HIV-Infected Man Who Presents for Preoperative Evaluation

A 66-year-old man with HIV infection presents for a preoperative risk assessment before a total hip replacement.

HISTORY

The patient received a diagnosis of AIDS 6 years earlier, after he had sought medical attention for an opportunistic infection. For the past 5 years, he has been taking highly active antiretroviral therapy (HAART), and he states that his HIV specialist has told him that his viral load is “undetectable.” Other than HIV infection, hypertension, and hyperlipidemia, he has no significant past medical history or complaints. His medications consist of atazanavir 300 mg daily, ritonavir 100 mg daily, fixed-dose emtricitabine 200 mg/tenofovir 300 mg daily, atenolol 50 mg daily, and atorvastatin 10 mg daily. He does not smoke cigarettes or use alcohol. He typically swims laps 3 times a week for 30 minutes without any shortness of breath or cardiac complaints.

PHYSICAL EXAMINATION

The patient’s blood pressure is 136/78 mm Hg; other vital signs are normal. Height is 5 ft, 10 in; weight is 205 lb. Other than pain over the left hip area, the results of the physical examination are normal.

LABORATORY RESULTS

Initial laboratory studies show normal electrolyte, blood urea nitrogen, glucose, and creatinine levels. White blood cell (WBC) count is 9100/µL with 71% neutrophils and 19% lymphocytes. The absolute lymphocyte count is 1729/µL. Hemoglobin level is 14.6 g/dL, hematocrit is 41.9%, and platelet count is 240,000/µL. Low-density lipoprotein cholesterol level is 93 mg/dL. An ECG shows a normal sinus rhythm and no abnormalities. The patient’s wife provides a copy of his latest laboratory results: the CD41 cell count is 654/µL, and the HIV RNA level is less than 50 copies/mL.

Which of the following contributes to an increased risk of surgical morbidity and mortality in this patient?

A. His CD41 cell count and viral load.
B. History of an opportunistic infection/AIDS diagnosis.
C. Presence of antiretroviral therapy.
D. His age.

(Answer on Next Page)

Correct Answer: D, his age.

Since the advent of HAART, more patients with HIV infection are living longer. As these patients age, many may need surgical intervention. Much of the data about the surgical outcomes of patients living with HIV are retrospective; many studies lack control subjects and are heterogeneous in patient characteristics, grouping together various types of surgery, regardless of the urgency.

In the HAART era, many investigators report similar postoperative mortality for patients, regardless of the diagnosis of HIV infection.1 In a review of surgical outcomes, Madiba and colleagues2 concluded that “HIV infection should not be considered a significant independent factor for major surgical procedures.” Yet, some surgeons are reluctant to perform surgery in patients with HIV infection because of a belief that these patients have worse surgical outcomes than those who are HIV-negative.3

SURGICAL OUTCOMES IN HIV-INFECTED PATIENTS: WHAT THE DATA SHOW

In a retrospective 12-month study of surgical outcomes in HIV-infected patients matched with uninfected patients, Horberg and associates4 demonstrated that among HIV-infected patients, viral loads equal to or greater than 30,000 copies/mL conferred increased mortality (P 5 .007). In addition, these investigators found that CD41 cell counts of less than 50/µL were associated with higher complication rates (P 5 .006). They also identified higher postoperative pneumonia rates in the HIV-infected group (P 5 .04), but no statistically significant differences were seen for delayed wound healing, surgical site infections, wound dehiscence, or length of hospital stay and follow-up. This patient’s CD41 cell count is well above and his viral load is well below the parameters in this study. Thus, choice A is not correct.

In addition, Horberg and colleagues4 did not find that the use of HAART within 180 days before surgery had a protective effect. Another study of 77 unmatched HIV-infected patients also did not demonstrate any significant impact of HAART use or history of opportunistic infection on surgical morbidity or mortality.5 Thus, choice C is not correct.

In another retrospective study, Wiseman and associates1 reviewed all surgeries performed on patients with HIV infection in British Columbia from 1995 to 2002. These researchers identified the following independent predictors of 30-day postoperative mortality:

•Age older than 65 years (adjusted odds ratio [AOR], 1.83).
•Urgent/emergent hospital admission (AOR, 2.77).
•Prior history of surgery.
•Hemoglobin level of less than 12 g/dL.
•WBC count of higher than 11,000/µL.
•CD41 cell count of less than 50/µL (AOR, 2.69).

A prior AIDS diagnosis was not predictive of increased 30-day mortality in this study. Therefore, choice B is not correct.

Finally, during 1994 to 2005, Morrison and colleagues6 used the National Trauma Data Bank to identify 1379 (prevalence, 0.09%) HIV-infected patients, who had no statistically significant mortality difference, when compared with HIV-negative patients, except for those patients older than 65 years of age (P 5 .0115). These investigators also found statistically significant higher rates of bacteremia (P 5 .0047), pneumonia (P < .0001), and wound infection (P < .0001) in patients with HIV
infection, although no information regarding HAART status or CD41 cell counts was available in the data bank. Of all these parameters, this patient’s only risk factor is his age; thus, choice D is correct.

This patient’s viral infection is well controlled, and he has appropriate immune function. From an immunologic and cardiovascular standpoint, he is at low risk
for a moderate-risk operation and should proceed to surgery without additional testing. He is older than 65 years, which is indeed a risk factor, but this should not obviate the indicated surgery. His antiretroviral therapy should be continued during his operative and postoperative treatment, while vigilance should be maintained
to avoid any potential drug-drug interactions.

OUTCOME OF THIS CASE

The patient underwent an uneventful hip replacement. He was discharged on day 4, and he continues to do well with HAART.n