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УДК 616.9: 616.97 ББК 53/57
SOME CLINICAL CHARACTERISTICS OF HIV-POSITIVE PATIENTS IN CRITICAL CARE
UNIT IN RUSSIA
VERMA K., ZODINMA WIA A., FARSHATOVR.S.
BSMU, Ufa, Russia e-mail: [email protected], farshatov@ hashgmu.ru
Abstract
HIV/AIDS is at present a major disease in public health sector, with an estimated 35.3 million people infected globally. Many HIV-positive individuals present with serious illnesses that may require admission to critical care unit, and a large proportion of these are unaware of their HIV status. The data from these countries also suggest that 7-12% of HIV-positive patients admitted to hospital are treated in the critical care units. The purpose of the study was to evaluate clinical characteristics of the HIV-positive patients in critical care unit. The study is a retrospective folder review conducted from 01 November 2016 to 01 November 2017 in the surgical critical care unit of the City Hospital №21, Ufa city. All HIV-positive patients in critical care unit during this period were included in the analysis. Results. Six patients (33%) had hepatitis C, while three patients (16,6%) had both hepatitis B and C. Nine patients did not represent any blood-borne co-infection associated with HIV. Half of the patients (9 of 18) required mechanical ventilation, and two patients (11%) required inotropic support. Among the patients on respiratory support three patients (11%) required a tracheostomy. There were two complicated cases of liver cirrhosis further complicated by gastrointestinal tract bleeding. The group of patients analyzed presented with a mean APACHE II score of 21.6 and the average stay in CCU amongst them was 6 days. Three patients (16,6%) died in CCU while fifteen patients (83,3%) were discharged from the CCU and shifted to other general wards. This study shows that critical care outcomes for HIV-positive patients at the surgical critical care unit are comparable to those in the developed world. The study highlights the fact that outcomes of this patient population are dependent on the severity of acute illness, irrespective of receipt of ART and immune status. Further research is required to help and determine the perspective treatment modalities for HIVpositive patients.
Keywords: HIV, critical care unit, intensive care unit, human immunodeficiency virus.
Introduction. HIV/AIDS is at present a major Historically, respiratory failure accounted for the
disease in public health sector, with an estimated majority of CCU admissions in the HIV-positive
35,3 million people infected globally [2, 3]. Many patient population, with an associated mortality of
HIV-positive individuals present with serious 70%. However, contemporary evidence suggests
illnesses that may require admission to critical care that CCU outcomes are similar to those of HIV-
unit (CCU), and a large proportion of these are negative patients and that the indications for CCU
unaware of their HIV status [1, 5]. Today with the are mostly not related to opportunistic infections
help of highly active antiretroviral therapy (HAAT) (OIs) [1, 5, 6].
and other interventions HIV-positive patients in Objective. To evaluate clinical characteristics of
many countries are reported to have a life the HIV-positive patients in critical care unit (CCU). expectancy approaching that of the general Materials and methods. The study is a
population [6]. The data from these countries also retrospective folder review conducted from 01
suggest that 7-12% of HIV-positive patients November 2016 to 01 November 2017 in the
admitted to hospital are treated in the CCU [1, 5, 6]. surgical CCU of the city hospital №21, Ufa city. All
Despite evidence of the role of HAART in HIV-positive patients in CCU during this period
decreasing morbidity and mortality in HIV-positive were included in the analysis. patients, in resource-poor settings many people Data collection. A standardized form was used to
living with HIV do not have access to HAART or collect demographic information, including age and
receive treatment late. sex of the patient. Details of the length of stay in
CCU, utilization of mechanical ventilation and
inotropic support were also recorded. For the assessment of severity of illness the Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated using laboratory values obtained within 24 hours of CCU admission. The presence of blood-borne co-infections associated with HIV like Hepatitis C, B and other complications like liver cirrhosis and gastrointestinal (GIT) bleeding were also documented. The outcome of the stay in CCU was noted when the patient died or was discharged from the CCU.
Data analysis was performed using SPSS version 20 (IBM, USA). Normality of data was tested using the Kolmogorov-Smirnov test. Normally distributed data are presented as means (standard deviation (SD)) or, where highly skewed, as medians (interquartile range (IQR)); discrete data are presented as numbers (percentages).
The data obtained were then compared with the standard data of all the HIV-negative patients in CCU.
Table 1
Clinical characteristics of HIV-positive patients in critical care unit
No. of patients included 18
Age (mean age) 39
Gender: Male (%) Female (%) 78 22
Medical • Respiratory • Cardiovascular • Toxicology surgical • General surgery • Neurosurgery • Trauma 2 0 2 7 2 5
Results and discussion: From 01 November 2016 to 01 November 2017, 760 patients were admitted to the CCU. Of these, 18 were HIV-positive and were included in the analysis. Clinical characteristics of HIV positive patients were evaluated.
Patient clinical characteristics
A total of 18 patients were included in the analysis with the mean age of 39 years (Table 1) and the majority of them were male (78%).
We categorized HIV-positive patients admitted to CCU to 3 following groups (Table 2):
1. AIDS-related opportunistic infections (such as Pneumocystis pneumonia, Toxoplasmosis, Cryptococcal Meningitis, tuberculosis);
2. Complications unique to long-term survival with HIV or antiretroviral therapy (ART)-related (Atherogeni c/metabolic complications);
3. HIV-infected with medical/surgical conditions unrelated to HIV (such as trauma, elective surgery, pancreatitis).
Table 2
Classification of HIV-positive patients admitted to
CCU
HIV-positive patients in CCU
n %
AIDS-related opportunistic infections 2 11
Complications unique to long-term survival with HIV or ART-related 2 11
HIV-infected with medical/surgical conditions unrelated to HIV 14 78
Most of the patients included in the current study appertained to HIV-infected with medical or surgical conditions unrelated to HIV - 14 (78%). These conditions are the following: acute appendicitis, acute pancreatitis, acute ethanol intoxication, multiple trauma related to road traffic accident. Some of the patients of this group were admitted to the ICU because of complications caused by blood-borne infections associated with HIV (liver cirrhosis with variceal gastrointestinal tract bleeding - 2 patients). On the other hand two patients were admitted because of AIDS-related opportunistic infections (bilateral septic pneumonia).
Table 3
Blood-borne infections associated to HIV
No. of patients n (%)
Only Hepatitis C 6 (33,3%)
Only Hepatitis B 0
Hepatitis C and B 3 (16,6%)
Without Hepatitis B or C 9 (50%)
Six patients (33%) had hepatitis C, while three patients (16.6%) had both hepatitis B and C. Nine patients did not represent any blood-borne co-infection associated with HIV (Table 3). The similar routes of transmission for HIV and hepatitis B (HBV) and C (HCV) viral infections place patients with either infection at greater risk for HBV and HCV co-infection. [4, 7].
Half of the patients (9 of 18) required mechanical ventilation, and two patients (11%) required inotropic support. Among the patients on respiratory support three patients (11%) required tracheostomy. There were two complicated cases of liver cirrhosis out of which one was further complicated by gastrointestinal tract (GIT) bleeding. The group of patients analyzed presented with a mean APACHE II score of 21.6 and the average stay in CCU amongst them was 6 days. Three patients (16,6%)
died in CCU while fifteen patients (83,3%) were discharged from the CCU and shifted to other general wards.
Table 4
Patient clinical characteristics
Characteristic HIV positive, HIV
No. of patients negative,
n (%) (%)*
Mechanical ventilation 9 (50%) 24-35
Tracheostomy 3 (1в,в%) 12-15
Inotropic support 2 (11%) 29-31
Hemotransfusion 4 (22,2%) 4в-48
Renal replacement therapy - 11-13
Length of stay in CCU в days 5-в days
(average)
CCU mortality rate 3 (1в,в%) 15-17
the standard data of all the HIV-negative patients in CCU.
On evaluating and comparing the data obtained with the standard data of all the HIV-negative patients in CCU (Table 4), it may be concluded that there are similarities in the clinical characteristics of the HIV-positive patients and HIV-negative patients in the CCU.
Study limitations: The study has several significant limitations: 1) it is a single center study; 2) it suffers from the limitations and biases of its retrospective nature; 3) we were not able to find and document the microbiological cause of the cases of co-infections, which could offer an opportunity of prophylaxis.
Conclusions. This study shows that critical care outcomes for HIV-positive patients at the surgical CCU of the City Hospital №21, Ufa city are comparable to those in the developed world. The study highlights the fact that CCU outcomes of this patient population is dependent on the severity of acute illness, irrespective of receipt of ART and immune status. Further research is required to help and determine the perspective treatment modalities for HIV-positive patients.
Literature
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6. Predictors of short- and long-term survival in HIV infected patients admitted to the ICU / E. Casalino, G. Mendoza-Sassi, M. Wolff [et al.] // Chest. - 1998. - Vol. 113 (2). - P. 421-429. https://dx. doi.org/10.13 78/chest.113.2.421
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* - based on annual report of surgical CCU.
The clinical characteristics of the group of analyzed patients such as tracheostomy, length of stay in CCU and CCU mortality rate closely resemble to that of HIV-negative patients in CCU whereas, clinical characteristics like mechanical ventilation, inotropic support, hemotransfusion and renal replacement therapy showed deviations from
НЕКОТОРЫЕ КЛИНИЧЕСКИЕ ХАРАКТЕРИСТИКИ ВИЧ-ПОЛОЖИТЕЛЬНЫХ ПАЦИЕНТОВ В ОТДЕЛЕНИЯХ ИНТЕНСИВНОЙ ТЕРАПИИ В РОССИИ
ВЕРМА К., ЗОДИНМАВИЯА., ФАРШАТОВ Р.С. БГМУ, Уфа, Россия e-mail: karanverma1093@gmail. com, farshatov@,bashgmu. ru
Аннотация
ВИЧ/СПИД в настоящий время одно из самых серьезных заболеваний в секторе общественного здравоохранения, количество инфицированных людей в мире составляет примерно 35,3 миллионов человек. Многие ВИЧ-положительные пациенты поступают с серьезными заболеваниями, и их необходимо госпитализировать в отделения интенсивной терапии, и многие из них не знают о своем ВИЧ статусе. Данные из разных стран также показывают, что около 7-12% ВИЧ-положительных
пациентов, госпитализируются в больницу в отделения интенсивной терапии. Целью нашего исследования было оценить клинические характеристики ВИЧ-положительных пациентов, поступающих в отделения интенсивной терапии. Исследование заключается в ретроспективном анализе историй болезни за период с 1 ноября 2016 года по 1 ноября 2017 года в отделении экстренной хирургии городской больницы 21 в г. Уфа. Все ВИЧ-положительные пациенты, поступившие в этот период в отделение интенсивной терапии, были включены в наше исследование.
Результаты. 6 пациентов (33%) были инфицированы гепатитом С, в то время как 3 пациента (16,6%) имели два типа гепатита - гепатиты В и С. Девять пациентов не имели какой-либо коинфекции передаваемой через кровь и ассоциированной с ВИЧ-инфекцией. Половина пациентов (9 из 18) нуждались в механической вентиляции лёгких и двое пациентов (11%) находились на инотропной поддержке. Среди пациентов, находящихся на респираторной поддержке троим (11%) была наложена трахеостома. Также были два сложных пациента с циррозом печени, осложненным желудочно-кишечным кровотечением. В группе проанализированных пациентов средний показатель по шкале APACHE II составил 21,6, а среднее их пребывание в отделении интенсивной терапии составило 6 дней. Трое пациентов (16,6%) скончались в отделении, а другие 15 (83,3%) были переведены из отделения интенсивной терапии в другие общие палаты. Исследование показывает, что неотложная помощь оказываемая ВИЧ-положительным пациентам в отделении экстренной хирургии сопоставима с помощью, оказываемой в развитых странах мира. В исследовании подчеркивается тот факт, что результаты в этой группе пациентов зависят от тяжести заболевания и остроты протекающего процесса, независимо от приема антиретровирусной терапии и иммунного статуса. Необходимы дальнейшие исследования, чтобы помочь в определении дальнейших перспективных методов лечения ВИЧ-положительных пациентов.
Ключевые слова: ВИЧ, отделение неотложной помощи, отделение интенсивной терапии, вирус иммунодефицита человека.
