SURGERY IN THE SURGERY IN THE HIV POSITIVE HIV POSITIVE

PATIENTPATIENT

Dr A MoutonDr A Mouton

• HIV infectionHIV infection continues to be major cause of continues to be major cause of morbidity and mortalitymorbidity and mortality

• WHO estimate 40 million people world wide WHO estimate 40 million people world wide infectedinfected

• AIDS now fourth largest cause of death AIDS now fourth largest cause of death worldwideworldwide

• Sub-Sahara Africa → most common cause of Sub-Sahara Africa → most common cause of deathdeath

• 15% of HIV (+) patients and 30-50% of patients 15% of HIV (+) patients and 30-50% of patients with AIDS developed cancerwith AIDS developed cancer

PERI-OPERATIVE PERI-OPERATIVE GUIDELINES FOR GUIDELINES FOR

SURGERYSURGERY

II Pre-Operative workupPre-Operative workup::

• Pre-op analysis should help determine Pre-op analysis should help determine risk for post op complications.risk for post op complications.

• Detailed history – Opportunistic Detailed history – Opportunistic infection:infection:

- Prophylactic - Prophylactic antibioticsantibiotics

- ARV therapy - ARV therapy regimenregimen

Following risk factors should Following risk factors should be addressedbe addressed

– STDSTD– Cardiovascular statusCardiovascular status– Viral hepatitisViral hepatitis– TBTB– Drug and Alcohol abuseDrug and Alcohol abuse– NutritionNutrition– Disease status (CD4 count and viral Disease status (CD4 count and viral

load)load)

• Fluid-electrolyte and acid-base disturbances Fluid-electrolyte and acid-base disturbances are commonare common

a.)Hyponatremiaa.)Hyponatremia– CommonCommon– Poor prognosisPoor prognosis– Due to: - Volume Depletion from GIT lossesDue to: - Volume Depletion from GIT losses– Renal diseaseRenal disease– Inappropriate ADH secretionInappropriate ADH secretion– MedicationMedication– Third spacing of fluid 2° to Nefrotic Third spacing of fluid 2° to Nefrotic

syndrome syndrome

(↓ albumin)(↓ albumin)– 1°/2° adrenal insufficiency1°/2° adrenal insufficiency

B. Hypokalemia - 2° to vomiting, diarrhoea, B. Hypokalemia - 2° to vomiting, diarrhoea, and and

tubular acidosistubular acidosis

C. Hypocalemia - DrugsC. Hypocalemia - Drugs

- Malignancy, CMV- Malignancy, CMV

D. Hypo-uricaemia - Assorted opportunistic D. Hypo-uricaemia - Assorted opportunistic

infections like CMVinfections like CMV

- Indicates ↑ morbidity - Indicates ↑ morbidity and and

mortalitymortality

CD4 COUNTS AND VIRAL CD4 COUNTS AND VIRAL LOADSLOADS::

• CD4 counts determine staging of HIV CD4 counts determine staging of HIV disease and need for prophylaxis.disease and need for prophylaxis.

• Viral Loads determine effectiveness of Viral Loads determine effectiveness of ARV treatment.ARV treatment.

• Higher complication rate of CD4 Higher complication rate of CD4 <200cell/mm³ and post operative viral <200cell/mm³ and post operative viral load > 10000 copies/ml.load > 10000 copies/ml.

• Viral load > 10000 copies/ml suggest Viral load > 10000 copies/ml suggest that ARV is no longer effective.that ARV is no longer effective.

PREDICTORS OF POST OP PREDICTORS OF POST OP COMPLICATIONSCOMPLICATIONS

• Follow percent CD4 count in addition to absolute CD4 count.Follow percent CD4 count in addition to absolute CD4 count.• Significant change in absolute CD4 count in setting of stable Significant change in absolute CD4 count in setting of stable

percent CD4, demonstrate immunological stability.percent CD4, demonstrate immunological stability.

TRAM et alTRAM et al::

• Post operative percent CD4 Post operative percent CD4 < < 18 and pre to post operative change 18 and pre to post operative change in percent CD4 of 3 independent risk factor for post-op morbidity.in percent CD4 of 3 independent risk factor for post-op morbidity.

JONES et alJONES et al::

• - Most important risk factor for post-op complications is ASA - Most important risk factor for post-op complications is ASA classification (measure classification (measure

• general health status) general health status) • - HIV (+) not independent risk factor.- HIV (+) not independent risk factor.

IN SUMMARYIN SUMMARY::(Risk for (Risk for Complications)Complications)

• i)i) ASA risk class.ASA risk class.• ii)ii) Post-op percent CD4.Post-op percent CD4.• iii)iii) Pre to post-op change in percent Pre to post-op change in percent

CD4.CD4.• iv)iv) CD4 <200cell/mm³ (infection CD4 <200cell/mm³ (infection

risk)risk)

QUESTION:QUESTION:

-- Impaired immunity a consequence of Impaired immunity a consequence of surgery in HIV (+) patient?surgery in HIV (+) patient?

-- Does surgical intervention impact on Does surgical intervention impact on the course of HIV infections?the course of HIV infections?

DATA EVALUATING IMMUNE DATA EVALUATING IMMUNE FUNCTION AFTER FUNCTION AFTER

TRAUMATIC INJURY:TRAUMATIC INJURY:

• i.)i.) Loss of delayed type hypersensitivity.Loss of delayed type hypersensitivity.• ii.)ii.) Impair Lymphocyte proliferation. Impair Lymphocyte proliferation.• iii)iii) Production of an immune suppressive Production of an immune suppressive

factor.factor.• iv.)iv.) Alteration in number of circulating Alteration in number of circulating

CD4 CD4

/CD8 lymphocytes/CD8 lymphocytes

RAHL et al:RAHL et al:

-- HIV (+) patient → on HAARTHIV (+) patient → on HAART-- Surgery - 50% major proceduresSurgery - 50% major procedures - 50% minor procedures- 50% minor procedures-- Surgery - 50% General surgerySurgery - 50% General surgery - 25% Gyne- 25% Gyne

- 25 Other- 25 Other-- Parameters - CD4 count before and after Parameters - CD4 count before and after

operationoperation - Viral load- Viral load

CD4CD4 ↑↑ ↓↓ --

>500>500 35%35% 65%65%

200 – 500200 – 500 30%30% 10%10% 60%60%

<200<200 16%16%

Viral load (within 180 day) - ⅓ had a higher Viral load (within 180 day) - ⅓ had a higher titer post optiter post op

- ⅔ unchanged or ↓- ⅔ unchanged or ↓

- First study that documents safety of surgery First study that documents safety of surgery inin

HIV (+) patient in term of Immune HIV (+) patient in term of Immune suppression in HAART era.suppression in HAART era.

- Magnitude of surgery and extent of immuneMagnitude of surgery and extent of immune

dysfunction pre-op did not impact on immune dysfunction pre-op did not impact on immune system adversely. system adversely.

(Determined by CD4 and viral load)(Determined by CD4 and viral load)

PERI OPERATIVE PERI OPERATIVE CONSIDERATIONCONSIDERATION

• Continue HAART Continue HAART -- Gautun et al. (2008) – 43 drug naïve AIDS patientsGautun et al. (2008) – 43 drug naïve AIDS patients

- mean baseline CD4 count 112- mean baseline CD4 count 112 - Follow up after 3 months- Follow up after 3 months

- 80% clinical improvement- 80% clinical improvement

- CD4 ↑ by > 50 in 85% of cases- CD4 ↑ by > 50 in 85% of cases - Mean CD4 increases from 112 baseline to 196 - Mean CD4 increases from 112 baseline to 196

Factor associated with ↑ risk for infectionFactor associated with ↑ risk for infectionI.) Systematic factors:I.) Systematic factors:

– DMDM– Corticosteroid useCorticosteroid use– ObesityObesity– Extreme of ageExtreme of age– Recent surgeryRecent surgery– Massive transfusionMassive transfusion– ASA class 3-5ASA class 3-5

ii.) Local factors:ii.) Local factors:

Foreign bodyForeign body

ElectrocauteryElectrocautery

Epinephrine injectionEpinephrine injection

Wounds drainsWounds drains

Hair removal with razorHair removal with razor

Post irradiation to sitePost irradiation to site

POST OPERATIVE POST OPERATIVE MANAGEMENT:MANAGEMENT:

Most complication: (1)Most complication: (1) CD4 < 200 cell/mm³CD4 < 200 cell/mm³

(2)(2) Poor nutritional status(↓Alb)Poor nutritional status(↓Alb)

(3)(3) ± Neutropenia± Neutropenia

Clinical adrenal insufficiency occurring in 5%Clinical adrenal insufficiency occurring in 5%

HIV(+) and 20% AIDS patients post-opHIV(+) and 20% AIDS patients post-op..

POST OP INFECTIONS:POST OP INFECTIONS:

- Approach to patient with fever → determined by - Approach to patient with fever → determined by presence and nature of surgery and CD4 and presence and nature of surgery and CD4 and viral load.viral load.

- Most fevers from common case:- Most fevers from common case: -- PneumoniaPneumonia -- Intravascular cathetersIntravascular catheters -- UTIUTI -- HepatitisHepatitis -- TrombophelitisTrombophelitis

- Important to distinguish between post op Important to distinguish between post op complications complications

and development of opportunistic infections.and development of opportunistic infections.

PULMONARY PULMONARY COMPLICATIONSCOMPLICATIONS

• Most frequent complicationMost frequent complication• Initial diagnostic management rely on Initial diagnostic management rely on

knowledge of Immune dysfunction.knowledge of Immune dysfunction.• Nosocamial Pneumonia (S Aureus and gram Nosocamial Pneumonia (S Aureus and gram

(-) (-)

- Late in disease (<CD < 100)- Late in disease (<CD < 100)• Dyspnea or cough – careful assessment that Dyspnea or cough – careful assessment that

is guided by clinical presentation and CD4is guided by clinical presentation and CD4• - FBC, blood culture, CXR.- FBC, blood culture, CXR.

HYPO ADRENALISM:HYPO ADRENALISM:

- Stress of surgery – unmask - Stress of surgery – unmask previously unsuspected hypo previously unsuspected hypo adrenalism.adrenalism.

- Non specific Sx:Non specific Sx:

- Electrolyte changes (↓Na - Electrolyte changes (↓Na ↓Ka)↓Ka)

- Hypotension- Hypotension

CONCLUSIONCONCLUSION

- HIV (+) patients are not at ↑ risk for HIV (+) patients are not at ↑ risk for complications, unless there medical health complications, unless there medical health indices are poor, CD4 <200, their CD4 ratio indices are poor, CD4 <200, their CD4 ratio changing, Viral load > than 10 000 changing, Viral load > than 10 000 copies/ml.copies/ml.

- Ethically, it is difficult to refuse an HIV (+) Ethically, it is difficult to refuse an HIV (+) patients services if you provide these patients services if you provide these services to non HIV positive patients.services to non HIV positive patients.

- In era of HAART surgical outcomes HIV (+) In era of HAART surgical outcomes HIV (+) patients has been excellent. There is no patients has been excellent. There is no data to suggest that major surgery data to suggest that major surgery influences HIV disease progression.influences HIV disease progression.