SURGERY IN THE HIV POSITIVE PATIENT

1. SURGERY IN THE HIV POSITIVE PATIENT Dr A Mouton

2. HIV infectioncontinues to be major cause of morbidity and mortality • WHO estimate 40 million people world wide infected • AIDS now fourth largest cause of death worldwide • Sub-Sahara Africa → most common cause of death • 15% of HIV (+) patients and 30-50% of patients with AIDS developed cancer

3. PERI-OPERATIVE GUIDELINES FOR SURGERY

4. I Pre-Operative workup: • Pre-op analysis should help determine risk for post op complications. • Detailed history – Opportunistic infection: - Prophylactic antibiotics - ARV therapy regimen

5. Following risk factors should be addressed • STD • Cardiovascular status • Viral hepatitis • TB • Drug and Alcohol abuse • Nutrition • Disease status (CD4 count and viral load)

6. Fluid-electrolyte and acid-base disturbances are common a.)Hyponatremia • Common • Poor prognosis • Due to: - Volume Depletion from GIT losses • Renal disease • Inappropriate ADH secretion • Medication • Third spacing of fluid 2° to Nefrotic syndrome (↓ albumin) • 1°/2° adrenal insufficiency

7. B. Hypokalemia - 2° to vomiting, diarrhoea, and tubular acidosis C. Hypocalemia - Drugs - Malignancy, CMV D. Hypo-uricaemia - Assorted opportunistic infections like CMV - Indicates ↑ morbidity and mortality

8. CD4 COUNTS AND VIRAL LOADS: • CD4 counts determine staging of HIV disease and need for prophylaxis. • Viral Loads determine effectiveness of ARV treatment. • Higher complication rate of CD4 <200cell/mm³ and post operative viral load > 10000 copies/ml. • Viral load > 10000 copies/ml suggest that ARV is no longer effective.

9. PREDICTORS OF POST OP COMPLICATIONS • Follow percent CD4 count in addition to absolute CD4 count. • Significant change in absolute CD4 count in setting of stable percent CD4, demonstrate immunological stability. TRAM et al: • Post operative percent CD4 < 18 and pre to post operative change in percent CD4 of 3 independent risk factor for post-op morbidity. JONES et al: • - Most important risk factor for post-op complications is ASA classification (measure • general health status) • - HIV (+) not independent risk factor.

10. IN SUMMARY:(Risk for Complications) • i) ASA risk class. • ii) Post-op percent CD4. • iii) Pre to post-op change in percent CD4. • iv) CD4 <200cell/mm³ (infection risk)

11. QUESTION: - Impaired immunity a consequence of surgery in HIV (+) patient? - Does surgical intervention impact on the course of HIV infections?

12. DATA EVALUATING IMMUNE FUNCTION AFTER TRAUMATIC INJURY: • i.) Loss of delayed type hypersensitivity. • ii.) Impair Lymphocyte proliferation. • iii) Production of an immune suppressive factor. • iv.) Alteration in number of circulating CD4 /CD8 lymphocytes

13. RAHL et al: - HIV (+) patient → on HAART - Surgery - 50% major procedures - 50% minor procedures - Surgery - 50% General surgery - 25% Gyne - 25 Other - Parameters - CD4 count before and after operation - Viral load

15. Viral load (within 180 day) - ⅓ had a higher titer post op - ⅔ unchanged or ↓ • First study that documents safety of surgery in HIV (+) patient in term of Immune suppression in HAART era. • Magnitude of surgery and extent of immune dysfunction pre-op did not impact on immune system adversely. (Determined by CD4 and viral load)

16. PERI OPERATIVE CONSIDERATION • Continue HAART - Gautun et al. (2008) – 43 drug naïve AIDS patients - mean baseline CD4 count 112 - Follow up after 3 months - 80% clinical improvement - CD4 ↑ by > 50 in 85% of cases - Mean CD4 increases from 112 baseline to 196 Factor associated with ↑ risk for infection I.) Systematic factors: • DM • Corticosteroid use • Obesity • Extreme of age • Recent surgery • Massive transfusion • ASA class 3-5

17. ii.) Local factors: Foreign body Electrocautery Epinephrine injection Wounds drains Hair removal with razor Post irradiation to site

18. POST OPERATIVE MANAGEMENT: Most complication: (1) CD4 < 200 cell/mm³ (2) Poor nutritional status(↓Alb) (3) ± Neutropenia Clinical adrenal insufficiency occurring in 5% HIV(+) and 20% AIDS patients post-op.

19. POST OP INFECTIONS: - Approach to patient with fever → determined by presence and nature of surgery and CD4 and viral load. - Most fevers from common case: - Pneumonia - Intravascular catheters - UTI - Hepatitis - Trombophelitis • Important to distinguish between post op complications and development of opportunistic infections.

20. PULMONARY COMPLICATIONS • Most frequent complication • Initial diagnostic management rely on knowledge of Immune dysfunction. • Nosocamial Pneumonia (S Aureus and gram (-) - Late in disease (<CD < 100) • Dyspnea or cough – careful assessment that is guided by clinical presentation and CD4 • - FBC, blood culture, CXR.

21. HYPO ADRENALISM: - Stress of surgery – unmask previously unsuspected hypo adrenalism. • Non specific Sx: - Electrolyte changes (↓Na ↓Ka) - Hypotension

22. CONCLUSION • HIV (+) patients are not at ↑ risk for complications, unless there medical health indices are poor, CD4 <200, their CD4 ratio changing, Viral load > than 10 000 copies/ml. • Ethically, it is difficult to refuse an HIV (+) patients services if you provide these services to non HIV positive patients. • In era of HAART surgical outcomes HIV (+) patients has been excellent. There is no data to suggest that major surgery influences HIV disease progression.