Anesthesia for Infectious Diseases

Kanya Kumwilaisak MDDepartment of Anesthesiology

Faculty of MedicineChulalongkorn University

Infectious DiseaseAn infectious disease is a clinically evident illness resulting from the presence of pathogenic microbial agents

Mode of Transmission Respiratory system : contact with

aerosolized droplets, spread by sneezing, coughing, talking, kissing or even singing

Gastrointestinal system : are often acquired by ingesting contaminated food and water

Sexually transmitted diseases :are acquired through contact with bodily fluids, generally as a result of sexual activity

AIMS Prevent transmission

Patient to patient Patient to personal health care

provider Know pathophysiology of the

infectious diseases Know side effects of medications

Respiratory diseases Tuberculosis H1N1 influenza H5N1 influenza SARS

Tuberculosis

Tuberculosis

Diagnosis Symtoms : Persistent cough (eg,

lasting longer than 2 weeks),fever, night sweats, weight loss, shortness of breath, haemoptysis, and chest pain.

Positive tuberculin skin test Sputum exam and culture

MedicationsDrug Dose Side effect

First Line DrugsIsoniazid 5 mg/kg

(300mg)Hepatoxicityperipheral

neurotoxicitydrug interactions

Rifampin 10 mg/kg(600mg)

Hepatoxicitythrombocytopeniagastrointestinal upsetdrug interactions

Pyrazinamide

Based on weight

50 mg/kg (2 g)

Hepatotoxicitygastrointestinal upsetArthraglia

Ethambutol

15– 20 mg/kg daily

Ocular neuritis

Anesthetic management Elective surgery should be

postponed until they are no longer contagious (three negative sputum smears, improving symptoms and chest X ray)

Anesthetic management Liver function test, serum

creatinine and platelet count should be performed

If ethambutol is used, visual acuity and color vision should be assessed

Anesthetic management Type of anaesthetic technique will

depend on the type of surgery and degree of involment of respiratory tract

regional anaesthesia, patient must wear N95 mask

Anesthetic management OR with an antechamber or

separated from other areas The fewest health care workers HEPA filters are placed between

patient and the ventilator N95 mask in infectious particles

area

Anesthesia management CO2 absorber should be discarded Two bacterial filters at Y-piece and

expiratory limb— a case report Should delay at least 1 hour for the

next case No O2 flush for checking circuit

H1N1 infection Spread of infection to others Hyper reactive airway Reduced pulmonary functions and Involvement of other body organs

Postpone elective surgery till patient is H1N1 negative

In emergent H1N1 positive, it is prudent to operate in an Operation theatre with all precautions as per guidelines for infectious diseases like TB

Patient should be isolated throughout the stay in the hospital

H1N1 infection

H1N1 infection HEPA filters, connected between

patient outlet and standard anaesthesia tubing

a closed system suction catheter should be used

HIV infection Human immunodeficiency virus

(HIV) is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS)

Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk.

HIV infection

HIV infection Neurologic system Respiratory system Hematologic system Cardiovascular system Gastrointestinal system

AIDS Bacterial infection, multiple or recurrent Candida of the bronchi, trachea, lungs, or

esophagus CD4+ T lymphocyte count น้อยกวา่ 200 cells/µL3 Cervical cancer, invasive Coccidioidomycosis, disseminated or

extrapulmonaryCryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (>1 month) Cytomegalovirus other than liver, spleen, lymph

nodes

AIDS Cytomegalovirus retinitis or CMV (with loss of

vision)Herpes simplex virus with chronic ulcers (> 1 month), bronchitis, pneumonitis, esophagitis

HIV related encephalopathy Histoplasmosis, disseminated or

extrapulmonaryIsophoriasis, chronic intestinal (>1month)

Kaposi’s sarcoma Burkitt’s lymphomaImmunoblastic lymphoma Lymphoma of the brain, primary

AIDS Mycobacterium avium complex or kansasii,

disseminated or extrapulmonary Mycobacterium tuberculosis, any site Mycobacterium, any other species, pulmonary

or extrapulmonary Pneumocystis carinii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Recurrent Salmonella septicemia Toxoplasmosis of the brain Wasting syndrome due to HIV

Medications Category Examples

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)

zidovudine (AZT), didanosine, zalcitabine, stavudine,

lamivudine and abacavirNon-Nucleoside ReverseTranscriptase Inhibitors

(NNRTIs)

nevirapine, delavirdine, and efavirenz

Protease Inhibitors amprenavir, fosamprenavir, atazanavir, saquinavir,

ritonavir, indinavir and nelfinavir

Fusion Inhibitors enfuvirtideIntegrase Inhibitors raltegravir

Side Effects Inhibit cytochrome P-450 (CYP)3A4 Glucose tolerances HAART has both direct

hepatotoxicity and nephrotoxicity

Anesthetic management CD4 count < 200 cells/µL3 be

treated with anteretroviral drugs History and physical exam CBC, coagulation profile, LFT,

BUN/Cr, electrolyte Chest radiography ECG

Anesthetic management GA or RA Universal precaution Prevent transmission

Universal Precuation 1. มสีขุภาพอนามยัดีพรอมท้ังกายและใจ 2. การรกัษาความสะอาดของท่ีทํางาน 3. การระมดัระวงัไมใหสมัผัสสารคัดหลัง่ 4. การสวมเครื่องปองกันใหเหมาะสม 5. การตระหนักการปองกันการติดเชื้อ เชน มสีมาธิ หมัน่ลางมอื

Precaution Apparatus- ถงุมอื- หนากาก- เสื้อกาวน- รองเทา

Universal Precuation

Safe use and disposal of sharps ลดขัน้ตอนการสงตอดวยมอื ไมควรหักหรอืงอของมคีมกอนท้ิง ไมควรปลดเขม็ออกจากหลอดฉีดยากอนท้ิง ควรท้ิงในท่ีท่ีเหมาะสมทันทีหลังใชงาน ไมควรใชเขม็ท่ีมคีมดดูยา ท้ิงภาชนะของมคีมเมื่อมขีองเต็ม 2/3

แนวทางปฏิบติัเมื่อถกูของมคีมตํา ล้างแผลบรเิวณผิวหนังด้วยน้ำ�าสบู ่ mucosa ล้างด้วยน้ำ�าเกลือ พบแพททยทั์นทีเพื่อประเมนิการติดเชื�อ

Information for an Occupational Exposure Report1. Date and time of exposure2. Detailed description of the procedure being

performed3. Details of the exposure4. Details regarding the exposure source such as

known HBV, HCV, or HIV infection5. Details about the exposed HCW such as a

history of hepatitis B vaccination and antibody status

6. Details about counseling, postexposure management, and follow-up

HBV HBIG ภายใน 24 ชัว่โมงเพื่อเป็น passive

prophylaxis HBV vaccine Signs and serology until 6 months

HCV Check anti-HCV and alanine

aminotransferase activity Follow up 4-6 months ถ้าผล anti-HCV positive ควรตรวจ

recombinant immunoblot essay เพื่อยนืยนัการติดเชื�อ

HIV antiretroviral agents for

postexposure prophylaxis in24-36 hrs

Follow up serology after 6, 12 weeks and 6 months

Conclusion

Air-borneUniversal precautionMask n-95IsolationPrepare anesthesia circuitการท้ำาความสะอาดอุปกรณ์

Blood-borneUniversal precautionPrecaution apparatusHand HygieneSharpsการท้ำาความสะอาดอุปกรณ ์