MARLON REID- PGY2

A 25 y/o Male with HIV presents with a perforated Appendicits. Describe the perioperative
management for both patient and surgeon with respect to his HIV Status.

Introduction:
HIV:
Since the widespread availability of Antiretroviral (ART), the life expectancy of People Living with
HIV (PLHIV) approaches that of the normal population.
Viral Load:
ART has been proven to be very effective at reducing viral load and Improving CD4 Count. a VL
of less than 1000 is considered virally supressed. A VL less that 20 is considered undetectable and
the risk of transmission is almost nil. However with increasing Viral Load there is increased risk of
transmission.
CD 4 count:
CD count is a proxy to the competence of the immune system. CD4 counts less than 50
predisposes patients to AIDS defining illnesses such as Pneumocyctis Jiroveci Carinii. Typical
counts greater than 200 are thought to be immunocompetent.
Aim: The goal of perioperative management of PLHIV is to reduce surgical risks o the patient and
prevent/ reduce risk of transmission to the Health Care Team.
Presentation: Emergency It is important to recognize that the above patient presents as an
emergency therefore preoperative optimization of ART cannot be ensured.
CAVEAT: The care should involve a multidisciplinary approach involving surgeon, anaesthetists,
Nurses, Infectious Disease Physicians.

Preoperative measures:
Patient:
Obtain a History and Physical examination if possible to ascertain information re control of HIV.
Eg Duration of Illness, Compliance with ART, Hx opportunistic infection or AIDS defining illness.
Recent VL and CD4 count
HX HIV associated Nephropathy
Physical Examination:
General: Quick Nutritional assessment
Oral Thrush
Resp: Evidence of PCP
Investigation:
U&E - HIV associated nephropathy
CBC- for cytopenia GXM,
LFT and PTPT is Hepatic impairment suspected
Cxray: PCP
Continue ART throughout admission with as little interruption as possible
Commence antibiotics
Ensure adequate resuscitation
Thromboprophylaxis- mechanical or chemical
Surgeon:
Should adhere to universal precautions performing venepuncture
 MARLON REID- PGY2

Wearing of Gloves
Do not recap Needle
Proper disposal of Sharps
If surgeon has an open wound then he / she should avoid managing the patient.
Intraoperative:
General: Consider Laparoscopic Approach Over Open Appendectomy
Patient:
Antibiotics before incision
Ensure Adequate peritoneal lavage
Surgeon
Double Gloves, frequent Changing of gloves for long procedures
Face Shield or Goggles to prevent contact of secretions with mucous membrane
Use instruments for retraction and not hand
Use instruments to Handle Sharps
Use more electrosurgery device as opposed to Scalpel
SAFE technique: for surgical smoke/ Plume- ( Plume contains bacteria and viral particles/ DNA)
Postoperative:
Patient
Given that a perforated appendicitis is at least a contaminated wound then antibiotics should be
continued
Continue ART
If was not previously on ART to refer to Infectious disease
Early Ambulation to prevent Pneumonia and Venous thromboembolism
Early commencement of nutrition
Surgeon
Observe and carry out standard universal precautions

NOTE!!!!
If accidental exposure has occurred. Incident to be reported to the relevant authorities.
Completion of appropriate forms and assessment of the level of Exposure. With the
commencement of ART.
Risk of transmission through a needle stick is approximately 0.3 %. Dependent on the depth of
injury , gauge of the needle

ELECTIVE:
1
Difference with the elective cases. There is time to achieve compliance with ART, Viral Load
suppression and Improvements in CD count.

Also Able to Take a more in depth History:

PLHIV also misuse substances EG marijuana. Smoking cessation at least 4 weeks before
surgery.
Nutritional History?
Social Support?

Assess Liver Function, Kidney Function, Pulmonary function etc

 MARLON REID- PGY2

If patient is non-compliant with ART can involve other personnel:

Social Worker
Adherence counsellor
Enroll In Viral Load Suppression Activities- Adherence programs/ Peer support groups