The "buffalo hump" on the back of your neck is now too large to ignore anymore; it's time to get something done. And you sure aren't about to discontinue the HAART cocktail that has brought your T-cells up, your viral load down, and you-well-back to life again! So you talk it over with your doctor, and decide that a plastic surgeon may be able to help this unsightly fat mass ("lipodystrophy" is a fancy word for lumps and fat pads developing where you don't want them).

But what will you have to look forward to? You've been told "nothing to eat or drink 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? Do surgery and all the anesthesia drugs cause HIV disease to get worse? Do any of the drugs used during surgery interact with your antiretroviral drugs? These and many other questions may arise for you if you must undergo a surgical procedure.

Why is it that people who are having surgery must have nothing to eat or drink for several hours before? Because general anesthesia makes you unconscious. An unconscious person cannot swallow or cough up secretions in their 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, so consult with your doctor and/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, discuss with your doctor the advisability of skipping the dose!

What about the issue of postoperative nausea and vomiting? Occasionally the anesthetic agents or narcotic pain relieving drugs can cause stomach upsets. This usually resolves within 24 hours, and you can be reasonably 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. In other words, if your cocktail of antiretrovirals includes meds you take with food as well as meds you take on an empty stomach, you should probably skip all your meds for that dose on the morning of surgery. Be sure to confer with your doctor before discontinuing your meds.

Your care providers can give you anti-nausea drugs, which you should request if you have had postoperative nausea in the past. Also, if you need to stay on oral pain medications for a few days, here are some tips to help prevent stomach upsets common with these drugs (examples: Tylenol (also known as acetominophen) with codeine, oxycodone (Vicodin), hydrocodone (Percocet)): move very slowly; no sudden leaps out of bed; stick to "gentle" foods like crackers and soups; and drink lots of clear liquids like water, apple juice, and sodas. Ice chips can also help, and some of these meds can be very constipating.

Does the stress of anesthesia and surgery cause the viral load to climb and disease to progress? Review of the literature on this topic, and consultation with physicians in the specialty of HIV care, have shown that there are no deleterious effects of surgical intervention on HIV disease progression. There may be a temporary or transient increase, also called a blip, in viral load. And what if you do have a slight increase in viral load following surgery? It's been shown that, in people who have virologic suppression (that is, the viral load is less than 50 copies), blips are a frequent occurrence and are not associated with a sustained increase in viral load. Bottom line is that, if you have some problem that is amenable to surgery (some common examples in the HIV-infected population include: chronic sinus infections; genital warts; anal fissures or lesions; cervical lesions; increasingly, plastic surgery for lipodystrophy; and soon, even liver and kidney transplant surgery), then you should seek consultation with the appropriate surgeon and get the surgical repair done.

Do anesthetic drugs interact with HIV medications? The prescribing literature for all of the currently approved protease inhibitors -- saquinavir (Fortovase, or Invirase), ritonavir (Norvir), indinavir (Crixivan) and nelfinavir (Viracept) -- prohibits the concurrent administration of midazolam (Versed) and, with Norvir, meperidine (Demerol) as well). Versed is the most commonly used sedative drug in anesthesia and Demerol is a commonly used pain medication. 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 PIs. 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 PIs. As for the rest of the anesthetic and sedative drugs commonly used, there are no documented theoretical or observed interactions with the antiretroviral drugs.

However, remember that when you are going to have surgery, the doctors and nurses who will be caring for your surgical and anesthesia needs will most likely not have an in-depth knowledge of HIV disease or the drugs you are taking. Therefore, be prepared to patiently and thoroughly go over the entire regimen of HIV care, and refer the surgeon to your HIV doctor if questions arise that the doctor needs to address. 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. On this list, it would be helpful to note all known drug interactions (your HIV care practitioner can give you this information). 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.

Likewise, 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 in 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 team, you can deal with the surgical experience successfully while continuing to care for your HIV disease as well.

Chuck Griffis, CRNA, MS, is a nurse anesthetist at the UCLA Medical Center, and was a volunteer on the APLA AIDS Hotline from 1991—1997. He has written many articles and given many talks on HIV-related issues in anesthesia and operating room care. Suzette A. Chafey, RN, NP, MPH, is a clinical research nurse practitioner at the UCLA Center for Clinical AIDS Research and Education (CARE Center).

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