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Surgery Savvy For PWAs

September 1998

The "buffalo hump" on the back of your neck is now too large to ignore. It's time to get something done.

And you sure aren't about to discontinue the ritonavir cocktail that raised your T-cells, suppressed your viral load, and brought you, well, back to life! So you talk with your doctor, and decide that a plastic surgeon may be able to help this unsightly fat mass ("lipodystrophy" is just a fancy word for lumps and bumps developing where you don't want them).

But what will you have to look forward to? You've been told to not eat or drink for eight hours before the surgery. What about your meds? You may have heard that the anesthesia may make you nauseated, or even cause some vomiting after surgery. What about your meds? Will the stress of the surgery cause your viral load to climb? Does surgery and all the anesthesia drugs make HIV disease worse? Do any of the drugs used during surgery interact with your antiretroviral drugs?

Here are answers to a few of the common questions that may arise for you if you must undergo a surgical procedure.

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  • Why must people who are having surgery have nothing to eat or drink for several hours before the procedure?

    General anesthesia makes you unconscious. An unconscious person cannot swallow or cough up secretions in his or her throat, and such stuff may wind up in the lungs, causing serious pneumonia, which is avoided by having an empty stomach.

    However, important medications (those which can be taken on an empty stomach without causing problems) can be taken with water the morning of surgery without increasing this risk. Consult with your doctor or anesthetist about taking morning doses the day of surgery. This will not apply to medications that must be taken with food, and if taking a medication on an empty stomach makes you nauseated, skip the dose!


  • What about postoperative nausea and vomiting?

    Occasionally, anesthetic agents or narcotic pain-relieving drugs can cause stomach upsets. This usually resolves within 24 hours, and you can be assured that missing your regular medication doses for 24 hours will not cause an increase in viral load or disease progression. One principle to remember is: If you discontinue one med, you should discontinue them all until you can resume your regular medication schedule in order to prevent the possible development of resistant viral strains.

    Your care-providers can give you anti-nausea drugs, which you should request if you have had postoperative nausea in the past.

    If you need to stay on oral pain medications for a few days here are some tips: To help prevent stomach upsets common with acetominophen (Tylenol with codeine), oxycodone (Vicodin), hydrocodone (Percocet), and some other drugs, move very slowly, stick to "gentle" foods like crackers and soups and drink lots of water, apple juice and sodas.


  • Does the stress of anesthesia and surgery cause viral load to climb and disease to progress?

    Review of literature on this topic, and consultation with physicians in the specialty of HIV care has shown that there are no deleterious effects of surgical intervention. If you have some problem that is amenable to surgical intervention, you should seek consultation with the appropriate surgeon and get the surgical repair done. Common examples in the HIV-infected population include chronic sinus infections, genital warts, anal fissures or lesions, cervical lesions and, increasingly, plastic surgery for protease inhibitor lipodystrophy.


  • Do anesthetic drugs interact with HIV medications?

    Versed (midazolam) is the most commonly used sedative drug in anesthesia and Demerol (meperidine) is a commonly used pain medication. The prescribing literature for all of the currently approved protease inhibitors -- saquinavir (Fortovase/Invirase), ritonavir (Norvir), indinavir (Crixivan) and nelfinavir (Viracept) -- prohibits the concurrent administration of Versed and, with Norvir, Demerol as well. The theoretical concern is that the action of these drugs may be enhanced and prolonged because they are metabolized by the same enzymes in the liver as the protease inhibitors.

    However, it has been the experience of many anesthesia providers that intravenous Versed as commonly used for sedative purposes causes no problems in patients on protease inhibitors. As for the rest of the anesthetic and sedative drugs commonly used, there are no documented theoretical or observed interactions with the antiretroviral drugs.


    Educate your medical team

    When you are going to have surgery, remember that the doctors and nurses who will be caring for you will most likely not have an in-depth knowledge of HIV disease or the drugs you are taking. Be prepared to patiently and thoroughly go over the entire regimen of HIV care. If questions arise, refer the surgeon to your HIV doctor.

    If you have complicated conditions or are on multiple drugs, write all the information down on a list that you should keep with you at all times. Take it into the preoperative area with you to help get all the important information to your surgical team. Include your latest laboratory results (especially if you have been anemic or have other abnormalities) as well, in case your team needs to see them.

    If the surgical team gives you instructions or information that you are not comfortable with, call or see your HIV doctor about this. For example, explain how important it is to never miss a dose of antiretroviral medication. Explain food and dietary requirements of the drugs you are taking.

    Think ahead to the recovery room. Bring your medications with you and have your next dose of medication available (if you are able to take it) to avoid missing any doses if possible. You can ask your anesthetist for a dose of antinausea medication to help assure you can take your medications when you awaken from anesthesia.

    With careful, complete and patient communication with the surgical and anesthesia teams, you can deal with the surgical experience successfully while continuing to care for your HIV disease as well.


    This article has been reprinted at The Body with the permission of AIDS Project Los Angeles (APLA).


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    This article was provided by AIDS Project Los Angeles. It is a part of the publication Positive Living.
     
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