ANAESTHETIC CONSIDERATIONS IN AIDS PATIENTS
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Transcript of ANAESTHETIC CONSIDERATIONS IN AIDS PATIENTS
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ANAESTHETIC CONSIDERATION IN AIDS PATIENTS
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INCIDENCE OF SERO-POSITIVE CASES IN OUR HOSPITAL
YEAR NO OF LSCS /P.S CASES
SERO-POSITIVE CASES
INCIDENCE
2012 3769 22 0.58%
2013 4218 31 0.73%
HIV patients in India –around 5 million(2006)
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Why HIV patients are 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.
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How the disease affects the body system?
CVS:Pericardial
effusion,endocarditis,myocarditis,DC
M,PHT,IHD
RS:Kaposi’s
sarcoma,Lymphoma,Nocar
diosisCNS:
Peripheral and autonomic
neuropathy,increased ICP
Coagulation system:
Thromboembolism,
thrombocytopenia and
hypercoagulable state
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How the disease affects the body system?
GIT:↑Gastric emptying
time, diarrhoea,Hepato-biliary involvement,pancreatitis
RENAL:Nephropathy
ENDOCRINE:SIADH-
Hyponatremia,Hypo/
Hyperthyroidism
Disorders of HPA axis
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REVIEW OF ANTIRETERO VIRAL DRUGS
Drug class Subclass Available drugs
Reverse transcriptase inhibitors
Nucleoside/nucletide analogues
AbacavirDidanosineLamivudineZidovudine
Non-nuleotide analogues
NevirapineDelavirdine
Protease inhibitors
AtazanavirDarunavirIndinavir
Integrase inhibitors
Raltegavir
Entry inhibitors
Fusion inhibitors Enfuviritide
CCR-5 antagonists Maraviroc
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SIDE EFFECTS ASSOCIATED WITH ARV DRUGS
DRUG SIDE EFFECTSZidovidine Marrow
suppression,myopathy
Lamividine Diarrhoea,peripheral neuropathy
Tenofovir Renal toxicityDidanosine Diarrhoea.
P.neuropathyIndinavir Nephrolithiasis,
enzyme inhibitionRitonavir Enzyme inhibitionNevirapine Rash, enzyme
inductionPentamidine Bronchospasm,arry
thmia
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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
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PRE-ANAESTHETIC EVALUATION
Careful history and examination aboutCardiomyopathy, pulmonary complicationsPeripheral neuropathy. Bleeding episodes
Routine investigationsAnaemia
PFT CD4 count: if more than 500, infective complications
are less
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No surgery should be deferred on the basisof HIV positivity alone…
ASA risk class is more important than HIV status.
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CHOICE OF ANAESTHESIAG.A/R.A – Both are safe
considerations Drug interactions and multisystem involvement
when G.A is chosen
Presence of peripheral neuropathy,local infection and coagulopathyshould 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
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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
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ANAESTHETIC CONSIDERATIONS
Oesophageal or oro-pharyngeal lesions – difficult intubation and aspiration
Subtle or overt lung pathology
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ANAESTHETIC CONSIDERATIONS
Use of bacterial filters to protect the machine and circuit
SAB may be preferred for LSCS
Blood transfusion – to be kept minimum
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RISK OF CROSS INFECTION
Transmission of HIV in hospital:
o Exposure to infected body fluids of the patient
o Either because of sharp injury orsplashing of infected secretion to mucous membrane/broken skin
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Most of the injuries occur…
Due to overenthusiastic participationin 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
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Some points about the needle stick injury…
A single needle stick injury is associated with 0.31%risk of HIV transmission
Nearly 20% of the Anaesthesiologists would havehad a needle stick injury in the past 3 months…
Invariably occurs due to recapping especially forSeniors…
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The habit of wearing 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%
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Single or Double gloving…?
Single glove: 10 – 100 fold reduction in the dose of inoculam in needle stick injury
Double gloving reduces it further
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Patient to patient transmission:
• Contaminated anaesthetic circuits
• Laryngoscopes
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HOW TO PROTECT THE HOSPITAL PERSONNEL..?
UNIVERSAL PRECAUTIONS:
“Set of precautions designed to prevent transmission of HIV to health workers while providing health care”
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UNIVERSAL PRECAUTIONS:
• Washing Hands : with soap and water
• Wearing Gloves : single for ordinary procedures.Double for procedures involving handlingof sharp objects
• Eye glasses, cap, mask : covered glasses esp during ortho procedures
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UNIVERSAL PRECAUTIONS:
Impervious gowns : water impermeable
Handling of needles and sharps : Re-sheathing to be avoided
Beware of working in the depth during surgery
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UNIVERSAL PRECAUTIONS:
How to deal with the used materials after surgery..?
Soiled linen: Soaking in 1:100 hypochlrite solution for 30 min.
Metal Instruments: Wash with soap and waterSoak in 2% Gluteraldehyde solution for 30 minSharp instruments for 6 hoursThen they are autoclaved
Plastic tubing: soaking in 2% Gluteraldehyde for 6 hours or ETO sterlisation.
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NEW METHODS OF AVOIDING SHARP INJURY
RETRACTABLE SCALPEL SAFETY LANCETS
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SAFETY SYRINGES
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TYES OF SAFETY SYRINGES27/32
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SAFTEY CANULAS 28/32
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POST-EXPOSURE PROPHYLAXIS
As soon as possible after injury
Ideally within 1-2 hours
A combination of Zidovudine – 250mg b.dLamivudine – 150 mg b.dIndinavir – 800 mg tds for a duration of 4 weeks
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SUMMARY:
• Careful preoperative evaluation of patientsto 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
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“If the Anaesthesiologists serve for 30 years in the theatre,the risk of acquisition of HIV infection is 4.5%...!”
Concluding remarks…
If the universal precautionary methods are scrupulouslyfollowed, we can make this sentence false….
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THANK YOU
dr.r.selvakumar. M.D.D.A.DNB
professor of anaesthesiology,k.a.p.viswanatham govt medical college,trichirapalli.tamilnadu.