Posted January 2012
Effective antiretroviral therapy (ART) for people living with HIV has resulted in a life expectancy that approaches that of the general population.1 Both urgent and elective surgical procedures are a common part of HIV medical care. Although the relative risk of surgery in HIV-infected patients has been debated in the literature, retrospective studies have indicated favorable outcomes despite HIV serostatus and regardless of extent or duration of surgery.2-4
Overall health, particularly the presence or absence of organ failure, and nutritional state (albumin <2.5g/dL) have been found to be more reliable predictors of surgical outcome than CD4 count or viral load in HIV-infected patients.5-8 Some studies have shown poorer surgical outcomes for individuals with low CD4 counts, although this has not been a consistent finding.9,10 Viral suppression also has not been conclusively shown to improve surgical outcomes; however, in the setting of elective surgery, it is still recommended that ART be optimized preoperatively (see Antiretroviral Therapy).
This chapter addresses the perioperative management of HIV-infected individuals undergoing necessary surgical procedures. Surgical risk assessment for HIV-infected individuals is highly individualized, and all aspects of the HIV-infected patient’s clinical profile, including the indication for surgery, should be evaluated and discussed with the patient.5
II. RISK TO THE SURGICAL TEAM
Universal surgical precautions that apply to all patients should be followed. (AIII)
Data regarding HIV transmission risk through various types of non-surgical exposures suggest that risk to the surgical team is theoretically lower when patients have undetectable viral loads. However, universal surgical precautions that apply to all patients should be followed, regardless of an HIV-infected patient’s viral load.
III. PREOPERATIVE EVALUATION FOR HIV-INFECTED PATIENTS
The preoperative evaluation of HIV-infected patients should be the same as that for non-HIV-infected patients; however, clinicians should carefully assess for the following conditions that are more prevalent in the HIV-infected population (AIII):
- hepatic and renal dysfunction
- coronary artery disease and cardiac risk
- coagulopathy, thrombocytopenia, and neutropenia
- active alcohol or substance use, including both prescription and non-prescription drug use
- history of prior infection/colonization with methicillin-resistant Staphylococcus aureus (MRSA), particularly in men who have sex with men (MSM)
- drug allergies
Clinicians should obtain urine toxicology, with patient consent, if the substance use history is unreliable and there are concerns about substance use. Elective surgery should be deferred until active substance use has been addressed. (AIII)
Individuals with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (AIII)
Preoperative evaluation of the HIV-infected patient is similar to that of the general population; however, comorbidities, active substance use, and MRSA may be more prevalent in the HIV-infected population (see Table 1).
IV. PERIOPERATIVE MEDICATION MANAGEMENT FOR HIV-INFECTED PATIENTS
Clinicians should continue ART in the perioperative period with as little interruption as possible, particularly for patients co-infected with hepatitis B virus (HBV) who are receiving an ART regimen that also has activity against HBV. When ART interruption is necessary, all components of the regimen should be stopped and clinicians should consult with a provider who has experience in management of ART. (AI)
For patients who require prophylaxis for Pneumocystis jirovecii (PCP) and are unable to receive oral medications for more than 1 week, TMP/SMX should be administered intravenously. If there is a contraindication to TMP/SMX, pentamidine should be administered intravenously or by inhalation. (AIII)
Patients with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (AIII)
Clinicians should assess for potential drug-drug interactions before new medications are introduced. (AIII)
A. Continuation of ART During the Perioperative Period
ART should be continued through the perioperative period with as little interruption as possible. This is particularly important for patients who are co-infected with HBV and receiving an ART regimen that also has activity against HBV; discontinuation of these medications may lead to a flare of the underlying hepatitis.25 For patients who are unable to receive medications orally (NPO), a period of withholding ART will be necessary. When ART is withheld, all components of the regimen should be stopped.
TMP-SMX should be administered intravenously in individuals who require prophylaxis for Pneumocystis jirovecii pneumonia (PCP) but are NPO for more than 1 week. If TMP/SMX is contraindicated, pentamidine should be administered intravenously or by inhalation; however, aerosolized pentamidine may not be readily available and may be difficult to administer to patients who are intubated.
For patients who are able to receive liquids but not solids for more than 1 week, consideration should be given to converting the patient to an ART regimen that is available in liquid formulation. To ensure that the new regimen is fully suppressive, any changes to the ART regimen should only be done in consultation with a provider who has extensive experience in management of ART.
B. Potential Drug-Drug Interactions
Clinicians should consult a reliable drug interaction resource to identify potential interactions with antiretroviral medications, even for routine administration of commonly used medications in the perioperative period.
Potential for drug-drug interactions in patients receiving ART is increased due to the extensive cytochrome P450 interactions with both PIs and NNRTIs. Clinicians should assess for potential interactions before new medications are introduced.
In particular, caution should be used with anxiolytics and sedative/hypnotics, many of which have interactions with PIs that may be severe enough for their use to be contraindicated. For example, the common anesthesia medicine midazolam is contraindicated in combination with ritonavir. General anesthetics, such as halothane and enflurane, however, do not have significant interactions. Proton pump inhibitors, and to a lesser extent antacids and H2 blockers, may adversely affect the absorption of the PI atazanavir.
The following online resources provide information on antiretroviral drug interactions:
- HIV-Drug-Drug Interactions, available at: www.hivguidelines.org/
clinical-guidelines/ adults/ hiv-drug-drug-interactions
- Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, available at: www.aidsinfo.nih.gov
- Johns Hopkins Poc-IT Center, available at: http://www.hopkinsguides.com/hopkins/ub
- University of Liverpool drug interactions site, available at: www.hiv-druginteractions.org
- PDR Network, available at: www.pdr.net
- Eprocrates medical software, available at: www.epocrates.com
C. Wound Healing
Data are insufficient to determine whether wound healing is different in HIV-infected individuals receiving effective ART compared with non-HIV-infected individuals. At this time, standard recommendations should be followed for the use of perioperative antibiotics in the non-neutropenic HIV-infected patient.
V. POSTOPERATIVE MANAGEMENT OF HIV-INFECTED PATIENTS
HIV-infected patients should be mobilized postoperatively as soon as medically feasible because of increased risk of thromboembolic complications. (AII)
Clinicians should consider spontaneous pneumothorax in the differential diagnosis of acute onset dyspnea in patients with active PCP or a history of PCP. (AIII)
Clinicians should not withhold treatment for pain solely because a patient has a history of substance use. Rather, standard pain assessment and treatment protocols should be followed. (AII)
HIV-infected patients are at increased risk for hypercoagulability26 and may be at increased risk for thromboembolic complications in the postoperative period. Appropriate implementation of prophylactic protocols and prompt mobilization as soon as medically feasible is particularly important in the HIV-infected population.
Spontaneous pneumothorax should be considered in the differential diagnosis of acute-onset dyspnea. HIV-infected patients with active PCP or a history of PCP are at increased risk for spontaneous pneumothorax; individuals at highest risk include those with obvious cystic lesions on chest x-ray and those undergoing mechanical ventilation.27
Patients who are receiving methadone replacement therapy or who chronically use opiates may require increased doses of pain medication during the postoperative period. Management of pain in patients receiving buprenorphine/naloxone may be more challenging and should involve consultation with a pain management specialist. See Pain in the HIV-Infected Substance User.
1. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: A collaborative analysis of 14 cohort studies. Lancet 2008;392:293-299. [PubMed]
2. Guth AA, Hofstetter SR, Pachter HL. Human immunodeficiency virus and the trauma patient: Factors influencing post operative infectious complications. J Trauma 1996;41:251-255. [PubMed]
3. Sewell CA, Derr R, Anderson J. Operative complications in HIV-infected women undergoing gynecologic surgery. J Reprod Med 2001;46:199-204. [PubMed]
4. Jones S, Schechter CB, Smith C, et al. Is HIV infection a risk factor for complications of surgery? Mt Sinai J Med 2002;69:329-333. [PubMed]
5. Madiba TE, Muckart DJJ, Thomson SR. Human immunodeficiency disease: How should it affect surgical decision-making? World J Surg 2009;33:899-909. [PubMed]
6. Bizer L, Pettorino R, Ashikari A. Emergency abdominal operations in the patient with acquired immunodeficiency syndrome. J Am Coll Surg 1995;180:205-209. [PubMed]
7. Yii MK, Saunder A, Scott DF. Abdominal surgery in HIV/AIDS patients: Indications, operative management, pathology and outcome. Aust N Z J Surg 1995;65:320-326. [PubMed]
8. Harris HW, Schecter WP. Surgical risk assessment and management in patients with HIV disease. Gastroenterol Clin North Am 1997;26:377-391. [PubMed]
9. Čačala SR, Mafana E, Thomson SR, et al. Prevalence of HIV status and CD4 counts in a surgical cohort: Their relationship to clinical outcome. Ann R Coll Surg Engl 2006;88:46-51. [PubMed]
10. Guild GN, Moore TJ, Barnes W, et al. CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive. Clin Orthop Relat Res 2011 Dec 30. Epub ahead of print. [PubMed]
11. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the management of chronic kidney disease in HIV-infected patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2005;40:1559-1585. [PubMed]
12. D:A:D Study Group. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: A multi-cohort collaboration. Lancet 2008;371:1417-1426. [PubMed]
13. Strategies for Management of Anti-Retroviral Therapy/INSIGHT; DAD Study Groups. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients. AIDS 2008;22:F17-24. [PubMed]
14. Friis-Moller N, Reiss P, Sabin CA, et al. The DAD Study Group. Class of antiretroviral drugs and risk of myocardial infarction. N Engl J Med 2007;356:1723-1735. [PubMed]
15. Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. N Engl J Med 1995;333:845-851. [PubMed]
16. Horberg MA, Hurley LB, Klein DB, et al. Surgical outcomes in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Arch Surg 2006;141:1238-1245. [PubMed]
17. Tesoriero JM, Gieryic SM, Carrascal A, et al. Smoking among HIV positive New Yorkers: Prevalence frequency, and opportunities for cessation. AIDS Behav 2010;14:824-835. [PubMed]
18. Niaura R, Shadel WG, Morrow K, et al. Human immunodeficiency virus infection, AIDS, and smoking cessation: The time is now. Clin Infect Dis 2000;31:808-812. [PubMed]
19. Guidelines for the Prevention of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from CDC, National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Morb Mortal Wkly Rep MMWR 2009;58(RR-4):1-207. Available at: http://aidsinfo.nih.gov/
20. Mohri N, Akamo Y, Mizokami M, et al. Perforated acute appendicitis in a patient with AIDS/HIV infection: Report of a case. Surg Today 1995;25:62-64. [PubMed]
21. Kedzierska K, Rainbird MA, Lopez AF, et al. Effect of GM-CSF on HIV-1 replication in monocytes/macrophages in vivo and in vitro: A review. Vet Immunol Immunopathol 1998;63:111-121. [PubMed]
22. Whetten K, Reif S, Napravnik S, et al. Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast. Southern Med J 2005;98:9-14. [PubMed]
23. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856Findings. Rockville, MD; 2010. Available at: http://oas.samhsa.gov/NSDUH/
24. Diep BA, Chambers HF, Graber CJ, et al. Emergence of multi-drug resistant community associated methicillin resistant Staphylococcus aureus clone USA 300 in men who have sex with men. Ann Intern Med 2008;148:249-257. [PubMed]
25. Perillo RP. Acute flares in chronic hepatitis B: The natural and unnatural history of an immunologically mediated liver disease. Gastroenterology 2001;120:1009-1022. [PubMed]
26. Shen YM, Frenkel EP. Thrombosis and a hypercoagulable state in HIV-infected patients. Clin Appl Thromb Hemost 2004;10:277-280. [PubMed]
27. Pastores SM, Garay SM, Naidich DP, et al. Review: Pneumothorax in patients with AIDS-related Pneumocystis carinii pneumonia. Am J Med Sci 1996;312:229-234. [PubMed]