Monday, May 19, 2008

Elective Surgery in the HIV Positive Patient

Antiretroviral therapy has decreased the number of deaths from Acquired immunodeficiency syndrome (AIDS). Many patients with AIDS live with improved health and longer life expectancies. One of the adverse effects of antiretroviral therapy is the lipodystrophy syndrome. Patients are seeking treatment for this (elective reconstructive or therapeutic procedures), but also for other cosmetic procedures. The guidelines given in the article listed below could be used for other surgical procedures (ie hernia repair) that might be needed but are not emergencies.

The article listed below is well worth reading. Here are their conclusions:

1. The number of HIV-positive patients who still seek cosmetic surgery treatment for lipodystrophy is likely to increase.

2. HIV-positive patients are not at increased risk for complications unless their medical health indices are poor, their CD4 count is less than 200 cells/mm3, their CD4 ratio is changing, or their viral load is greater than 10,000 copies/ml.

3. The relative risk for transmission is unknown but is probably 0.03 percent for surgical sharps, considerably less than for hepatitis.

4. Ethically, it is difficult to refuse an HIV-positive patient services if you provide those services to non-HIV-positive patients.

5. Medicolegal implications: Refusing an HIV-positive patient appropriate care based on HIV-positivity alone is malpractice for omission of care and is a violation of the Americans with Disabilities Act.

Pre-operative Recommendations

  • Highly active antiretroviral therapy medications should be continued throughout the perioperative period to avoid the development of resistant viral strains.
  • Preoperative workup should assess cardiovascular status, insulin resistance/hyperlipidemia, viral hepatitis, tuberculosis, nutrition, and disease status (by means of absolute CD4 count and viral load within 3 months of surgery date).
  • Prophylactic antibiotic therapy has not been evaluated adequately in immunocompromised patients. So HIV-positive patients should be regarded in the context of normally associated risks factors (ie smoker, diabetes, etc) for surgical infection.

Post-operative Recommendations

  • If the patient cannot tolerate oral medications following the procedure, highly active antiretroviral therapy should be held and parenteral alternatives for antimicrobial prophylaxis should be used.
  • Follow normal patient care for given procedure.

Risks of Exposure to Surgeon and Team

The risk of HIV transmission is dependent on the type of exposure.

Percutaneous transmission through hollow-bore needlesticks with the transfer of one drop of blood (1/30 cc) has been estimated to be 0.3 percent per occurrence.

The risk of transmission from suture needlesticks and other sharps is thought to be on the order of a magnitude lower than that, or 0.03 percent.

Mucous membrane exposure transmission risk is approximately 0.09 percent.

The risk of transmission from nonintact skin exposure is estimated to be less.

The risk of transmission from fluids or tissue other than blood is considered to be significantly lower than the risk of transmission from blood.

It should be noted that the average risk of hepatitis C seroconversion from occupational exposure is 1.8 percent, 10 times greater than HIV. The risk of seroconversion after exposure to hepatitis B is 37 to 62 percent

Postexposure Prophylaxis

Postexposure prophylaxis is associated with a reduction in the risk of HIV transmission by approximately 81 percent. The current Centers for Disease Control and Prevention recommendations are as follows:

* Postexposure prophylaxis should be initiated within hours of exposure.

* Start a basic two-drug regimen immediately (zidovudine or stavudine or tenofovir plus lamivudine or emtricitabine).

* If the source blood is drug resistant or the injury involves an increased risk for transmission, a third drug (lopinavir/ritonavir) should be added.

* If the source is determined to be HIV-negative, postexposure prophylaxis should be discontinued.

* The Centers for Disease Control and Prevention recommends 4 weeks of postexposure prophylaxis therapy.

* Unfortunately, nearly 50 percent of health care personnel report adverse events while taking postexposure prophylaxis and approximately one-third stop taking the drugs. The three-drug regimen should therefore be avoided when possible to decrease toxicity and increase compliance.

REFERENCES

Perioperative Guidelines for Elective Surgery in the Human Immunodeficiency Virus-Positive Patient; Plastic and Reconstructive Surgery:Volume 121(5)May 2008pp 1831-1840; Davison, Steven P. D.D.S., M.D.; Reisman, Neil R. M.D., J.D.; Pellegrino, Edmund D. M.D.; Larson, Ethan E. M.D.; Dermody, Meghan M.D.; Hutchison, Paul J. M.A.

2 comments:

Bongi said...

good. then at the moment i'm sitting at about 0.03% less 81%. somehow i remain nervous.

rlbates said...

Bongi, if it were me I would too. Hope you got started on the prophalaxis within hours of the stick.