Hiv and surgeons

HIV and SURGEONS By Dr NareshKumar M.S.(General Surgeon)

Human Immunodeficiency Virus Two types:-HIV-1 and HIV-2 HIV-1 is most common worldwide HIV-2 is most common in west Africa It is a Retrovirus Family:- Retroviridae Sub-family:-Lentivirinae It has Reverse Transcriptase Enzyme It is RNA dependant DNA Polymerase Normally DNA RNA Proteins But in HIV RNADNA mRNA Proteins Here Reverse Transcriptase converts RNA into DNA

GP-120 recognised by CD4 receptors on CD4 cells Virus fuses with CD4 cell membrane Releases its RNA and RTase into CD4 cell cytoplasm Reverse Transcription occurs dsDNA forms dsDNA enters CD4 cell nucleus Incorporates into CD4 cell DNA by Integrase Provirus forms This has two fates:- ,[object Object]

Virus fuses with CD4 cell membrane

Releases its RNA and RTase into CD4 cell cytoplasm

Incorporates into CD4 cell DNA by Integrase

Provirus forms,[object Object]

CD4 cells T-Helper Cells Monocytes Macrophages Dendritic Cells Langerhans Cells

These points of life cycle are important for therapeutic purpose:- RTase inhibitors:-NRTI:- Zidovudine, Lamivudine, Stavudine ect. NNRTI:- Nevirapine, Efavirenz Protease inhibitors:-Ritonavir, Indinavir ect Integrase inhibitors Fusion inhibitors:-inhibits fusion of HIV with CD4 cells:-Enfuvirtide

Modes of Transmission Sexual:-Homosexual, Heterosexual Blood, blood products and other body fluids Mother to foetus Breast Milk

No risk with Casual contact Eating Insects:-Mosquitoes Sharing things

Sexual Transmission Most common and important More risk in Homosexual Virus concentrates in seminal fluid, vaginal and cervical secretions Receptive anal intercourse has more risk because:- Thin fragile rectal mucus membrane Trauma during intercourse

Vaginal intercourse Is also important although vaginal mucosa is several layer thick than anal mucosa and less chances of trauma Chances of infection from male to female are more than female to male because:- Semen remains for longer time in vagina as compare to penis in vaginal secretions STDs:-Increases the risk due to:- Infection increases the vascularity of mucosa->increases langerhan’s cells Infection->Genital ulcer->increases risk

Lack of circumcision:- increases risk due to:- Increased susceptibility to STDs Increased susceptibility to micro trauma Highly vascular foreskin has more lymphocyte and langerhan cells Moist environment beneath foreskin ->increase micro flora  inflammation increase T cells Increases risk Oral sex less eficient than anal or vaginal but not totally safe

Blood, blood product and body fluids Transfusion related from:- Whole blood Platelets FFP Packed red cell Clotting factors

Previously was very imp. Mode of transmission Now there is screening of blood for HIV,HBV,HCV in all authorized blood banks all over the world 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 Infection of hemophiliacs has been reduced due to heat treatment of clotting factors HIV can be killed at 30*C for 30 min Hyper immune gamma globulin, HBV Ig, HBV vaccine and Rh immunoglobulin have no risk due to processing which kills HIV

Intravenous Drug Users They have high risk of infection due to:- Sharing injections, needles and syringes Water used to mix the drug Cotton through which drug is filtered I/V puncture is not necessary. S/C or I/m injection can transmit the disease

Risk increases with Duration of drug used Frequency of needle sharing Number of partners I/v > S/c or I/m

Occupational Exposure Small but definite and potential risk Person at risk are:- Health care worker (HCWs) Surgeons Lab Technicians All other who works with HIV infected material

Needle Stick Injury Most common mode Risk of HIV:- 0.3% HBV:- 6-30% HCV:- 1.8% 1ml of infected blood has 50 HIV RNA compared with 109 HBV particles There are incidences when patient was positive for HBV and HIV both but the HCW became infected with HBV only Hollow needles 10 times more dangerous than solid needles

Most of needle injuries(27%) occurs from improper disposal Injury occurs most commonly on Index finger and Palm adjacent to thumb of non dominant hand

Factors associated with increased risk of transmission Deep injury Presence of visible blood on instrument Device placed directly in vein or artery Early or terminal illness in patient High viral load Source patient dies within 2 months of exposure Large diameter needle

Mucus membrane contact Due to spillage or splash of infected material on face, mouth, eyes etc. Risk :- 0.09% Intact skin has no risk

Non intact skin If HCW has injury to any body part Abrasion of skin Ulcer of skin Average risk not known Risk is less than mucus membrane contact Risk of infection from body fluids other than blood is less but has not been quantified

Various body fluids causing infection High risk Blood Amniotic fluids CSF Breast milk Pericardial fluid Peritonial fluid Pleural fluid Synovial fluid Unfixed tissue or organ Vaginal sec. Seminal fluid Sliva associated with dental procedure Low risk Urine Vomit Saliva Faeces Sweat Tears

Mother to fetus or infant Can occur during pregnancy, delivery or breast feeding Imp. In developing countries Perinatal most common because:- HIV IgA increases 3-6 months after birth Culture and P24 antigenimia increases wks to months after birth PCR becomes positive many months after birth Cesarean section decreases transmission

In the absence of prophylactic ART probability of transmission is:- 15-25% in developed countries 25-35% in developing countries This is due to:- Adequate prenatal and natal care Better general health of pregnant female

Factor associated with high transmission Well documented High maternal viremia Low CD4 count Prolonged interval b/w membrane rupture and delivery Potential Chorioamnionitis STDs Preterm delivery Cigarette smoking Vit A deficiency Obstetric procedure like:- Amniocentesis Fetal scalp electrode episiotomy

Breast feeding Imp. In developing countries where it is continued for long time Factor that increase the risk:- Detectable HIV In breast milk Mastitis Low CD4 count Vit. A deficiency

Risk highest in early months of breast feed avoidance of breast feeding is controversial Although vit. A deficiency increase the risk but its supplementation does’t protects

Clinical Manifestations Spectrum changes from:- Primary infection (with or without acute syndrome) clinical latency symptomatic disease Means HIV +ve patient may not be having AIDS, but an AIDS patient will always be HIV +ve. Acute symptoms:- 50-70% experience acute syndrome 3-6 wks after primary infection It remains for 1 to several wks Due to high viremia n low CD4 count

Symptoms are Fever Pharangitis Lymphadenopathy(70%) Headache Arthralgia Lethargy Anorexia/ weight loss Nausea/ vomiting/ diarrhea Meningitis Encephalitis Peripheral neuropathy Myelopathy Mucocutaneous ulcer

Seroconversion period Also called window period Extend from day of HIV exposure to the day of appearance of HIV antibodies in blood This is 12 wks(3 months) During this HIV test will be negetive

Clinical latency Average period is 7-10 yrs During this pt is infected Virus replicates CD4 count progressively decreasing No symptoms Av. Rate of T cell decline is 50/µl/yr

Symptomatic disease AIDS:-anyone with CD4 count <200/µl or having opportunistic diseases (infections/ neoplasm) Infection are:- bacterial:-TB MAC inf MDR TB Salmonellosis Viral:- VZV HSV CMV

Protozoan :- PCP Toxoplasmosis Fungal Cryptococus Histoplasmosis Coccidioides immitis Neoplasm Kaposi sarcoma Lymphoma Peri anal warts Melanoma Testis n oral cancer

Prophylaxis Better than cure V. imp. Because no cure of HIV/AIDS Mortality 100% Safe sex:-be faithful to your partner Use condoms or other barrier methods during intercourse Avoid unnatural ways of sex like anal sex Early recognition of STDs n treatment

Universal precautions Concept by US CDC Every specimen should be handled as if it came from someone infected with blood borne disease All patients treated with full infection controlled procedures Not possible to apply to all so UK NHS has given concept of “Standard precautions”

Standard precautions Within any category of operations there are general precautions appropriate for the procedure with additional specific precautions for different patients So all pts should be screened n additional precautions applied to those who r HIV POSITIVE or high risk:- Homosexual IDUs Haemophiliac Partner of a member of one of the above group

Presentation to surgeon HIV positive pt may present with any disease that are normally managed by the surgeon with specific conditions related to HIV syndrome like:- Colorectal n anal ds Lymph node excision biopsy Splenectomy for thrombocytopenia Chronic venous assess These ds are treated in the same way as in HIV negative pts

Training n education Corner stone of all infection control programmes Should be provided to all staff at all levels Main focus on:- Modes of transmission Use of std precautions Disposal of sharps n body fluids Issue of stigma n discrimination Human rights n obligations Area posting of warning signs

Screening of patients Screening of all patients for HIV, HBV, HCV is very important Even if HIV test is negative, it is not 100% sure that patient is not infected because 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

Methods of prevention Barrier method Methodical approach to all procedures Proper care n disposal of sharps Controlled n deliberate manner of procedure

Barrier method Can prevent >50% exposure Gloves:- need to wear gloves while doing any of the following procedure:- Dressing a wound Starting I/V drip Taking blood samples Doing any operative procedure Doing PR, PV or oral cavity exam

No need to wear Physical exam of pt when the pt has no open wound Giving I/M inj

Double gloves Two pairs of gloves produces better protection Single glove can reduce the volume of blood from needle injury by 50% Double gloves give extra protection Risk can be reduced by 5 folds Bt it decreases the sensitivity of hand n fingers More comfortable to wear large glove inside n a ½ size smaller glove outside

Use only good quality gloves Use only disposable gloves Gloves should be discarded after single use Should not be washed or disinfected as:- Micro-organisms can not be easily washed Washing may enhance the penetration of liquid through unidentified holes Disinfection can deteriorate the gloves

If glove breaks during procedure immediately change it After use dispose of in plastic bags Cap n mask Need to be worn during any operation No need to wear in ward In ward wear only while doing major dressings

Eye glasses or shields Certain situations where need to be worn:- Orthopedic OT:-high speed drills or bone cutters used Obstetric OT:-during delivery Dental procedure:-high speed drills used General surgery OT:-require exposure to medium sized arteries which may get injured

Plastic apron/gown During prolonged procedure, excessive blood loss or body fluid spillage surgeon’s gown may get soaked at the level of operating table Surgeon’s under clothes may get soaked So plastic apron should be worn

Footwear To wear “chappals” in OT is very unsafe Wear the footwear that will protect the feet, ankle and lower part of legs Wellington shoes are of this type n should be used Contaminated shoes should be removed while wearing gloves Should be brush scrubbed with soap n hot water Use disposable shoe coverings

Methodical approach Carry out operation in orderly manner Surgical assistants should be minimum Reduce the number of staff in OT to cover essential roles only Remove all extra equipments Staff members having abrasions eczema should be excluded Avoid any in coordination in passing instruments

Clearly announce while handing over sharp instrument Use kidney tray to pass instruments Use retractors only to retract the tissue Assistants should be still when surgeon is doing any delicate procedure like suturing or sharp dissection When assistant is changing the position surgeon should stop operating All procedure should be done in correct sequence

Controlled and deliberate manner Maintain attention to hemostasis Avoid unexpected bleeding Don’t be panicky Don’t be in hurry Stitching should be done with needle holder n forceps Retraction to the tissue with free hand must be with utmost care

While stitching the only movement should be by the surgeon, assistant should stay still Where possible use alternative methods like blunt suture needles, staples, surgical adhesives, cautery Thimbles to protect the index finger of non dominant hand Magnetic pads to place sharps Scalpel blade should be removed from blade holder with clamp or artery forceps

Disposal of sharps n body fluids After use sharps should be placed in puncture proof containers puncture proof containers must be available near the operating area Should not be thrown on the floor or in garbage container

All the body fluids should be handled with utmost care taking all the precautions Swabs should be counted, but not left exposed on the instrument troley, should be placed in deep swab pockets

Disposable instruments should be placed in yellow bags, sealed n double bagged with a hazard label attached Soiled linen should be handled as little as possible with minimum agitation Placed into special bags, marked and send to laundry Normal laundry cycles should be used Bulk blood, suctioned fluid, excretions and secretions should be placed in leakage proof container n carefully poured down a drain

Infective material should either be incinerated or decontaminated before disposal in a sanitary fill All spills on floor should be cleaned with 1:1000 solution of house hold bleach Soiled cleaning equipments should be cleaned and decontaminated or disposed off properly

Hand washing V. imp. Practice to prevent infection Hands must be washed before wearing gloves Use of gloves doesn’t eliminates the need for washing Hands should be washed when gloves are removed Wash immediately after unprotected exposure After a glove tears or breaks Before leaving a work area

In emergency care Risk is more in emergency department due to:- HIV status of the patient who comes in emergency is not known Patient needs urgent care so can not wait for HIV test report HCWs have to work quickly sometimes no time to think about precautionary measures

Precautions Disposable gloves should be the standard component of emergency equipment Gloves should be donned by all personnel prior to initiate any emergency patient care Extra pair of gloves should be available Gloves should fit tightly at the wrist Gloves should be changed b/w patient contacts

While wearing gloves avoid handling personal items like pen, comb etc. Gloves should be removed taking care to avoid contact with exterior surface Mask, eye shields and gowns should be available in emergency These should be used according to the level of exposure Needles should not be recapped If recapping can not be avoided either use One handed “scoop” technique or Mechanical device to hold the needle sheath

Needles should not be bent or broken by hand Should not be removed from syringe Should be burnt in needle incinerator Or placed with syringe in puncture proof container Reusable needles should be left on syringes in a puncture proof container No transmission during mouth to mouth respiration has been documented

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 Disposable should be used once n then disposed off If reusable thoroughly cleaned n disinfected after each use Hands should be washed after every procedure, removing gloves or if contaminated

To prevent infection to patients Patient safety is 10 concern when giving injectable medication Special attention must be paid to the initial and subsequent use of multi dose vials Changing needles b/w patients but not syringes is not safe practice Same needles may be used for same patient under special circumstances (acupuncture)

All reusable syringes n needles must be appropriately cleaned and sterilized by boiling Prior to any blood transfusion full identification of the patient and product must be made HCWs who have previous significant exposure or have potential risk factors must seek HIV,HBV n HCV testing

What to do if exposure occurs Gently wash the area with soap n water immediately Blood should be squeezed out of puncture wound Mucus membrane should be irrigated with water, saline or sterile irrigants Eyes should be irrigated with water or saline Full history should be taken about time, type, circumstances of exposure Type of instrument causing injury Gauze of needle, depth of wound

Whether gloves were worn or not Whether source pt is known HIV positive or not CD4 count of source HIV RNA load Current or previous ART Any resistance to any drug If status of source is unknown:- Ask to agree to HIV test Enquire about high risk factors

Post exposure prophylaxisDecision to start PEP based on two factors Exposure code HIV status code

Recommendations EC1+HIVSC1PEP probably not required EC1+HIVSC2basic regimen EC2+HIVSC1 basic regimen EC2+HIVSC2expanded regime EC3+HIVSC1or2 expanded regime EC2or3+HIVSC unknown basic regimen

Regimens Basic regimen:-Two NRTI for 1 month Zidovudine – 300 mg BD + Lamivudine – 150 mg BD Lamivudine + Stavudine 40 mg BD Didanosine 200mg BD + Stavudine 40mg BD Expended regimen:-Two NRTI+ One PI Zidovudine + Lamivudine + Indinavir 800mg TDS/Ritonavir 100mg BD/Lopinavir 400mg BD/squinavir for 1 month PEP should be started ideally with in 1 hr Preferably with in 72 hr May be considered up to 5 days with specialist advice

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 n 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

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