pharangitis<br />Lymphadenopathy(70%)<br />Headache<br />Arthralgia<br />Lethargy<br />Anorexia/ weight loss<br />Nausea/ vomiting/ diarrhea<br />Meningitis<br />Encephalitis<br />Peripheral neuropathy<br />Myelopathy<br />Mucocutaneous ulcer<br />
  38. 38. Seroconversion period<br />Also called window period<br />Extend from day of HIV exposure to the day of appearance of HIV antibodies in blood<br />This is 12 wks(3 months)<br />During this HIV test will be negetive<br />
  39. 39. Clinical latency<br />Average period is 7-10 yrs<br />During this pt is infected<br />Virus replicates<br />CD4 count progressively decreasing<br />No symptoms<br />Av. Rate of T cell decline is 50/µl/yr<br />
  40. 40. Symptomatic disease<br />AIDS:-anyone with CD4 count <200/µl or having opportunistic diseases (infections/ neoplasm)<br />Infection are:- bacterial:-TB<br />MAC inf<br />MDR TB<br />Salmonellosis<br />Viral:-<br />VZV<br />HSV<br />CMV<br />
  41. 41. Protozoan :-<br />PCP<br />Toxoplasmosis<br />Fungal <br />Cryptococus<br />Histoplasmosis <br />Coccidioides immitis<br />Neoplasm<br />Kaposi sarcoma<br />Lymphoma<br />Peri anal warts<br />Melanoma<br />Testis n oral cancer<br />
  42. 42. Prophylaxis <br />Better than cure<br />V. imp.<br />Because no cure of HIV/AIDS<br />Mortality 100%<br />Safe sex:-be faithful to your partner<br />Use condoms or other barrier methods during intercourse<br />Avoid unnatural ways of sex like anal sex<br />Early recognition of STDs n treatment<br />
  43. 43. Universal precautions<br />Concept by US CDC<br />Every specimen should be handled as if it came from someone infected with blood borne disease <br />All patients treated with full infection controlled procedures<br />Not possible to apply to all so UK NHS has given concept of “Standard precautions”<br />
  44. 44. Standard precautions<br />Within any category of operations there are general precautions appropriate for the procedure with additional specific precautions for different patients<br />So all pts should be screened n additional precautions applied to those who r HIV POSITIVE or high risk:-<br />Homosexual<br />IDUs<br />Haemophiliac<br />Partner of a member of one of the above group<br />
  45. 45. Presentation to surgeon<br />HIV positive pt may present with any disease that are normally managed by the surgeon with specific conditions related to HIV syndrome like:-<br />Colorectal n anal ds<br />Lymph node excision biopsy<br /> Splenectomy for thrombocytopenia<br />Chronic venous assess<br />These ds are treated in the same way as in HIV negative pts <br />
  46. 46. Training n education<br />Corner stone of all infection control programmes<br />Should be provided to all staff at all levels<br />Main focus on:-<br />Modes of transmission<br />Use of std precautions<br />Disposal of sharps n body fluids<br />Issue of stigma n discrimination<br />Human rights n obligations<br />Area posting of warning signs<br />
  47. 47. Screening of patients<br />Screening of all patients for HIV, HBV, HCV is very important<br />Even if HIV test is negative, it is not 100% sure that patient is not infected because<br />Patient may be in window period when HIV antibodies have not yet formed in the patient (detected by the HIV test kits)<br />So precautionary measures are very important<br />
  48. 48. Methods of prevention<br />Barrier method<br />Methodical approach to all procedures<br />Proper care n disposal of sharps<br />Controlled n deliberate manner of procedure <br />
  49. 49. Barrier method<br />Can prevent >50% exposure<br />Gloves:- need to wear gloves while doing any of the following procedure:-<br />Dressing a wound<br />Starting I/V drip<br />Taking blood samples<br />Doing any operative procedure<br />Doing PR, PV or oral cavity exam<br />
  50. 50. No need to wear<br />Physical exam of pt when the pt has no open wound<br />Giving I/M inj<br />
  51. 51. Double gloves<br />Two pairs of gloves produces better protection<br />Single glove can reduce the volume of blood from needle injury by 50%<br />Double gloves give extra protection<br />Risk can be reduced by 5 folds<br />Bt it decreases the sensitivity of hand n fingers<br />More comfortable to wear large glove inside n a ½ size smaller glove outside<br />
  52. 52. Use only good quality gloves<br />Use only disposable gloves<br />Gloves should be discarded after single use<br />Should not be washed or disinfected as:-<br />Micro-organisms can not be easily washed<br />Washing may enhance the penetration of liquid through unidentified holes<br />Disinfection can deteriorate the gloves<br />
  53. 53. If glove breaks during procedure immediately change it<br />After use dispose of in plastic bags<br />Cap n mask<br />Need to be worn during any operation<br />No need to wear in ward<br />In ward wear only while doing major dressings<br />
  54. 54. Eye glasses or shields<br />Certain situations where need to be worn:-<br />Orthopedic OT:-high speed drills or bone cutters used<br />Obstetric OT:-during delivery<br />Dental procedure:-high speed drills used<br />General surgery OT:-require exposure to medium sized arteries which may get injured<br />
  55. 55. Plastic apron/gown<br />During prolonged procedure, excessive blood loss or body fluid spillage surgeon’s gown may get soaked at the level of operating table<br />Surgeon’s under clothes may get soaked<br />So plastic apron should be worn<br />
  56. 56. Footwear<br />To wear “chappals” in OT is very unsafe<br />Wear the footwear that will protect the feet, ankle and lower part of legs<br />Wellington shoes are of this type n should be used<br />Contaminated shoes should be removed while wearing gloves<br />Should be brush scrubbed with soap n hot water<br />Use disposable shoe coverings <br />
  57. 57. Methodical approach<br />Carry out operation in orderly manner<br />Surgical assistants should be minimum<br />Reduce the number of staff in OT to cover essential roles only<br />Remove all extra equipments<br />Staff members having abrasions eczema should be excluded<br />Avoid any in coordination in passing instruments<br />
  58. 58. Clearly announce while handing over sharp instrument<br />Use kidney tray to pass instruments<br />Use retractors only to retract the tissue<br />Assistants should be still when surgeon is doing any delicate procedure like suturing or sharp dissection<br />When assistant is changing the position surgeon should stop operating<br />All procedure should be done in correct sequence<br />
  59. 59. Controlled and deliberate manner<br />Maintain attention to hemostasis<br />Avoid unexpected bleeding<br />Don’t be panicky<br />Don’t be in hurry<br />Stitching should be done with needle holder n forceps<br />Retraction to the tissue with free hand must be with utmost care<br />
  60. 60. While stitching the only movement should be by the surgeon, assistant should stay still<br />Where possible use alternative methods like blunt suture needles, staples, surgical adhesives, cautery<br />Thimbles to protect the index finger of non dominant hand<br />Magnetic pads to place sharps<br />Scalpel blade should be removed from blade holder with clamp or artery forceps<br />
  61. 61. Disposal of sharps n body fluids<br />After use sharps should be placed in puncture proof containers<br />puncture proof containers must be available near the operating area<br />Should not be thrown on the floor or in garbage container<br />
  62. 62. All the body fluids should be handled with utmost care taking all the precautions<br />Swabs should be counted, but not left exposed on the instrument troley, should be placed in deep swab pockets <br />
  63. 63. Disposable instruments should be placed in yellow bags, sealed n double bagged with a hazard label attached<br />Soiled linen should be handled as little as possible with minimum agitation<br />Placed into special bags, marked and send to laundry<br />Normal laundry cycles should be used<br />Bulk blood, suctioned fluid, excretions and secretions should be placed in leakage proof container n carefully poured down a drain<br />
  64. 64. Infective material should either be incinerated or decontaminated before disposal in a sanitary fill<br />All spills on floor should be cleaned with 1:1000 solution of house hold bleach<br />Soiled cleaning equipments should be cleaned and decontaminated or disposed off properly<br />
  65. 65. Hand washing<br />V. imp. Practice to prevent infection<br />Hands must be washed before wearing gloves<br />Use of gloves doesn’t eliminates the need for washing<br />Hands should be washed when gloves are removed<br />Wash immediately after unprotected exposure<br />After a glove tears or breaks<br />Before leaving a work area<br />
  66. 66. In emergency care<br />Risk is more in emergency department due to:-<br />HIV status of the patient who comes in emergency is not known<br />Patient needs urgent care so can not wait for HIV test report<br />HCWs have to work quickly sometimes no time to think about precautionary measures<br />
  67. 67. Precautions <br />Disposable gloves should be the standard component of emergency equipment<br />Gloves should be donned by all personnel prior to initiate any emergency patient care<br />Extra pair of gloves should be available<br />Gloves should fit tightly at the wrist<br />Gloves should be changed b/w patient contacts<br />
  68. 68. While wearing gloves avoid handling personal items like pen, comb etc.<br />Gloves should be removed taking care to avoid contact with exterior surface<br />Mask, eye shields and gowns should be available in emergency<br />These should be used according to the level of exposure<br />Needles should not be recapped<br />If recapping can not be avoided either use<br />One handed “scoop” technique or<br />Mechanical device to hold the needle sheath<br />
  69. 69. Needles should not be bent or broken by hand<br />Should not be removed from syringe<br />Should be burnt in needle incinerator <br />Or placed with syringe in puncture proof container<br />Reusable needles should be left on syringes in a puncture proof container<br />No transmission during mouth to mouth respiration has been documented <br />
  70. 70. But because of risk salivary transmission of other inf. And theoretical risk of HIV n HBV during artificial ventilation, disposable airway equipments and resuscitation bags should be used<br />Disposable should be used once n then disposed off<br />If reusable thoroughly cleaned n disinfected after each use<br />Hands should be washed after every procedure, removing gloves or if contaminated<br />
  71. 71. To prevent infection to patients<br />Patient safety is 10 concern when giving injectable medication<br />Special attention must be paid to the initial and subsequent use of multi dose vials<br />Changing needles b/w patients but not syringes is not safe practice<br />Same needles may be used for same patient under special circumstances (acupuncture)<br />
  72. 72. All reusable syringes n needles must be appropriately cleaned and sterilized by boiling<br />Prior to any blood transfusion full identification of the patient and product must be made<br />HCWs who have previous significant exposure or have potential risk factors must seek HIV,HBV n HCV testing<br />
  73. 73. What to do if exposure occurs<br />Gently wash the area with soap n water immediately<br />Blood should be squeezed out of puncture wound<br />Mucus membrane should be irrigated with water, saline or sterile irrigants<br />Eyes should be irrigated with water or saline<br />Full history should be taken about time, type, circumstances of exposure<br />Type of instrument causing injury<br />Gauze of needle, depth of wound<br />
  74. 74. Whether gloves were worn or not<br />Whether source pt is known HIV positive or not<br />CD4 count of source<br />HIV RNA load<br />Current or previous ART<br />Any resistance to any drug<br />If status of source is unknown:-<br />Ask to agree to HIV test<br />Enquire about high risk factors<br />
  75. 75. Post exposure prophylaxisDecision to start PEP based on two factors<br />Exposure code<br />HIV status code<br />
  76. 76. Exposure code<br />
  77. 77. HIV status code<br />
  78. 78. Recommendations<br />EC1+HIVSC1PEP probably not required<br />EC1+HIVSC2basic regimen<br />EC2+HIVSC1 basic regimen<br />EC2+HIVSC2expanded regime<br />EC3+HIVSC1or2 expanded regime<br />EC2or3+HIVSC unknown basic regimen<br />
  79. 79. Regimens <br />Basic regimen:-Two NRTI for 1 month <br />Zidovudine – 300 mg BD + Lamivudine – 150 mg BD<br />Lamivudine + Stavudine 40 mg BD<br />Didanosine 200mg BD + Stavudine 40mg BD<br />Expended regimen:-Two NRTI+ One PI<br />Zidovudine + Lamivudine + Indinavir 800mg TDS/Ritonavir 100mg BD/Lopinavir 400mg BD/squinavir for 1 month<br />PEP should be started ideally with in 1 hr<br />Preferably with in 72 hr<br />May be considered up to 5 days with specialist advice<br />
  80. 80. Side effects<br />PEP is very toxic so its use is weighed against toxicity<br />Should not be used for exposure that poses negligible risk<br />Don’t use three drug regimen for all HIV exposure<br />Most common is nausea and diarrhea<br />Mild n reversible may be relieved by domperidone and loperamide<br />PIs cause peripheral neuropathy<br />Indinavir:- Nephrolithiasis, Hyperbilirubinemia <br />NRTI Abacavir causes hypersensitivity reaction<br />NNRTI not used causes acute fulminant liver failure<br />Efavirenz is teratogenic, Steven Johnson Syndrome, dizziness, insomnia, psychiatric illness<br />
  81. 81. Investigations before prescribing PEP<br />Full medical history <br />Risk of pregnancy<br />CBC<br />LFT<br />RFT<br />Zidovudine + Lamivudine + Ritonavir are safe in pregnancy<br />Alone Zidovudine gives 80% protection. Combinations provide extra protection<br />
  82. 82. Follow up<br />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<br />Follow up every 1-2 wk to check side effects, toxicity and adherence to regimen<br />Instruct to seek medical advice immediately if experiences acute viral symptoms<br />Advise to:- have safe sex<br />Use barrier methods during intercourse<br />Don’t donate blood or organs during follow up period <br />
  83. 83. Safe to continue performing exposure prone procedure as risk of seroconversion is low and the risk of onward transmission is remote<br />PEP for HBV:->90% effective<br />If source HBV +ve n HCW not previously vaccinated give full vaccine series n HBIg with in 24 hr not later than 1 wk<br />If HCW previously vaccinated check antibody titer if inadequate give 1 dose vaccine n 1 dose HBIg<br />If source HBV negative no need of PEP<br />
  84. 84. PEP for HCV<br />No PEP available<br />Follow up up to 6 months<br />Test for antibodies at 3 and 6 month interval<br />LFT every month to detect early acute hepatitis<br />Treatment of acute hepatitis with Interferon +/- Ribavirin can prevent development of chronic hepatitis<br />
  85. 85. Conclusion <br />Occupational exposure of HIV,HBV n HCV is small but potential risk <br />Screening of every patient is necessary<br />Personal protective measure with universal precautions with additional safety measures against high risk patients are the mainstay to decrease risk<br />PEP is very imp. N should be started as early as possible without waiting for HIV test report of source patient<br />
  86. 86. Thank You<br />