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Chapter 37. HIV and Anesthesia

Harsha Nalabolu, MD

  • Normal CD4 count 500–1,200/mm3
  • Viral load low if <5,000/mL, high if >10,000

Assess organ systems; modify anesthetic plan as appropriate.

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Assessment of Organ Systems
CNS/PNS
  • In early stages peripheral neuropathies are not uncommon, whereas in later stages central demyelinating neuropathies with dementia occur
  • Coexisting CNS infections can create mass effects increasing ICP
Pulmonary
  • Opportunistic infections; most commonly pneumocystis carinii pneumonia (PCP) occurs when CD4 count is less than 200
  • PCP can result in pneumatoceles that can rupture, leading to pneumothorax necessitating prolonged mechanical ventilation; CXR may be normal; however, CT chest scans reveal bilateral hazy infiltrates
  • Tuberculosis, nocardiosis, and lymphomas can also affect the lungs
Cardiac
  • Patients with long-standing HIV infections develop myocarditis and up to 30% may develop dilated cardiomyopathy
Hematologic
  • Some patients present with hypercoaguable state or idiopathic thrombotic thrombocytopenia
  • Antiretroviral agents such as AZT cause bone marrow suppression leading to coagulopathic state

A thorough medication review, and especially an understanding of each medication’s side effects, is important.

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Side Effects of HIV Medications
Drug name (generic)Common side effects
Nucleoside analog reverse transcriptase inhibitors (NRTIs)
  • Retrovir (zidovudine), AZT
  • Videx (didanosine), ddi
  • Zerit (stavudine), d4t
  • Hivid (zalcitabine), ddC
  • Epivir (lamivudine), 3Tc
  • Hepsera (adefovir)
  • Ziagen (abacavir)
  • Pancytopenia, neuropathy, myopathy
  • Peripheral neuropathy, pancreatitis, GI
  • Peripheral neuropathy, pancreatitis
  • Peripheral neuropathy, pancreatitis
  • Peripheral neuropathy, GI, rash
  • Renal toxicity, increased LFTs, GI
  • GI, rash, myalgia
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  • Viramune (nevirapine)
  • Sustiva (efavirenz)
  • Rescriptor (delavirdine)
  • GI, increased LFTs, rash, p450 induction
  • GI, increased LFTs, rash, teratogenicity
  • GI, increased LFTs, rash
Protease inhibitors (PIs)
  • Invirase, Fortovase (saquinavir)
  • Crixivan (indinavir)
  • Norvir (ritonavir)
  • Viracept (nelfinavir)
  • Agenerase (amprenavir)
  • GI, hyperglycemia, inhibits p450 CYP3A
  • GI, hyperglycemia, inhibits p450 CYP3A, renal failure, nephrolithiasis
  • GI, hyperglycemia, inhibits p450 CYP3A, increased LFTs
  • GI, hyperglycemia, inhibits p450 CYP3A
  • Rash, inhibits p450 CYP3A
Fusion inhibitor
• EnfuvirtideBacterial pneumonia, injection site pain
Antipneumocystis antibiotic
• PentamidineArrhythmias, bronchospasm (aerosolized), electrolyte abnormalities

  • CBC, electrolytes, renal function, LFTs, and coagulation profile
  • CD4 count and viral load <3 months
  • EKG as well as a TTE if long-standing disease or if symptoms suggest cardiac involvement
  • CXR should be routinely performed, as well as a chest CT if CD4 count <200
  • MRI of brain or spine if demyelinating neuropathy suspected
  • Consider delaying an elective case if CD4 <200 due to an increased risk in postoperative infectious complications. If CD4 <50, increased 6-month mortality following surgery
  • Do not stop HIV medications; discuss with ID specialist if patient unable to take PO postoperatively
  • Transfusion relatively contraindicated: consider EPO if risk of high blood loss (see autologous transfusion chapter 66)

  • Anesthetic technique based on patient’s preoperative evaluation (systems affected)
  • Regional anesthesia is preferred if possible due to lack of interactions ...

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