HIV IN SURGERY

BY

DR. D. BOOPATHY,M.B,M.S.,

PROF. JE NESAM HOSPITAL,

CHENNAI.

THE EVOLUTION OF A PANDEMIC

INTRODUCTION

                  l      SYPHILIS --- FIRST APPEARED IN 1495—COLUMBUS SAILOR

                                                                433 YEARS REMEDY–PENICILLIN–1928–ALEXANDER FLEMING

                                             l      AIDS         --- 1981--- CALIFORNIA---5 YOUNG MEN—PNEU.CARINI

REMEDY--- HOW LONG ?

                  l      PLAGUE   ----1/4 TH OF HUMAN POPULATION DESTROYED

                  l      AIDS ? 

WHAT AIDS DOES-SPECTRUM

 PROGRESSIVE DESTRUCTION OF IMMUNE SYSTEM

                                                                              DEPLETION OF CD-4 COUNTS

                                                                              ASYMPTOMATIC TO SYMPTOMATIC DISEASE WITH INTERMITTENT

                                                                              AND CHRONIC    MANIFESTATION

                                                                              LIFE THREATNING OPPURTNISTIC INFECTION/ MALIGNANCY/WASTING

MALIGNANCIES

•           KAPOSI SARCOMA

•                    NHL

•                    HODGKINS

•                    HIGH GRADE LYMPHOMAS

•                    PRIMARY CNS LYMPHOMA

•                    ANOGENITAL SQUAMOUS CELL CA

•                    ANAL CARCINOMA

•                    CERVICAL CARCINOMA

ORAL MANIFESTATIONS

•  COMMON MANIFESTATION IN HIV

•   KAPOSI SARCOMA

•   FIRST MANIFESTATION OF AIDS (HOMOSEXUALS)

•   PALATE IS THE COMMONEST LOCATION OF ORAL KS

•   LARGE BLUE/ PURPLE RED NODULES/PATCHES

•   CONFIRMED BY BIOPSY

•   CLINICAL FEATURES  

                                            - PAINFUL/ MASTIGATION DIFFICULTY

•    TREATMENT – SMALL  LESION -  SURGICAL/LASER

•     INTERLESION CHEMO

•    SCLEROSING AGENT

                                           - LARGE LESION – RADIATION TREATMENT

ORAL LESIONS

LYMPHOMA

•    NHL

•    IT MAY BE ONLY LESION-TO DIAGNOSE

•    PRESENT AS DIFFUSE SWELLING/NODULES/ULCER

•    B-CELL ORIGIN

ORAL CANCER

BASAL CELL CA

&

 SQUAMOUS CELL CA

ORAL CANDIDIASIS

            \     FIRST OPPORTUNISTIC INFECTION

                                                  -  USUALLY MADE ON CLINICAL APPEARANCE

            \     SIMPLE TEST : POTTASIUM HYDROXIDE/PAS/GRAM        STAIN

            \  WOMEN – VAGINAL CANDIDA APPEAR EARLY

            \      TYPES – ERYTHEMATOUS/ PSEUDOMEMBRANOUS

            \     ANGULAR CHEILITIS : CRACK, FISSURES AT THE ANGLE OF THE MOUTH

            \     TREATMENT - KETACONAZOLE

APHTHOUS ULCER

•     RECURRENT APHTHOUS ULCER/ CANKER SORES

•        TREATMENT

•        TOPICAL STEROIDS

•        SYSTEMIC STEROIDS

•        THALIDOMID

GIT MANIFESTATIONS

        l      MOUTH TO ANUS – ENTIRE GIT

        l      MUCOSA OF GIT MANY TIMES LARGER THAN SKIN

        l      ONLY SINGLE LAYER OF GUT EPITHELIUM SEPARATES   “MILIEU INTERIOR” FROM HOSTILE EXTERNAL

                               WORLD

        l      DISTAL COLON IS THE PORTAL OF ENTRY- HOMOSEX

        l      RECTAL MUCOSA BREAK DOWN- VIRAL ENTRY-M-CELLS-LYMPHOCYTES – DISSEMINATION

        l      GUT- GULT – LARGEST LYMPHOID ORGAN- ACT AS RESERVOIR FOR HIV INFECTED LYMPHOCYTES

        l      MORE PATIENTS – DIE OF MALNUTRITION/WASTING- CALLED “SLIM DISEASE”

OESOPHAGUS

                    l      MOST COMMON SYMPTOM- ODYNOPHAGIA

        l      STICKING OF FOOD

        l      CMV – MOST COMMON VIRAL PATHOGEN

        l      KS – OCCASIONALLY FOUND

PROTOCOL

GASTRIC DISEASES

•      PARIETAL CELL DYSFUNCTION- ACID OUTPUT DECREASED-

                     BACTERIAL OVERGROWTH       

•     H. PYLORI DECREASED INCIDENCE

ENTEROCOLITIS

HEPATO BILARY DISEASE

PROTOCOL FOR LIVER MANAGEMENT

INDICATIONS FOR LIVER BIPOSY

       l   UNEXPLAINED ABNORMAL LIVER BIOCHEMISTRY

       l   UNEXPLAINED FEVER

       l   HEPATOMEGALY

BILARY TRACT DISEASE

l   PAPILLARY STENOSIS

l   SCLEROSING CHOLANGITIS

l   STRICTURE

l   ACALCULOUS CHOLECYSTITIS

PANCREATIC DISEASE

PERITONEAL AND MESENTRIC DISEASE

l   INTRA PERTIONEAL ABCESSES/ MASSES

l   ASCITIES- PARACENTESIS- DIAG. TOOL

l   PERITONITIS- VISCUS PERFORATION

l   SPONTANEOUS BACTERIAL PERTONITIS

 

INDICATIONS FOR LAPAROTOMY

l   BOWEL PERFORATION - MALIGNANCY(KS/

       LYMPHOMA),CMV  

l   APPENDICITIS

l   CHOLECYSTITIS

l   BOWEL OBSTRUCTION

l   INTESTINAL ISCHEMIA

UNIVE RSAL PRECAUTIONS

l   STRICT ISOLATION

l   RESPIRATORY ISOLATION

l   PROTECTIVE ISOLATION

l   ENTERIC PRECAUTIONS

l   WOUND & SKIN PRECAUTIONS

l   DISCHARGE PRECAUTIONS

l   BLOOD PRECAUTIONS

UNIVERSAL PRECAUTIONS

l     HAND WASHING AND GLOVES

               - SINGLE MOST IMPORTANT MEASURE

l     PROTECTIVE GOWNS

l     MASK AND PROTECTIVE EYE WEAR

l     PROTECTION FROM NEEDLES & SHARP INS.

l     DISPOSAL OF SHARPS & CONTAMINATED WASTE

l     HANDLING OF LINEN

l     DISINFECTION, STERILISATION , AND WASTE

     MANAGMENT

 

UP – BODY FLUIDS

SPECIAL CONSIDERATION FOR SURGEON

•    ENGINEERING CONTROLS

•    WORK PRACTICE CONTROL

•    PERSONAL PROTECTIVE EQUIPMENT

•    ADMINISTRATIVE CONTROL

ENGINEERING CONTROLS

        l   LAPAROSCOPIC TECHNIQUE

        l   LASER AND ULTRASONIC DISSECTORS

        l   STAPLERS

        l   OPERATING ROOM

                    l  BLUNT TIPPED NEEDLE

                    l  FINGER PROTECTIVE STRIPS

                    l  MAGNETIC PASSING TRAY

                    l  SHIELDED SCALPELS

WORK PRACTICE CONTROL

                     l AWARENESS AND CAUTION – ALL TIMES

                                l   ORAL ANNOUNCEMENTS

                                l    SHARP INSTRUMENTS- MAYO STAND

                                l    STAPLING – NON SUTURE TECHNIQUE

                                l    INSTRUMENT TIES

                                l    NO DIGITAL PALPATIONS OF NEEDLES

PERSONEL PROTECTIVE EQUIPMENT

        l   GLOVES – DOUBLE , TRIPLE

        l   BODY AND FACIAL PROTECTION

                                                                      - GOGGLES

                                                                      - GARMENTS

ADMINISTRATIVE CONTROL

        l   ROTATION OF WORKERS

                                                     - DECREASE EXPOSURE

        l   CERTAIN LAW STANDARDS

        l   STRICT POLICES

        l   IMMUNISATION FOR ALL STAFF                                      

STERLIZATION AND DISINFECTION STRATEGIES

•   HIGH LEVEL DISINFECTION- ALL

•     INTERMEDIATE LEVEL DISINFECTION-MOST

•     LOW LEVEL LEVEL DISINFECTION

 CDC CLASSIFICATION SCHEMES FOR STERILANTS,DISINFECTANTS AND SANITIZERS