1. Dr. ANSHUMAN AASHU
1ST YEAR PGT

2.  GENERAL EPIDEMIOLOGY OF AIDS
 SURGERY IN HIV INFETED PATIENTS
 OCCUPATIONAL RISK OF HIV TRANSMISSION
IN SURGEONS
 PRECAUTIONARY MEASURES
 MANAGEMENT STRATEGY IN EVENT OF
EXPOSURE.

3.  AIDS is a viral disease caused by a retrovirus
of lentivirus family called HIV.
 Contains a core containing two single
stranded RNA, Reverse Transcriptase enzyme,
and core proteins.
 The envelope contains a glycoprotien (gp120)
– affinity for CD4 antigens.
 CD4+ cells are the target for HIV infection,
most commonly being the T-helper cells.
 Also involves macrophages, dendritic cells
etc.

4. Structure of the HIV

5.  After infecting the CD4+ cells, leads to the
rapid destruction of such cells leading to
different manifestations.
 Most common cell involved being T-helper
cells, leads to immunodeficiency and hence
several opportunistic infections.
 Some neoplasms (Kaposi’s sarcoma and
Lymphoma) also associated with HIV
infection.

6. Prodromal flu-like
illness
(1-4 weeks)
Seroconversion
(6 months)
Asymptomatic
phase
(8-10 yrs)
AIDS related
complex
AIDS
defining
illness

7.  Sexual.
 Body fluids.
◦ Blood and blood products.
◦ Semen, vaginal secretions.
◦ Saliva.
◦ Milk.
◦ Peritoneal, pleural and pericardial fluids.
◦ Synovial fluids.
◦ CSF.
◦ Urine, vomit, tears, sweat, feces (lower risk).
 Perinatal transmission.

8.  For diagnosis of AIDS related infection or
neoplasm.
 For surgical complications of AIDS.
 For other indications as in general
population.

9.  Lymph nodes almost always show follicular
hyperplasia, so not reliable for diagnosis.
 Excision/Incision biopsy of lymph node or
soft tissues required for diagnosis of
lymphoma, sarcoma, tuberculosis etc.
 Due to the risk of transmission, FNAC should
be considered first and surgical biopsy be
reserved for inconclusive FNAC reports.

10.  Abscesses.
 Ano-rectal diseases.
 Acute abdominal emergencies.
 Hepato-biliary and splenic disorders.
 Neoplasms.
 Intracranial SOLs.

11.  With profound immunodeficiency, abscesses
are common presentations in HIV+ patients.
 Young adult patients of either sex with
pyomyositis are particulary likely to have
AIDS.
 Treatment consists of simple Incision &
Drainage as in normal conditions.

12.  Most frequent reason for surgical
interventions in HIV+ patients.
 HIV+ male homosexuals have higher
incidence of such disorders than other HIV+
patients.
 Perianal sepsis, Fissures, Fistula, Warts,
Squamous cell carcinoma commonly seen.
 Large perianal incisions and division of
internal anal sphincter should be avoided.
Setons are ideal for fistulas.

13.  Anal warts are mostly resistant to medical
therapy with podophyllin. So electrocautery or
laser should be used.
 Other conditions may mimic perianal sepsis
like:-
◦ Massive ulceration following Herpes simplex.
◦ Kaposi’s sarcoma presenting as bleeding
hemorrhoids.
◦ Lymphoma as perianal abscess.
◦ Chronic indolent ulcer caused by M. avium
intracellulare.

17.  Acute abdomen may be a presentation in
about 12-45% of AIDS patients but surgery is
required in only upto 5% cases mainly for
appendicitis, obstruction or perforation.
 CMV infection, Kaposi’s sarcoma, Lymphoma
all may present with bowel obstruction or
perforation or even obstructive appendicitis.
 Requires laparotomy for perforations and
acute obstructions.
 30% of all acute appendicitis are related to
AIDS related illness. Requires appendectomy.

18.  Appendicitis carries higher risk of perforation
and abscess formation.
 Typhlitis common presentation in AIDS
patients.
 Other opportunistic infections of GIT may
also present as acute abdominal
emergencies.

19.  Chronic hepatits B and C infections are
common co-infections with AIDS.
 Small liver abscesses secondary to infections
with cryptococcus, histoplasma, candida etc
are common.
 Acute acalculous cholecystitis more common
in AIDS patients. Require cholecysectomy.
 Biliary obstruction due to compression by
enlarged portal lymph node or due to
infection with cryptosporidium, CMV or
mirosporidium may be seen.

20.  Multiple splenic abscesses leading to
splenomegaly is common.
 Splenectomy may be required for traumatic or
spontaneous rupture of spleen found to be
more common in patients with AIDS.
 May also be required for associated
thrombocytopenia.

21.  Kaposi’s sarcoma and Non Hodgkin’s
lymphoma common neoplasms associated
with AIDS infection.
 Surgery often required for biopsy purposes or
for other complications.

22.  In HIV positive patients, toxoplasmosis
causes brain abscess. If medical treatment
fails then CT guided stereotatic needle
aspiration.

23.  Necrotizing arteriopathy leading to aneurysm
formation common in HIV infected patients.
 Salmonella arteritis especially common
leading to pseudoaneurysm.
 Infected pseudoaneurysms also common in IV
drug abusers (high risk group for HIV
infection).
 Vascular reconstructions usually helpful.

24.  Studies show same rate of post-operative
complications in HIV positive as with
asymptomatic HIV negative patients.
 Incidence of infection after anorectal surgery
in HIV positive patients is independent of
CD4 cell counts.
 Relation between viral load and post
operative infection is still under trial.

25.  The surgeon is regularly exposed to blood,
which is the most infective medium for HIV
transmission. Incidence of accidental
exposure to infected patients blood is 6.4%.
 Risk is greater when there are more HIV
particles in blood i.e. during the earliest
and later stages of the disease.
 Risk with needle stick injury is 0.3%
 Risk of transmission in surgery is 1 in
28000-50000 per hour of operations.

26.  Extent of risk of infection to the surgeons
depends on:
◦ Prevalence of HIV in patient population.
◦ Number of procedures carried out by the
surgeon.
◦ Length of the period of risk.
 Risk is more when
◦ When surgery lasted for > 3 hours.
◦ > 300ml blood loss present during surgery.
◦ In major vascular, intra-abdominal and
gynaecological surgeries.

27.  Most common mode
 Risk of HIV:- 0.3%
 1ml of infected blood has
50 HIV RNA compared
with 109 HBV particles
 Hollow needles 10 times
more dangerous than
solid needles
 Most of needle
injuries(27%) occurs from
improper disposal.

28.  Deep injury.
 Visible blood on instrument.
 Prick directly into vein or artery.
 High viral load.
 Hollow needle > solid needle
 Large diameter needles.

29.  Recommended by CDC (USA) in 1987.
 Every patient to be treated and precautions
observed as if he/she has the infection.
 Use of protective barriers while dealing with
body fluids like blood, semen, vaginal
secretions, CSF, synovial fluid, pleural,
pericardial, peritoneal and amniotic fluids.
 Feces, sweat, tear, saliva, urine, vomitus,
nasal secretions not included.

30.  Corner stone of any precautionary program.
 All HCWs should be trained and educated
about different aspects of the infection that
include:
◦ Mode of transmission.
◦ Standard precutionary guidelines.
◦ Method of disposal.
◦ Social stigma and discrimination issues.
◦ Posting of warning signs for others.

31. Screening of patients
 Screening of patients for HIV,
HBV, HCV is very important
 Even if HIV test is negative, it
is not 100% sure that patient
is not infected.
 Patient may be in window
period when HIV antibodies
have not yet formed in the
patient (detected by the HIV
test kits)
 So precautionary measures
are very important.

32.  Revised CDC reommendations (2006) for HIV
testing in health care settings and screening
pregnant women:
◦ HIV screenings is recommended for patients in all health
care settings including pregnant women after the patient
is notified that the testing will be performed unless the
patient declines (opt-out testing).
◦ Persons at high risk for HIV infection should be screened
for HIV at least annually.
◦ Written informed consent from the individual should not
be required; general consent for medical care is
sufficient and encompasses consent for HIV testing.
◦ HIV screening should be included in the routine panel of
prenatal screening for pregnant women.
◦ HIV diagnostic testing as part of prevention counseling
associated with controlling HIV transmission or as part
of HIV screening program is not required.

33.  Noncompliance with recommendations on
universal precautions amounts to upto 84% in
emergency conditions.
 Hence, certain basic standard precautions
must be observed like wearing gloved while
drawing blood or inserting cannula.
 Routine wearing of gloves for examination of
AIDS patients are not recommended unless
for open wounds.

34.  Needles and sharps must always be disposed
in puncture-proof containers.
 Such containers should be present as near as
practically possible.
 Proper waste disposal.
 Additional precautions are to be observed
while performing on HIV+ patients:
◦ Barrier method
◦ Methodical approach

35.  DOUBLE GLOVES
(reduces risk by 5
fold)
 CAP AND MASK
 EYE GLASSES OR
SHIELDS
 PLASTIC
APRON/GOWN
 FOOTWEAR(wellington
shoes)

36.  Undue haste should be avoided.
 Assistants and other staffs should be
minimum.
 Incisions should be large so as to have
minimal requirement of retraction by
assistants.
 Surgery should be done in orderly manner
with meticulous attention to avoid as much
blood loss as possible.
 Clumsy transfer of instruments should be
avoided. Sharps preferably be transferred in
kidney dishes.

37.  TREATMENT OF EXPOSED LOCAL SITE:
◦ Skin: thorough cleaning with soap water. Never put
fingers reflexly into mouth.
◦ Eyes: Irrigation with fresh water.
◦ Oral cavity: spit out immediately and rinse with
water several times.
 Prompt exposure report regarding the time,
nature etc of exposure should be reported.

38.  Source
◦ HIV testing after proper consent. If known to be HIV
positive then assess the health status and the
possibility of drug resistance if on anti retro-viral
therapy
 Recipient
◦ Baseline serological testing for HIV, HBV and HCV.
 Nature of exposure.

39.  Depending upon the risk and toxicity
balance.
 Decision to start PEP depends on:
◦ Severity of exposure (Exposure Code, EC)
◦ HIV status of source (Status Code, SC).
 If required, should be started within 2-24
hours of exposure and not later than 72
hours.
 Effectivity decreases with increasing duration
since exposure.

42. EC SC. PEP recommendation
1 1 PEP may not be warranted. NO known risk
1 2 Basic regimen. Negligible risk
2 1 Basic Regimen. Negligible risk
2 2 Expanded Regimen. Increased transmission
risk.
2/3 Unknown Basic Regimen

43.  Consists of two NRTIs for 1 month.
 Zidovudine 300mg BD+Lamivudine 150mg
BD.
 Zidovudine 300mg BD+Stavudine 40mg BD.
 Didanosine 200mg BD+Stavudine 40mg BD.

44.  Consists of 2 NRTIs+ 1 PI for 1 month.
 Any of the basic regimen+ any one of the
following:
◦ Indinavir 800mg TDS.
◦ Ritonavir 100mg BD.
◦ Saquinavir 1000mg BD.
◦ Lopinavir 400mg BD.

45. Side effects
 PEP is very toxic so its use is weighed against
toxicity
 Should not be used for exposure that poses
negligible risk
 Don’t use three drug regimen for all HIV exposure
 Most common is nausea and diarrhea
 Mild and reversible may be relieved by
domperidone and loperamide
 PIs cause peripheral neuropathy
 Indinavir:- Nephrolithiasis, Hyperbilirubinemia
 NRTI Abacavir causes hypersensitivity reaction
 NNRTI not used causes acute fulminant liver failure
 Efavirenz is teratogenic, Steven Johnson Syndrome,
dizziness, insomnia, psychiatric illness

46. Investigations before prescribing
PEP
 Full medical history
 Risk of pregnancy
 CBC
 LFT
 RFT
 Zidovudine + Lamivudine + Ritonavir are
safe in pregnancy
 Alone Zidovudine gives 80% protection.
Combinations provide extra protection

47. Follow up
 Perform baseline HIV test of HCW at the time
of exposure which will be negative then repeat
at 6 wk, 12wk and 6 month interval to see any
seroconversion
 Follow up every 1-2 wk to check side effects,
toxicity and adherence to regimen
 Instruct to seek medical advice immediately if
experiences acute viral symptoms
 Advise to:- have safe sex
 Use barrier methods during intercourse
 Don’t donate blood or organs during follow up
period
 Safe to continue performing exposure prone
procedure as risk of seroconversion is low and
the risk of onward transmission is remote