Mouton Surgery

7/27/2019 Mouton Surgery

1/22

SURGERY IN THE

HIV POSITIVE

PATIENT

Dr A Mouton


2/22

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 withAIDS developed cancer


3/22

PERI-OPERATIVE GUIDELINES

FOR SURGERY


4/22

I Pre-Operative workup:

Pre-op analysis should help determine risk

for post op complications.

Detailed history Opportunistic infection:

- Prophylactic antibiotics

- ARV therapy regimen


5/22

Following risk factors should be

addressed

STD

Cardiovascular status

Viral hepatitisTB

Drug and Alcohol abuse

Nutrition

Disease status (CD4 count and viral load)


6/22

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


7/22

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


8/22

CD4 COUNTS AND VIRAL LOADS:

CD4 counts determine staging of HIV diseaseand need for prophylaxis.

Viral Loads determine effectiveness of ARVtreatment.

Higher complication rate of CD4 10000 copies/ml. Viral load > 10000 copies/ml suggest that ARV

is no longer effective.


9/22

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 of3 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.


10/22

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


11/22

QUESTION:

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

- Does surgical intervention impact on the course

of HIV infections?

DATA A AT G


12/22

DATA EVALUATING IMMUNEFUNCTION 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


13/22

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


14/22

CD4 -

>500 35% 65%

200500 30% 10% 60%


15/22

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

- 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 systemadversely.

(Determined by CD4 and viral load)


16/22

PERI OPERATIVE

CONSIDERATION

Continue HAART

- Gautun et al. (2008)43 drug nave 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 infectionI.) Systematic factors:

DM

Corticosteroid use Obesity Extreme of age Recent surgery Massive transfusion ASA class 3-5


17/22

ii.) Local factors:

Foreign body

Electrocautery

Epinephrine injection

Wounds drains

Hair removal with razor

Post irradiation to site


18/22

POST OPERATIVE

MANAGEMENT:

Most complication: (1) CD4 < 200 cell/mm

(2) Poor nutritional status(Alb)

(3) Neutropenia

Clinical adrenal insufficiency occurring in 5%

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


19/22

POST OP INFECTIONS:

-Approach to patient with fever determined by presence andnature 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.


20/22

PULMONARY COMPLICATIONS

Most frequent complication

Initial diagnostic management rely onknowledge of Immune dysfunction.

Nosocamial Pneumonia (S Aureus and gram (-)

- Late in disease (


21/22

HYPO ADRENALISM:

- Stress of surgeryunmask previouslyunsuspected hypo adrenalism.

- Non specific Sx:

- Electrolyte changes (Na Ka)

- Hypotension


22/22

CONCLUSION

- HIV (+) patients are not at risk for complications,unless there medical health indices are poor,CD4 than 10 000 copies/ml.

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

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

Mouton Surgery

Documents

Transcript of Mouton Surgery