Current issues in critical care of the human immunodeficiency virus-infected patient*

Abstract

HIV-infected patients are less likely to be admitted to the intensive care unit with opportunistic infections but more likely to be admitted with problems unrelated to HIV infection or with conditions related to antiretroviral therapy. With current management strategies, more patients survive intensive care unit admission. Intensivists need to be familiar with antiretroviral therapy to recognize life-threatening toxicities unique to these drugs; to avoid drug interactions, which are extremely common and potentially life-threatening; and to avoid enhancing HIV drug resistance, an occurrence that could have devastating consequences for the patient following intensive care unit discharge.

Antiretroviral therapyand anaesthesia

“…24 A decision needs to be taken whether the ARVs should be stopped, continued or whether to switch to another regimen. 27 The exact risk of stopping HAART in the ICU patient is largely unknown, but carries the risk of viral load rebound and drug resistance. The SMART study, testing intermittent ARV treatment guided by CD4 count, clearly demonstrated increased rates of opportunistic disease and death.…”

“…39 The intensivist needs to be familiar with ARV therapy and its possible toxicity. 27 Life-threatening toxicities are discussed above, and include lactic acidosis, hypersensitivity syndromes, druginduced hepatitis, IRIS and cardiovascular events. 27 The associated drug interactions (see Table II) and metabolic complications, as stated previously, cause major management difficulties in the ICU.…”

“…Protocols in gastric acid suppression routinely followed in the ICU may also be problematic in many ARV regimens since H 2 antagonists and proton pump inhibitors are contraindicated if PIs are administered. 27 Renal and hepatic impairment play a role in the HAART dose administration. 24 NRTIs must be adjusted during renal impairment.…”

“…41 These patients are now less likely to be admitted with problems related to opportunistic infections but more likely to be admitted with conditions unrelated to the HIV infection or with conditions specifically related to the HAART regimen. 27 Drug delivery, doses, interactions and HAART toxic side effects are a major concern. 24 A decision needs to be taken whether the ARVs should be stopped, continued or whether to switch to another regimen.…”

“…No prospective studies so far have been published on the effects of ARVs in the ICU, but one retrospective study has focused on ARV benefits in the patient admitted to the ICU with severe pneumocystis carinii pneumonia (PCP). 27 Morris et al performed a retrospective study on 58 patients admitted to the ICU with PCP. Patients who were continued on ARVs or where HAART was initiated had a mortality rate of 25% compared to a 63% mortality rate in patients who did not receive ARVs.…”