Perioperative Management

Perioperative Management

Risks

Medical Care Criteria Committee, January 2012

RECOMMENDATION
Risks
  • Universal surgical precautions that apply to all patients should be followed. (A3)

Risk to Patients

Effective antiretroviral therapy (ART) for people living with HIV has resulted in a life expectancy that approaches that of the general population [Antiretroviral Therapy Cohort Collaboration 2008]. Both urgent and elective surgical procedures are a common part of HIV medical care. Although the relative risk of surgery in patients with HIV has been debated in the literature, retrospective studies have indicated favorable outcomes despite HIV serostatus and regardless of extent or duration of surgery [Guth et al. 1996; Sewell et al. 2001; Jones et al. 2002]. 

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 patients with HIV [Madiba et al. 2009; Bizer et al. 1995; Yii et al. 1995; Harris and Schecter 1997]. Some studies have shown poorer surgical outcomes for individuals with low CD4 counts, although this has not been a consistent finding [Čačala et al. 2006; Guild et al. 2011]. 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. 

KEY POINT
  • Neither CD4 cell count nor HIV viral load should be used as sole determinants of a given patient’s surgical risk [Madiba et al. 2009].

This chapter addresses the perioperative management of individuals with undergoing necessary surgical procedures. Surgical risk assessment for patients with HIV is highly individualized, and all aspects of the patient’s clinical profile, including the indication for surgery, should be evaluated and discussed with the patient [Madiba et al. 2009].

Risk to the Surgical Team

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.

References

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]

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]

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]

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]

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]

Harris HW, Schecter WP. Surgical risk assessment and management in patients with HIV disease. Gastroenterol Clin North Am 1997;26:377-391. [PubMed]

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]

Madiba TE, Muckart DJJ, Thomson SR. Human immunodeficiency disease: How should it affect surgical decision-making? World J Surg 2009;33:899-909. [PubMed]

Sewell CA, Derr R, Anderson J. Operative complications in HIV-infected women undergoing gynecologic surgery. J Reprod Med 2001;46:199-204. [PubMed]

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]

Preoperative Evaluation

Medical Care Criteria Committee, January 2012

RECOMMENDATIONS
Preoperative Evaluation
  • The preoperative evaluation of patients with HIV should be the same as that for patients without HIV; however, clinicians should carefully assess for the following conditions that are more prevalent in people with HIV (A3):
    • 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. (A3)
  • Individuals with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (A3)

Preoperative evaluation of a patient with HIV is similar to the evaluation in patients who do not have HIV; however, comorbidities, active substance use, and MRSA may be more prevalent in people with HIV (see Table 1).

Table 1: Surgical Management Considerations for Patients with HIV and Comorbidities and Other Conditions
Comorbidity Risks Pre- and Perioperative Recommendations Comments

Hepatic dysfunction: Increased prevalence of hepatic dysfunction from ART or from preexisting liver disease.

Surgical risk: Co-infection with HBV or HCV may predispose to increased bleeding risk due to coagulopathy or thrombocytopenia.

  • Assess for hepatic dysfunction preoperatively because of the possible impact on dosing or selection of anesthetics, perioperative antibiotics, and other medications.
Renal dysfunction: Increased prevalence of renal dysfunction from HIV-associated nephropathy (HIVAN) and other causes [Gupta et al. 2005].
  • Assess for renal dysfunction preoperatively because of the possible impact on dosing or selection of anesthetics, perioperative antibiotics, and other medications.
  • If there are renal function changes in the perioperative period, review ART regimen for agents that may require renal dose adjustment.

Coronary artery disease and cardiac abnormalities: Increased prevalence of CAD from metabolic dysfunction due to HIV infection and/or ART [D:A:D Study Group 2008; SMART/INSIGHT and D:A:D Study Groups 2008; Friis-Moller et al. 2007].

QT prolongation or other cardiac abnormalities may occur in advanced HIV infection or in patients receiving certain medications [a].

  • Assess for coronary artery disease preoperatively.
  • Perform careful review of preoperative EKG results.
  • Anti-arrhythmics, methadone, PIs, antipsychotics, or macrolide antibiotics can cause QT prolongation or other cardiac abnormalities, especially if more than one such agent is administered concurrently.

Respiratory complications: Prevalence of underlying pulmonary disease is increased due to the increased risk for bacterial pneumonia [Hirschtick et al. 1995; Horberg et al. 2006] and high prevalence of smoking [Tesoriero et al. 2010; Niaura et al. 2000] in patients with HIV.

Surgical risk: Risk for postoperative pneumonia is increased in patients with HIV.

  • Carefully evaluate for respiratory complications in the perioperative period.

Thrombocytopenia and neutropenia: Idiopathic thrombocytopenic purpura may occur at any stage of HIV infection.

Neutropenia is common in individuals with HIV and severe immunosuppression [b].

  • Consult with hematologist prior to surgical procedure when platelet counts approach 50,000 per µl.
  • Routine use of G-CSF not recommended [Kaplan et al. 2009] but in perioperative period may consider G-CSF [c] use to maintain absolute neutrophil count >1,000 cells/mm3 (CIII) [Mohri et al. 1995; Kedzierska et al. 1998].
  • Neutropenia may be caused by medications (e.g., ZDV, TMP-SMX), HIV infection itself, bone marrow infiltration from malignancy or systemic infection.
  • G-CSF is recommended over GM-CSF due to theoretical concerns regarding potential stimulation of HIV replication by the latter, although the possible mechanism by which GM-CSF might affect HIV-1 replication remains unclear [Mohri et al. 1995].
Hemophilia
  • Coordination between surgical team and hematologist is recommended for transfusion of factor replacement in anticipation of surgery.

Substance use (SU): SU disorders are more prevalent in individuals with HIV than in the general population [Whetten et al. 2005; SAMHSA 2010].

Surgical risks: Increased risk for complications from surgery and anesthesia, notably cardiac complications associated with cocaine use; increased risk for withdrawal symptoms in the postoperative period for unrecognized alcohol, benzodiazepine, or heroin use [d].

  • Obtain detailed history of substance use.
  • Consider obtaining urine toxicology screen, with patient consent.
  • For elective surgery, observe appropriate period of abstinence with the use of substitute medications such as methadone or benzodiazepines as appropriate.
  • Alcohol withdrawal may be life-threatening if symptoms are not recognized early.
Methicillin resistant staphylococcus aureus (MRSA): Community-acquired MRSA infection is more common in MSM than in the general population [Diep et al. 2008].
  • Assess for a history of previous MRSA infection/colonization, particularly in MSMs.
  • Use vancomycin instead of cefazolin for prophylaxis when indicated in patients with positive history of MRSA.
Drug allergies: HIV-infection is associated with a higher incidence of medication allergies.
  • Obtain a careful history of allergies.
Abbreviation key: HBV, hepatitis B virus; HCV, hepatitis C virus; MSM, men who have sex with men; PI, protease inhibitor; ZDV, zidovudine.
References

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]

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]

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]

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]

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]

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]

Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the 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. [PubMed]

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]

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]

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]

SAMHSA. 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 10-4856. 2010. http://www.gmhc.org/files/editor/file/a_pa_nat_drug_use_survey.pdf

SMART/INSIGHT Study Groups, D:A:D Study Group. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients. AIDS 2008;22:F17-24. [PubMed]

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]

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]

Perioperative Medication Management

Medical Care Criteria Committee, January 2012

RECOMMENDATIONS
Continuation of ART
  • 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. (A1)
  • 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. (A3)
  • Patients with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (A3)
  • Clinicians should assess for potential drug-drug interactions before new medications are introduced. (A3)
Potential Drug-Drug Interactions
  • Clinicians should consult a reliable resource on drug interactions to identify potential interactions with antiretroviral medications, even for routine administration of medications commonly used in the perioperative period.

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 with HIV/HBV co-infection who are taking an antiretroviral medication regimen that also has activity against HBV; discontinuation of these medications may lead to a flare of the underlying hepatitis [Perillo 2001]. 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.

Potential Drug-Drug Interactions

The 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.

RESOURCES: DRUG-DRUG INTERACTIONS

The following websites provide information on antiretroviral drug interactions:

Wound Healing

Data are insufficient to determine whether wound healing is different in patients with HIV taking effective ART compared with patients who do not have HIV. At this time, standard recommendations should be followed for the use of perioperative antibiotics in non-neutropenic patients with HIV.

Reference

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]

Postoperative Management

Medical Care Criteria Committee, January 2012

RECOMMENDATIONS
Postoperative Management
  • Patients with HIV should be mobilized postoperatively as soon as medically feasible because of increased risk of thromboembolic complications. (A2)
  • Clinicians should consider spontaneous pneumothorax in the differential diagnosis of acute onset dyspnea in patients with active PCP or a history of PCP. (A3)
  • 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. (A2)

Patients with HIV are at increased risk for hypercoagulability [Shen and Frenkel 2004] 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 patients with HIV.

Spontaneous pneumothorax should be considered in the differential diagnosis of acute-onset dyspnea. Patients with HIV who have 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 [Pastores et al. 1996]

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 NYSDOH AI Pain in the Substance User with HIV Guideline.

References

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]

Shen YM, Frenkel EP. Thrombosis and a hypercoagulable state in HIV-infected patients. Clin Appl Thromb Hemost 2004;10:277-280. [PubMed]

 

All Recommendations

Medical Care Criteria Committee, January 2012

ALL RECOMMENDATIONS: PERIOPERATIVE MANAGEMENT GUIDELINE
Risks
  • Universal surgical precautions that apply to all patients should be followed. (A3)
Preoperative Evaluation
  • The preoperative evaluation of patients with HIV should be the same as that for patients without HIV; however, clinicians should carefully assess for the following conditions that are more prevalent in people with HIV (A3):
    • 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. (A3)
  • Individuals with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (A3)
Continuation of ART
  • 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. (A1)
  • 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. (A3)
  • Patients with a history of MRSA colonization or infection should receive vancomycin instead of cefazolin for prophylaxis when indicated. (A3)
  • Clinicians should assess for potential drug-drug interactions before new medications are introduced. (A3)
Potential Drug-Drug Interactions
  • Clinicians should consult a reliable resource on drug interactions to identify potential interactions with antiretroviral medications, even for routine administration of medications commonly used in the perioperative period.
Postoperative Management
  • Patients with HIV should be mobilized postoperatively as soon as medically feasible because of increased risk of thromboembolic complications. (A2)
  • Clinicians should consider spontaneous pneumothorax in the differential diagnosis of acute onset dyspnea in patients with active PCP or a history of PCP. (A3)
  • 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. (A2)