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[Anesthesia in the HIV positive or AIDS patient]
1Service d'anesthésie-réanimation chirurgicale, hôpitaux universitaires de Strasbourg, hôpital civil, Strasbourg, France.
Objective:
To analyze the current anaesthetic management of HIV/AIDS patients.
Data Sources:
References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service, personal files.
Study Selection:
Original articles, reviews, cases reports, letters to the editor in French and English were analyzed and selected.
Data Extraction:
Current data on HIV infection, perioperative clinical and biological symptoms, arguments for choice of the type of anaesthesia, risks of transmitting HIV to health care workers and protective measures were extracted.
Data Synthesis:
Twenty per cent of HIV-positive patients require surgery during their illness. Anaesthesia and surgery decrease cell mediated immunity and modify the activity of immune mediators. These changes are more pronounced under general anaesthesia compared to regional anaesthesia. They are transient and not clinically significant. Poor information is available concerning the perioperative management of HIV-positive patients and the effects of anesthesia on their immune status. Preoperative evaluation focuses on the following three important data: patient's status, surgery, and anaesthesia. In patients in good clinical conditions who comply with treatment, the anesthetist assesses the effects of the antiretroviral treatment and the risk of interactions between anaesthetic and antiretroviral agents. Etomidate, atracurium, cisatracurium, remifentanil and desflurane are not dependent on hepatic metabolism by the cytochrome P450 system. In patients in bad clinical conditions or in patients who do not comply with treatment, attention focuses on cardiovascular, pulmonary, neurologic and nutritional status. The specific antiretroviral treatment is not discontinued in the perioperative period, as far as compatible with the type of surgery and associated dysfunction of the digestive tract. Regional anaesthesia offers the benefits of not interfering with the immune system and antiretroviral agents. However, the viral infection can be enhanced by regional anaesthesia due to the cofactors' effect of local anaesthetic agents in cerebrospinal fluid. Homologous blood transfusion is not recommended as it increases postoperative infection and viral activation. Erythropoietin can be of benefit in selected cases. In the future, supportive immunotherapy will probably be the main tool for perioperative management of HIV and AIDS patients.