1) Anesthetic considerations are important for patients with HIV/AIDS undergoing surgery. While HIV alone is not a reason to withhold surgery, regional anesthesia is preferred over general anesthesia due to immune system effects. 2) A thorough pre-operative evaluation should be conducted to assess organ system involvement and optimize the patient's status. Intra-operatively, non-cytochrome P450 metabolized drugs are preferred due to drug interactions. 3) Precautions must be taken to prevent transmission between patient and staff, as well as between patients. Post-exposure prophylaxis should begin within 2 hours of a potential exposure.

1. ANAESTHETIC
CONSIDERATIONS IN
AIDS PATIENT
Presentor:
Dr. M Sabari Kreeshan,
1st yr DNB Resident,
Anesthesiology
Moderator:
Dr. Sangeeta Singh,
HOD, Anaesthesiology Dept.

2. ANAESTHETIC CONSIDERATIONS
• Approximately 20% of all patients with HIV infection undergo surgery at some time during
the course of their illness. Most of the procedures are for HIV-related problems; however,
sometimes they are unrelated .
• There is no justification to withhold surgical intervention on the grounds of HIV infection
alone
• Concern has been expressed over the depression of cell-mediated immunity and alterations
in immune function such as depression of natural killer cell, T-lymphocyte, monocyte and
neutrophil activity after general anaesthesia.
• However, the changes seem to be transient and do not lead to increased likelihood of
postoperative infection.

3. PRE-OP
• Regardless of whether Pt receiving HAART and has an undetectable viral load, Pts
with HIV/AIDS always considered a potential source of Infection
• HAART has no protective effect in reducing perioperative risks
• Thorough history taking , review of systems and Phy. Exams( to r/o systemic invt)
• Essential inv- CBC, RFT, LFT, Coagulational studies, CXR, ECG, Echo or stress test .
• Safety Profile- Regional Anes. > GA (Depression of NK cells, T cells, monocytes and
Neutrophils with GA)
• Regional Anaesthesia is safe but consider local infections, bleeding problems and
neuropathies.

4. PRE-OP
• Multiple Systems Affected to be Considered:
1. CVS- Pericardial Effusion, Endocarditis, myocarditis, Pulmonary arterial Hypertension.
Check for changes in ECG(50%)
2. Respiratory system- Kaposis sarcoma, Lymphoma, Pneumocystis carini, Typical
Mycobacterium, Nocardiosis. Check PFT, ABG, Spirometry.
3. CNS- Peripheral and Autonomic Neuropathy, Increased ICP, Meningitis and
Encephalitis (viral, Bacterial, aseptic, Fungal, Toxoplasma,Cryptococcus). 90% with AIDS
have CNS manifestations.
4. GIT- Cryptosporidium, CMV, Esophageal Candidiasis, Kaposis Sarcoma of Mouth and
Upper Airway leads to difficult Intubation
5. Others- Myopathy( Avoid Scoline), Anemia, Thrombocytopenia, Leucopenia, CMV
Adrenalitis (perioperative steroid supplementation), CD4 counts (>500 preferred)

5. INTRA-OP
1. Drug Interactions:
Protease Inhibitors and NNRTI’s are most commonly implicated HAART agents
associated with drug interactions.
Halothane with HAART can cause hepatic or renal dysfunction
Propofol and NRTI’s taken together may promote mitochondrial dysfunction and lactic
acidosis.
PREFERRED DRUGS- Etomidate, Atracurium, Desflurane, Remifentanyl (independent of
Cytochrome P450)
DRUGS NOT PREFERRED- Midazolam, Fentanyl due to cytochrome P450 enzymes
induction . Scoline is not preferred in pts with signs of myopathy, peripheral neuropathy
and any nervous invt.

7. INTRA-OP
2. Transmission of infection:
i) Pt to Anaesthetist-
a. Needle stick injuries( 20% of anaesthesiologists had atleast one needle stick injury over past
3 months) with 0.3% HIV Transmission. Hollow needle injuries have increased risk.
b. Splashing HIV containing body fluid in the eyes , nose or mouth with risk of transmission
0.1%
c. Contamination of Broken skin with Patients Body fluids with <0.1% transmission risk.
ii) Pt To Pt-
a. Reusing of syringes and reusing Airway devices without proper sterilization.
b. Not disposing Airway tubes

8. INTRA OP
• Obstetric Anaesthesia
Approximately 2.1 million children under 15 are infected with HIV/AIDS worldwide as a
result of mother-to-child transmission(MTCT).
In the absence of any intervention, an estimated 15–30% of mothers with HIV infection
will transmit the infection during pregnancy and delivery and 10–20% through breast
milk.
Vertical transmission is dramatically reduced by antiretroviral therapy. Current evidence
supports the use of Nevirapine given to mother at delivery and the neonate within 72 h
of delivery to prevent MTCT.
Elective Caesarean section appears independently to reduce the incidence of vertical
transmission and, when combined with antiretroviral therapy (ART), the rate of
transmission falls to 2%.

9. POST OP
• No significant increase In perioperative complications (wound dehiscence, hospital
stay, follow up visits etc;) compared with similar cohorts who are not HIV positive
• 1 yr mortality is higher in HIV Pts.
• Higher incidence of postoperative Pneumonia
• CD4+ count <50 cells/cubicmm and viral loads >30k copies/ml – Worst outcome in
terms of post op mortality

10. POST EXPOSURE PROPHYLAXIS
• Clean wound with Soap and Water, Mucosal exposure- rinse with water
• Start HIV PEP regimen ASAP(within 2hrs of exposure)
• Treat for 4 weeks
• If source tested and if negative – discontinue PEP (controversial)
• 2 Drug Regimen
1. Zidovudine and Lamivudine (combivir)
2. Lamivudine and Stavudine
3. Didanosine and Stavudine
• 3 Drug regimen has addition of either Indinavir/ Nelfinavir/ Efavirenz/ Abacavir to 2
drug regimen

11. ROCK THE RIBBON