Anesthesia for Infectious Diseases

Kanya Kumwilaisak MD Department of Anesthesiology Faculty of Medicine Chulalongkorn University

Infectious Disease
An infectious disease is a clinically evident illness resulting from the presence of pathogenic microbial agents

Mode of Transmission

Respiratory system : contact with aerosolized droplets, spread by sneezing, coughing, talking, kissing or even singing Gastrointestinal system : are often acquired by ingesting contaminated food and water Sexually transmitted diseases :are acquired through contact with bodily fluids, generally as a result of sexual activity

AIMS

Prevent transmission Patient to patient Patient to personal health care provider Know pathophysiology of the infectious diseases Know side effects of medications

Respiratory diseases

Tuberculosis H1N1 influenza H5N1 influenza SARS

Tuberculosis

Tuberculosis

Diagnosis

Symtoms : Persistent cough (eg, lasting longer than 2 weeks),fever, night sweats, weight loss, shortness of breath, haemoptysis, and chest pain. Positive tuberculin skin test Sputum exam and culture

Medications
Drug
First Line Drugs

Dose

Side effect

Isoniazid Rifampin

5 mg/kg (300mg) Hepatoxicity peripheral neurotoxicity drug interactions

10 mg/kg (600mg)

Hepatoxicity thrombocytopenia gastrointestinal upset drug interactions

gastrointestinal upset Arthraglia Ocular neuritis

Pyrazinamide Based on weight Hepatotoxicity

50 mg/kg (2 g) 15 20 mg/kg daily

Ethambutol

Anesthetic management

Elective surgery should be postponed until they are no longer contagious (three negative sputum smears, improving symptoms and chest X ray)

Anesthetic management

Liver function test, serum creatinine and platelet count should be performed If ethambutol is used, visual acuity and color vision should be assessed

Anesthetic management

Type of anaesthetic technique will depend on the type of surgery and degree of involment of respiratory tract regional anaesthesia, patient must wear N95 mask

Anesthetic management

OR with an antechamber or separated from other areas The fewest health care workers HEPA filters are placed between patient and the ventilator N95 mask in infectious particles area

Anesthesia management

CO2 absorber should be discarded Two bacterial filters at Y-piece and expiratory limb a case report Should delay at least 1 hour for the next case No O2 flush for checking circuit

H1N1 infection

Spread of infection to others Hyper reactive airway Reduced pulmonary functions and Involvement of other body organs

H1N1 infection

Postpone elective surgery till patient is H1N1 negative In emergent H1N1 positive, it is prudent to operate in an Operation theatre with all precautions as per guidelines for infectious diseases like TB Patient should be isolated throughout the stay in the hospital

H1N1 infection

HEPA filters, connected between patient outlet and standard anaesthesia tubing a closed system suction catheter should be used

HIV infection

Human immunodeficiency virus (HIV) is a lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS) Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk.

HIV infection

HIV infection

Neurologic system Respiratory system Hematologic system Cardiovascular system Gastrointestinal system

AIDS

Bacterial infection, multiple or recurrent Candida of the bronchi, trachea, lungs, or esophagus CD4+ T lymphocyte count 200 cells/L3 Cervical cancer, invasive Coccidioidomycosis, disseminated or extrapulmonaryCryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal (>1 month) Cytomegalovirus other than liver, spleen, lymph nodes

AIDS

Cytomegalovirus retinitis or CMV (with loss of vision)Herpes simplex virus with chronic ulcers (> 1 month), bronchitis, pneumonitis, esophagitis HIV related encephalopathy Histoplasmosis, disseminated or extrapulmonaryIsophoriasis, chronic intestinal (>1month) Kaposis sarcoma Burkitts lymphomaImmunoblastic lymphoma Lymphoma of the brain, primary

AIDS

Mycobacterium avium complex or kansasii, disseminated or extrapulmonary Mycobacterium tuberculosis, any site Mycobacterium, any other species, pulmonary or extrapulmonary Pneumocystis carinii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Recurrent Salmonella septicemia Toxoplasmosis of the brain Wasting syndrome due to HIV

Medications
Category Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs) Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Protease Inhibitors Examples zidovudine (AZT), didanosine, zalcitabine, stavudine, lamivudine and abacavir nevirapine, delavirdine, and efavirenz amprenavir, fosamprenavir, atazanavir, saquinavir, ritonavir, indinavir and nelfinavir enfuvirtide

Fusion Inhibitors

Integrase Inhibitors

raltegravir

Side Effects

Inhibit cytochrome P-450 (CYP)3A4 Glucose tolerances HAART has both direct hepatotoxicity and nephrotoxicity

Anesthetic management

CD4 count < 200 cells/L3 be treated with anteretroviral drugs History and physical exam CBC, coagulation profile, LFT, BUN/Cr, electrolyte Chest radiography ECG

Anesthetic management

GA or RA Universal precaution Prevent transmission

Universal Precuation

2. 3. 4. 5.

1.

Universal Precuation
Precaution Apparatus -

- -
-

Safe use and disposal of sharps

2/3

mucosa

Information for an Occupational Exposure Report

1. Date and time of exposure 2. Detailed description of the procedure being performed 3. Details of the exposure 4. Details regarding the exposure source such as known HBV, HCV, or HIV infection 5. Details about the exposed HCW such as a history of hepatitis B vaccination and antibody status 6. Details about counseling, postexposure management, and follow-up

HBV

HBIG 24 passive prophylaxis HBV vaccine Signs and serology until 6 months

HCV

Check anti-HCV and alanine aminotransferase activity Follow up 4-6 months anti-HCV positive recombinant immunoblot essay

HIV

antiretroviral agents for postexposure prophylaxis in24-36 hrs Follow up serology after 6, 12 weeks and 6 months

Conclusion
Blood-borne
Air-borne
Universal precaution Precaution apparatus Hand Hygiene Sharps Universal precaution Mask n-95 Isolation Prepare anesthesia circuit