Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
63 Cards in this Set
- Front
- Back
|
HIV on L&D Scope of the Problem
|
Us as of December 2005
475,000 patients living with AIDS > 1,000,000 asymptomatic patients with HIV >550,000 deaths Worldwide as of December 2006 40,000,000 infected with HIV 2/3 in sub-Saharan Africa 75% of women infected worldwide are in this region |
|
|
______represent the fastest growing population of persons with AIDS in the US
|
women
|
|
|
In 2002, HIV leading cause of death for _______aged 25-34 in US
|
black women
|
|
|
HIV-1 virus is a _______ and _____-______ virus
|
retrovirus and single-strand RNA
|
|
|
HIV-2 is similar to HIV-1 and produces AIDS as well
IS it common in the US? |
Common in western Africa but rare in US
|
|
|
Most common mode of transmission is ____ ___ ____ _____
|
sexually thru genital mucosa
Within 2 days, virus can be detected in internal iliac lymph nodes Within 4-11 days virus cultured from plasma |
|
|
For infection to occur, virus must bind to....
|
cell surface receptor, the CD4 antigen complex:
Helper T-cells Monocytes Macorphages Placental cells |
|
|
See rapid rise in _____ _____that spreads to lymphoid organs and brain
|
plasma viremia
CD4 + T-lymphocytes infected early and remaining cell count helps define disease progression |
|
|
T or F: Plasma viral load very high initially, declines during latent period and rises again as disease progresses
|
True
|
|
|
When are HIV pts extremely infectious?
|
Patient with acute infection and those in late stages of disease extremely infectious
|
|
|
Acute infection is transient, symptomatic illness
What are the symptoms? |
Fever, fatigue, rash, HA, lymphadenopathy, pharyngitis, myalgia, arthralgia, N/V/D
|
|
|
Viral half-life about __ hours and turnover as high as _ ___/day
|
6, 1 billion/day
Said to be “fastest genome evolution ever described” |
|
|
Virus may be latent for __years or more in some but
Ultimately rising count |
10
extreme compromise of immune system and CD4+ T-lymphocyte count of less than 200 means final stages Diagnosis of AIDS made when any one of number of AIDS-indicator conditions develop (table 33.1, p. 587) |
|
|
Clinical Manifestations of HIV
|
Secondary to immune suppression initally
Opportunistic infections, unusual malignancies GI disturbances common Multi-organ disease as people live longer We worry most about neurologic, pulmonary, and hematological complications |
|
|
HIV on L&D
Neurologic Manifestations: Initial, Latent, and Late S/S |
Initial systemic infection:
Viral particles can be isolated from CSF Headache, photophobia, retroorbital pain Aseptic meningitis Cognitive and affective changes (depression and irritability) Cranial and peripheral neuropathies Usually self-limited, but persistent dysfunction may occur Asymptomatic (latent) phase: Demyelinating neuropathy Persistent CSF abnormalities Late infection (symptomatic AIDS) Meningitis Diffuse encephalopathy Myelopathy Peripheral neuropathy Focal brain disorders Myopathy Drug-induced neurologic toxicity |
|
|
Pneumocystis carinii pneumonia (PCP)
|
Usually only with severe immunosuppression
Severe hypoxemia, diffuse interstitial infiltrates on CXR Mortality > 60% in patients requiring intubation Steroid therapy decreases likelihood of resp. failure |
|
|
TB
|
Reactivation of latent disease due to impaired immunity
Increased likelihood of getting disease |
|
|
Other Pulmonary Manifestations
|
Increased incidence of pneumonia from impaired humoral immunity
Increased risk of fungal pneumonia |
|
|
Hematologic Manifestations
|
Leukopenia
Anemia Thrombocytopenia - ITP common Treatment:Antiviral therapy & Variable response with steroids |
|
|
HIV on L&D
Interaction with Pregnancy |
In US
1995 1.7/1000 2000 in New York City 6.2/1000 |
|
|
****Risk Factors for Vertical Transmission (7)
|
Severity of maternal disease
Maternal viral burden Substance abuse Co-existing STDs Prolonged rupture of membranes Chorioamnionitis Breastfeeding: 2 times more likely to transmit |
|
|
****Prevention of Vertical Transmission (3)...hint: what drugs would you give and what type of delivery is best?
|
Zidovudine (ZDV) orally during pregnancy, IV during labor, and orally to infant decreased transmission from 25% to 8% in trial in 1994
Multidrug therapy can decrease transmission to 1-2% Elective C-section prior to labor may decrease transmission by 80% |
|
|
Effect of HIV on Pregnancy
|
In absence of advanced, symptomatic AIDS, HIV infection doesn’t seem to worsen perinatal outcome
Antiretroviral therapy doesn’t increase risk of preterm delivery, LBW, low Apgar, or stillbirth Pregnancy doesn’t accelerate disease No evidence that antiretroviral drugs are teratogenic Same drug therapy used for pregnant female as nonpregnant |
|
|
Neuraxial Anesthesia and HIV
|
No evidence that HIV patients are more susceptible to infection from neuraxial anesthesia
ASA recommends gown be worn during invasive procedures |
|
|
Is CSE ok for HIV pt?
Is HIV-seropositive patient at increased risk for meningitis? |
Most will use technique when appropriate
Usually fine to use this method of anesthesia. |
|
|
PDPH in HIV pt. How do you treat it?
|
Conservative therapy first
Blood can enter subarachnoid space after blood patch |
|
|
Will blood patch accelerate CNS manifestations of AIDS?
|
No deterioration in cognitive function in patients after blood patch in study by Tom in 1992
OK to do blood patch if necessary |
|
|
General Anesthesia in HIV pts
|
No evidence to support increased risk of pulmonary complications
Causes transient depression of immune function, insignificant in normal patients No evidence to suggest effect is more severe in HIV patients |
|
|
Strategies to Minimize Transmission to unifected patient (5)
|
1.Transfusion threshold
Non-pregnant patients tolerate Hgb levels as low as 7 (may go home with Hgb of 7) 2. Directed donation Will blood be available when needed? 3.Autologous blood transfusion How to determine who is at risk? LBW babies if mom’s hgb < 9 has been reported 4.Normovolemic hemodilution 5.Cell saver |
|
|
Strategies to Minimize Transmission to health care worker (2)
|
1.Universal blood and body-fluid barrier precautions
2.Post-exposure prophylaxis |
|
|
Universal Precautions
|
ALL patients, ALL patients
When contact with any infectious material is anteicipated: Blood, amniotic fluid, CSF, saliva Barrier must be effective: Gowns, gloves, mask, eye shield |
|
|
Avoid recapping needles: Less and More sever exposure
|
Less severe exposure: solid needle, superficial injury
More severe exposure: large bore hollow needle, deep puncture, visible blood on device, needle used in artery of vein |
|
|
Postexposure Prophylaxis
|
Risk of transmission After needle stick is estimated to be 0.3%:
56 known and 138 suspected cases of occupational transmission Factors: Viral burden of source, volume of inoculum (hollow vs. solid needle), portal of entry (intact skin, mucous membrane, percutaneous) |
|
|
T or F: Primate studies demonstrate that antiretroviral drugs any time after inoculation can prevent seroconversion
|
False: Primate studies demonstrate that antiretroviral drugs SHORTLY after inoculation can prevent seroconversion
|
|
|
80% reduction in transmission to exposed health care workers who received _____
|
ZDV
|
|
|
Treatment if Exposed
|
Local wound care
Tetanus toxoid Hepatitis B antibody titers Chemoprophylaxis as indicated: Need for treatment and number and types of agents used will depend upon severity of exposure and HIV status of source |
|
|
Drug abuse among pregnant women on the increase
Estimated that __% of women of childbearing age are heavy drinkers and many take multiple drugs in combination |
5
Most drugs that are abused readily cross the placenta |
|
|
The Drug-Addicted Mother:
Commonly Abused Drugs (7) |
Alcohol
Tobacco Opioids Cocaine Amphetamines Caffeine Marijuana |
|
|
Chief abnormality associated with alcohol abuse is ___ ____ _____
|
fetal alcohol syndrome (FAS)
|
|
|
Characteristics of FAS
|
Prenatal and post-natal growth deficiency
Microcephaly Mental retardation Occurs in app. 1/3 of infants born to moms who drink 3 or more oz./day during pregnancy No safe level of consumption during pregnancy identified |
|
|
Alcohol Abuse and Pregnancy
Problems with anesthesia include |
Hemodynamic instability
Increased resistance to drugs Larger doses of induction agents if chronic; Lower doses if intoxicated SCh may be prolonged by liver disease Regional OK but more sedation may be needed Severe hypotension may be seen from dehydration, cardiomyopathy, autonomic neuropathy CV disease leading cause of death in alcoholics |
|
|
Tobacco Use and Pregnancy
|
Most commonly abused drug
Nearly 2,000 compounds have been identified in cigarettes (nicotine, carbon monoxide, cyanide) Nicotine increases maternal HR, BP, and peripheral vasoconstriction Fewer CV problems in 12-24 hours Placental abruption and impaired resp. function associated with smoking |
|
|
Mothers that smoke: Infants tend toward LBW and may have _____ ____deficiency caused by _____
|
Vitamin B12
cyanide |
|
|
Mothers that smoke:
Risk of prematurity doubles what are the %s? |
(from 6-12%)
|
|
|
What are 2 conditions that may be seen in the infant of a mother that abused tobacco?
|
Infants may have increased Hct: CO attached to Hgb of fetus and hypoxemia causes increased erythropoiesis
SIDS occurs two times more often than in non-smoking moms |
|
|
Tobacco Use and Pregnancy
Anesthetic Considerations |
Limited pulmonary function:
Regional if possible Carboxyhemoglobin levels fall to nonsmoking within 48 hours: Some recommend nicotine patches during pregnancy Perioperative morbidity increased from hypersecretion, impaired tracheobronchial clearance, small airway narrowing Ciliary function improves in 1-2 weeks 4-6 weeks needed for morbidity to be same as in nonsmoking See increased gastric volume (increased aspiration risk) |
|
|
Caffeine and Pregnancy
|
Most commonly used behaviorally active substance in world
80% of pregnant women ingest caffeine daily Acts on dopaminergic system in similar manner to amphetamines and cocaine Readily crosses placenta Can have half-life of 100 hours in infant Can’t metabolize FDA advises “avoid or use sparingly” |
|
|
Caffeine is a known teratogen in animals, associated with what complications?
|
spontaneous Ab, LBW, stillbirth, premature delivery, fetal arrhythmias
|
|
|
Most common symptom from caffeine withdrawal is _______and may confuse diagnosis of ______
|
headache
PDPH |
|
|
____most commonly abuse opioid during pregnancy
|
Heroin
|
|
|
Opioid Abuse and Pregnancy
|
Increasing numbers of women are on methadone
Use linked to FGR, preterm labor, abruption, chorioamnionitis, increased risk for C-section due to fetal distress Withdrawal during 3rd trimester may result in meconium staining, asphyxia, and neonatal death |
|
|
Baby can have opioid withdrawal after delivery...what might you see?
|
Increased likelihood for resp distress, seizures, hyperthermia and SIDS
Avoid naloxone Neonatal withdrawal can last for several months Mortality rate 1% |
|
|
T or F: C-section may be required for fetal distress in a mother that abuses opioids
|
True
Mom must receive drugs to avoid withdrawal Don’t use agonist/antagonist Expect more meds for post-op analgesia Regional OK but may need more sedation |
|
|
Cocaine Abuse and Pregnancy
|
Acts as local at Na+ and K+ channels but blocks re-uptake of catecholamines and neurotransmitters at nerve terminals: Norepinephrine, dopamine, epinephrine, serotonin
Increased levels of these cause tachycardia, vasoconstriction, HTN, decreased UBF See catecholamine excess during acute intoxication and depletion in chronic addict |
|
|
Cocaine Abuse and Pregnancy: Neonatal Complications
|
Rapidly crosses placenta: May constrict vessels in placenta and umbilical cord
Linked to spontaneous Ab, abruption, rupture Abruption and fetal distress common causes of emergent sections Transient CNS irritability at birth LBW, FGR Longer hospital stays, more congenital defects, more complications, long-term developmental deficits |
|
|
Cocaine Abuse and Pregnancy:
is an epidural ok? |
Epidural placement will reduce pain and anxiety
Important in helping minimize uterine vascular resistance from catecholamines |
|
|
How do you treat HTN with Cocaine abuse pt? (3)
|
Hydralazine:
Reflex tachycardia not a good thing Beta-blocking drugs: Propranolol causes severe HTN when used in cocaine intoxicated patient - contraindicated Blocks beta-receptors and leaves alpha-receptors unblocked See alpha stimulation “unopposed” by beta-receptor stimulation Called unopposed alpha-stimulation Regional good also. |
|
|
Which beta blocker is better to treat HTN in the cocaine abuser?
|
Labetolol:
Beta-blocking effects greater than alpha so titrate carefully Unopposed alpha effects… Some recommend use of NTG along with labetolol |
|
|
Be very careful of hypotension
in the patient being treated for HTN that abuses cocaine. Why? *****Why might ephedrine be ineffective in treating hypotension in these patients? |
State of vasoconstriction (like in preeclampsia)
Phenylephrine effective…be careful of dose |
|
|
Cocaine Abuse and Pregnancy
General Anesthesia |
Volatiles may sensitize myocardium to dysrhythmias induced by catecholamines
Ketamine is best avoided or titrated very carefully if needed MAC is decreased with chronic use but may be increased with acute use Watch HTN on induction |
|
|
Amphetamines
Methamphetamines |
Sympathomimetic amines
Stimulate SNS by increasing neurotransmitter release from presynaptic terminals Used orally, IV, inhaled Crystal meth is smokable and similar to “crack” cocaine in adverse maternal and neonatal outcomes Abuse in women may be related to appetite suppression and weight loss Clinical effects look like cocaine Infants have abnormal sleep pattern, tremors, hypertonia, high-pitched cry, poor or frantic sucking, vomiting, sneezing, tachypnea Moms have prolonged HTN, tachycardia, arrhythmias, hyperreflexia, fever Chronic use may lead to psychosis These women may abuse multiple drugs Treatment and considerations same as cocaine |
|
|
Marijuana and Pregnancy
|
Use during pregnancy 5-35%
THC active ingredient and can cause mile tachycardia and euphoria Rapidly crosses placenta Accumulation in fatty tissue makes elimination very slow which results in prolonged exposure in fetus (up to 30 days) Elevates CO levels in blood and less O2 is available for fetus No significant problems R/T anesthesia with marijuana use Same considerations as for smoker Recent use may lead to additive effects of our drugs May prolong SCh activity from inhibition of cholinesterase activity No contraindications to regional or general anesthesia |
|
|
The patient on OB you’re called to care for has a urine drug test positive for THC and methamphetamine. She is 35 weeks, in active labor and 6 cm dilated. Other lab work is normal. She requests an epidural. B/P is 156/90, HR 110. There is no proteinuria. She appears uncomfortable and very anxious.
|
Yes
|
