Anaesthesia in HIV/AIDS patients.

Objective: To analyze the current anaesthetic management of HIV/AIDS patien ts. Data sources: References were obtained from computerized bibliographic rese arch (Medline(R)), recent review articles, the library of the service, pers onal 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 ex tracted. Data synthesis: Twenty per cent of HIV-positive patients require surgery du ring their illness. Anaesthesia and surgery decrease cell mediated immunity and modify the activity of immune mediators. These changes are more pronou nced under general anaesthesia compared to regional anaesthesia. They are t ransient and not clinically significant. Poor information is available conc erning the perioperative management of HIV-positive patients and the effect s of anesthesia on their immune status. Preoperative evaluation focuses on the following three important data: patient's status, surgery, and anaesthe sia. In patients in good clinical conditions who comply with treatment, the anesthetist assesses the effects of the antiretroviral treatment and the r isk of interactions between anaesthetic and antiretroviral agents. Etomidat e, atracurium, cisatracurium, remifentanil and desflurane are not dependent on hepatic metabolism by the cytochrome P450 system. In patients in bad cl inical conditions or in patients who do not comply with treatment, attentio n focuses on cardiovascular, pulmonary, neurologic and nutritional status. The specific antiretroviral treatment is not discontinued in the perioperat ive period, as far as compatible with the type of surgery and associated dy sfunction of the digestive tract. Regional anaesthesia offers the benefits of not interfering with the immune system and antiretroviral agents. Howeve r, the viral infection can be enhanced by regional anaesthesia due to the c ofactors' effect of local anaesthetic agents in cerebrospinal fluid. Homolo gous blood transfusion is not recommended as it increases postoperative inf ection and viral activation. Erythropoietin can be of benefit in selected c ases. In the future, supportive immunotherapy will probably be the main too l for perioperative management of HIV and AIDS patients. (C) 1999 Elsevier, Paris.