IMMUNOCOMPROMISED IN

SURGERY

MOHD FARIS BIN MOHD PUADI

M132001834
UniSHAMS
For diagnosis of AIDS related infection or
neoplasm.
For surgical complications of AIDS.
For other indications as in general
population.
Lymph nodes almost always show follicular
hyperplasia, so not reliable for diagnosis.
Excision/Incision biopsy of lymph node or
soft tissues required for diagnosis of
lymphoma, sarcoma, tuberculosis etc.
Due to the risk of transmission, FNAC should
be considered first and surgical biopsy be
reserved for inconclusive FNAC reports.
Abscesses.
Ano-rectal diseases.
Acute abdominal emergencies.
Hepato-biliary and splenic disorders.
Neoplasms.
Intracranial SOLs.
With profound immunodeficiency, abscesses
are common presentations in HIV+ patients.
Young adult patients of either sex with
pyomyositis are particulary likely to have
AIDS.
Treatment consists of simple Incision &
Drainage as in normal conditions.
Most frequent reason for surgical
interventions in HIV+ patients.
HIV+ male homosexuals have higher
incidence of such disorders than other HIV+
patients.
Perianal sepsis, Fissures, Fistula, Warts,
Squamous cell carcinoma commonly seen.
Large perianal incisions and division of
internal anal sphincter should be avoided.
Setons are ideal for fistulas.
Anal warts are mostly resistant to medical
therapy with podophyllin. So electrocautery or
laser should be used.
Other conditions may mimic perianal sepsis
like:-
◦ Massive ulceration following Herpes simplex.
◦ Kaposi’s sarcoma presenting as bleeding
hemorrhoids.
◦ Lymphoma as perianal abscess.
◦ Chronic indolent ulcer caused by M. avium
intracellulare.
Acute abdomen may be a presentation in
about 12-45% of AIDS patients but surgery is
required in only upto 5% cases mainly for
appendicitis, obstruction or perforation.
CMV infection, Kaposi’s sarcoma, Lymphoma
all may present with bowel obstruction or
perforation or even obstructive appendicitis.
Requires laparotomy for perforations and
acute obstructions.
30% of all acute appendicitis are related to
AIDS related illness. Requires appendectomy.
Appendicitis carries higher risk of perforation
and abscess formation.
Typhlitis common presentation in AIDS
patients.
Other opportunistic infections of GIT may
also present as acute abdominal
emergencies.
Chronic hepatits B and C infections are
common co-infections with AIDS.
Small liver abscesses secondary to infections
with cryptococcus, histoplasma, candida etc
are common.
Acute acalculous cholecystitis more common
in AIDS patients. Require cholecysectomy.
Biliary obstruction due to compression by
enlarged portal lymph node or due to
infection with cryptosporidium, CMV or
mirosporidium may be seen.
Multiple splenic abscesses leading to
splenomegaly is common.
Splenectomy may be required for traumatic or
spontaneous rupture of spleen found to be
more common in patients with AIDS.
May also be required for associated
thrombocytopenia.
Kaposi’s sarcoma and Non Hodgkin’s
lymphoma common neoplasms associated
with AIDS infection.
Surgery often required for biopsy purposes or
for other complications.
In HIV positive patients, toxoplasmosis
causes brain abscess. If medical treatment
fails then CT guided stereotatic needle
aspiration.
Necrotizing arteriopathy leading to aneurysm
formation common in HIV infected patients.
Salmonella arteritis especially common
leading to pseudoaneurysm.
Infected pseudoaneurysms also common in IV
drug abusers (high risk group for HIV
infection).
Vascular reconstructions usually helpful.
The surgeon is regularly exposed to blood,
which is the most infective medium for HIV
transmission. Incidence of accidental
exposure to infected patients blood is 6.4%.
Risk is greater when there are more HIV
particles in blood i.e. during the earliest
and later stages of the disease.
Risk with needle stick injury is 0.3%
Risk of transmission in surgery is 1 in
28000-50000 per hour of operations.
Extent of risk of infection to the surgeons
depends on:
◦ Prevalence of HIV in patient population.
◦ Number of procedures carried out by the
surgeon.
◦ Length of the period of risk.

Risk is more when

◦ When surgery lasted for > 3 hours.
◦ > 300ml blood loss present during surgery.
◦ In major vascular, intra-abdominal and
gynaecological surgeries.
Most common mode
Risk of HIV:- 0.3%
1ml of infected blood has
50 HIV RNA compared
with 10 9 HBV particles
Hollow needles 10 times
more dangerous than
solid needles
Most of needle
injuries(27%) occurs from
improper disposal.
1. Clean with saline and anti-sepctic after
squeezing to exit the blood at the injured
site.

2. Change the virused gloves (Double

Gloves).

3. Schedule for vaccination and immunization

in Hep B and C (no in HIV+)
Deep injury.
Visible blood on instrument.
Prick directly into vein or artery.
High viral load.
Hollow needle > solid needle
Large diameter needles.
Recommended by CDC (USA) in 1987.
Every patient to be treated and precautions
observed as if he/she has the infection.
Use of protective barriers while dealing with
body fluids like blood, semen, vaginal
secretions, CSF, synovial fluid, pleural,
pericardial, peritoneal and amniotic fluids.
Feces, sweat, tear, saliva, urine, vomitus,
nasal secretions not included.
Noncompliance with recommendations on
universal precautions amounts to upto 84% in
emergency conditions.
Hence, certain basic standard precautions
must be observed like wearing gloved while
drawing blood or inserting cannula.
Routine wearing of gloves for examination of
AIDS patients are not recommended unless
for open wounds.
Needles and sharps must always be disposed
in puncture-proof containers.
Such containers should be present as near as
practically possible.
Proper waste disposal.
Additional precautions are to be observed
while performing on HIV+ patients:
◦ Barrier method
◦ Methodical approach
DOUBLE GLOVES
(reduces risk by 5
fold)
CAP AND MASK
EYE GLASSES OR
SHIELDS
PLASTIC
APRON/GOWN
FOOTWEAR(wellington
shoes)
Undue haste should be avoided.
Assistants and other staffs should be
minimum.
Incisions should be large so as to have
minimal requirement of retraction by
assistants.
Surgery should be done in orderly manner
with meticulous attention to avoid as much
blood loss as possible.
Clumsy transfer of instruments should be
avoided. Sharps preferably be transferred in
kidney dishes.
TREATMENT OF EXPOSED LOCALSITE:
◦ Skin: thorough cleaning with soap water. Never put
fingers reflexly into mouth.
◦ Eyes: Irrigation with fresh water.
◦ Oral cavity: spit out immediately and rinse with
water several times.
Prompt exposure report regarding the time,
nature etc of exposure should be reported.
Source
◦ HIV testing after proper consent. If known to be HIV
positive then assess the health status and the
possibility of drug resistance if on anti retro-viral
therapy
Recipient
◦ Baseline serological testing for HIV, HBV and HCV.
Nature of exposure.