With respect to patients with HIV disease admitted to Intensive Care for a non-HIV related cause:
a) What relevant information about the patient’s HIV disease would you elicit from the history, examination and investigations to assist management? (50% marks)
b) Discuss the issues associated with the administration of antiretroviral therapy in the Intensive Care Unit. (50% marks)
No prospective studies evaluating safety, efficacy & timing of ART in the ICU
1) ART interruption- Difficulty with administering oral drugs in the critically ill especially with GI dysfunction. No parenteral preparations. Treatment interruption can lead to resistance mutations (effects seen up to 3 months after). Interruption also has HIV- specific and non-HIV specific risks (cardiovascular, renal, liver)
2) Toxicities and Side Effects- Dose adjustment required with organ failure (renal or hepatic). Specific toxicities and complications such as lactic acidosis, pancreatitis, liver failure, cardiovascular disease and hypersensitivity reactions.
3) Drug Interactions- With commonly used ICU drugs such as midazolam, PPIs, H2 blockers, amiodarone.(specific names of drugs not required)
4) Immune Reconstitution Syndrome- May complicate new initiation of ART in ICU. Worsens respiratory failure from PJP or TB. Worsens neurological status from Cryptococcus or TB. Increased risk soon after commencement of ART and with low CD4 counts.
What relevant information is required to manage this patient?
In brief, as far as ART is concerned:
Manifestations of IRIS may include:
ART might have numerous side effects:
Oh's Manual: Chapter 68 (pp. 710) HIV and acquired immunodeficiency syndrome by Alexander A Padiglione and Steve McGloughlin
Zolopa, Andrew R., et al. "Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial." PloS one 4.5 (2009): e5575.
Huang, Laurence, et al. "Intensive care of patients with HIV infection." New England Journal of Medicine 355.2 (2006): 173-181.
Murdoch, David M., et al. "Immune reconstitution inflammatory syndrome (IRIS): review of common infectious manifestations and treatment options."AIDS research and therapy 4.1 (2007): 9.
Bajwa, Sukhminder Jit Singh, and Ashish Kulshrestha. "The potential anesthetic threats, challenges and intensive care considerations in patients with HIV infection." Journal of pharmacy & bioallied sciences 5.1 (2013): 10.
Duggal, Abhijit, et al. "OUTCOMES OF HIV PATIENTS REQUIRING INVASIVE MECHANICAL VENTILATION AS COMPARED TO PATIENTS WITH AIDS." CHEST Journal 136.4_MeetingAbstracts (2009): 115S-a.