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ANAESTHETIC CONSIDERATIONS IN AIDS PATIENTS
1) HIV/AIDS patients present special challenges for anesthesia due to the virus' effects on multiple body systems and interactions with antiretroviral drugs. 2) Evaluation of patients should assess organ involvement and potential for drug interactions. Anesthetic plans must be tailored to individual patients while minimizing interruptions to antiretroviral therapy. 3) Strict universal precautions including protective equipment, careful handling of sharps and contaminated materials, and safety equipment help minimize risk of infection to hospital staff from needle sticks or exposure to bodily fluids.
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ANAESTHETIC CONSIDERATIONS IN AIDS PATIENTS
- 1. ANAESTHETIC CONSIDERATION IN AIDSPATIENTS 1/32
- 2. INCIDENCE OF SERO-POSITIVECASES IN OUR HOSPITAL YEAR NO OF LSCS /P.S CASES SERO- POSITIVE CASES INCIDEN CE 2012 3769 22 0.58% 2013 4218 31 0.73% HIV patients in India –around 5 million(2006) 2/32
- 3. Why HIV patientsare 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. 3/32
- 4. How the diseaseaffects the body system? CVS: Pericardial effusion,endocardit is,myocarditis,DCM ,PHT,IHD RS: Kaposi’s sarcoma,Lympho ma,Nocardiosis CNS: Peripheral and autonomic neuropathy, increased ICP Coagulation system: Thromboembolism, thrombocytopenia and hypercoagulable state 4/32
- 5. How the diseaseaffects the body system? GIT: ↑Gastric emptying time, diarrhoea, Hepato-biliary involvement, pancreatitis RENAL: Nephropathy ENDOCRINE: SIADH- Hyponatremia, Hypo/Hyperthyro idism Disorders of HPA axis 5/32
- 6. REVIEW OF ANTIRETERO VIRALDRUGS Drug class Subclass Available drugs Reverse transcriptase inhibitors Nucleoside/nucletide analogues Abacavir Didanosine Lamivudine Zidovudine Non-nuleotide analogues Nevirapine Delavirdine Protease inhibitors Atazanavir Darunavir Indinavir Integrase inhibitors Raltegavir Entry inhibitors Fusion inhibitors Enfuviritide CCR-5 antagonists Maraviroc 6/32
- 7. SIDE EFFECTS ASSOCIATED WITHARV DRUGS DRUG SIDE EFFECTS Zidovidine Marrow suppression,myopathy Lamividine Diarrhoea,peripheral neuropathy Tenofovir Renal toxicity Didanosine Diarrhoea. P.neuropathy Indinavir Nephrolithiasis, enzyme inhibition Ritonavir Enzyme inhibition Nevirapine Rash, enzyme induction Pentamidine Bronchospasm,arrythmia 7/32
- 8. 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 8/32
- 9. PRE-ANAESTHETIC EVALUATION Carefulhistory and examination about Cardiomyopathy, pulmonary complications Peripheral neuropathy. Bleeding episodes Routine investigations Anaemia PFT CD4 count: if more than 500, infective complications are less 9/32
- 10. No surgery shouldbe deferred on the basis of HIV positivity alone… ASA risk class is more important than HIV status. 10/32
- 11. CHOICE OF ANAESTHESIA G.A/R.A– Both are safe considerations Drug interactions and multisystem involvement when G.A is chosen Presence of peripheral neuropathy, local infection and coagulopathy should 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 11/32
- 12. 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 12/32
- 13. ANAESTHETIC CONSIDERATIONS Oesophagealor oro-pharyngeal lesions – difficult intubation and aspiration Subtle or overt lung pathology 13/32
- 14. ANAESTHETIC CONSIDERATIONS Useof bacterial filters to protect the machine and circuit SAB may be preferred for LSCS Blood transfusion – to be kept minimum 14/32
- 15. RISK OF CROSSINFECTION Transmission of HIV in hospital: o Exposure to infected body fluids of the patient o Either because of sharp injury or splashing of infected secretion to mucous membrane/broken skin 15/32
- 16. Most of theinjuries occur… Due to overenthusiastic participation in 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 16/32
- 17. Some points aboutthe needle stick injury… A single needle stick injury is associated with 0.31% risk of HIV transmission Nearly 20% of the Anaesthesiologists would have had a needle stick injury in the past 3 months… Invariably occurs due to recapping especially for Seniors… 17/32
- 18. The habit ofwearing 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% 18/32
- 19. Single or Doublegloving…? Single glove: 10 – 100 fold reduction in the dose of inoculam in needle stick injury Double gloving reduces it further 19/32
- 20. Patient to patienttransmission: • Contaminated anaesthetic circuits • Laryngoscopes 20/32
- 21. HOW TO PROTECTTHE HOSPITAL PERSONNEL..? UNIVERSAL PRECAUTIONS: “Set of precautions designed to prevent transmission of HIV to health workers while providing health care” 21/32
- 22. UNIVERSAL PRECAUTIONS: • WashingHands : with soap and water • Wearing Gloves : single for ordinary procedures. Double for procedures involving handling of sharp objects • Eye glasses, cap, mask : covered glasses esp during ortho procedures 22/32
- 23. UNIVERSAL PRECAUTIONS: Imperviousgowns : water impermeable Handling of needles and sharps : Re-sheathing to be avoided Beware of working in the depth during surgery 23/32
- 24. UNIVERSAL PRECAUTIONS: How todeal with the used materials after surgery..? Soiled linen: Soaking in 1:100 hypochlrite solution for 30 min. Metal Instruments: Wash with soap and water Soak in 2% Gluteraldehyde solution for 30 min Sharp instruments for 6 hours Then they are autoclaved Plastic tubing: soaking in 2% Gluteraldehyde for 6 hours or ETO sterlisation. 24/32
- 25. NEW METHODS OFAVOIDING SHARP INJURY RETRACTABLE SCALPEL SAFETY LANCETS 25/32
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- 27. TYES OF SAFETYSYRINGES 27/32
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- 29. POST-EXPOSURE PROPHYLAXIS As soonas possible after injury Ideally within 1-2 hours A combination of Zidovudine – 250mg b.d Lamivudine – 150 mg b.d Indinavir – 800 mg tds for a duration of 4 weeks 29/32
- 30. SUMMARY: • Careful preoperativeevaluation of patients to 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 30/32
- 31. “If the Anaesthesiologistsserve for 30 years in the theatre, the risk of acquisition of HIV infection is 4.5%...!” Concluding remarks… If the universal precautionary methods are scrupulously followed, we can make this sentence false…. 31/32
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