MANAGEMENT OF HIV INFECTED PATIENT IN ICU

Abstract

SUMMARY T he acquired immune deficiency syndrome (AIDS) epidemic grew until it became a major global health problem with, social, and economic consequences that were not seen with any other disease. In the last 35 years since this disease was known, it killed more than 25 million people and continued to affect 36.9 million people worldwide many of whom could die if life saving therapies are not available to them. Highly active antiretroviral therapy (HAART) increases life expectancy of HIV-infected patients in the ICU by about 3-4 folds, and improves the clinical features for these patients by improving immune function and increasing helper T lymphocyte counts. Also overall mortality of critically ill HIV-infected patients has decreased in the HAART era and patients are more commonly admitted to ICU with non-HIV-related illnesses. In the HAART era, patients with HIV infection admitted to the ICU fall into three general categories; category 1 includes patients with AIDS-related opportunistic infections (such as PCP, toxoplasma encephalitis or cryptococcal meningitis). Category 2 includes patients with complications of HAART, or related to long-term survival of HIV patients. Category 3 include those admitted to the ICU for medical and surgical conditions that have no link to HIV such as trauma. Respiratory failure is the most common indication for ICU admissions in AIDS patients. PCP, bacterial pneumonia and pulmonary TB, continue to be significant causes of respiratory failure. Sepsis also accounts for 15%–30% of all ICU admissions of HIV infected individuals. Other causes for ICU admissions include CNS opportunistic infections, cardiac diseases that have higher incidences due to endothelial dysfunction, and dyslipidaemia occurring with HIV infection, and hepatic failure especially if HIV is co-infected with hepatitis C or hepatitis B viruses. Use of HAART in ICU is problematic, and may cause life-threatening complication as lactic acidosis, and Immune reconstitution inflammatory syndrome (IRIS), drug interactions with drugs commonly used in ICU. Finally we must to recognize that HAART use in ICU is life saving, and any interruption for any reason in ICU enhances HIV resistance to ART, so starting, continuing, or stopping HAART in ICU is very important issue decided by the whole medical team.