English Version
Antiretroviral therapy has increased the life expectancy of patients who are infected with the human immunodeficiency virus (HIV) and has reduced the incidence of illnesses associated with the acquired immunodeficiency syndrome (AIDS). However, the frequency of pulmonary, cardiac, gastrointestinal, and renal diseases that are often not directly related to underlying HIV disease has increased. Although the guiding principles of management in the intensive care unit (ICU) pertain to critically ill patients with HIV infection, antiretroviral therapy and unresolved questions regarding its use in the ICU add an additional level of complexity to already complicated cases. This review focuses on some of the important clinical problems related to the use of antiretroviral therapy in critically ill patients with HIV infection and on the challenging issues associated with the intensive care of such patients, including legal statutes concerning HIV testing and disclosure, the administration of antiretroviral medications, important potential drug interactions with medications commonly used in the ICU, and controversies surrounding the use of antiretroviral therapy in the ICU.
Complications Associated with HIV Infection
Pulmonary Disease
Since the beginning of the AIDS epidemic, respiratory failure has been the most common indication for ICU admission among patients with HIV infection. However, the proportion of ICU admissions caused by respiratory failure has declined (Fig. 1). Pneumocystis pneumonia, bacterial pneumonia (including that due to methicillin resistant Staphylococcus aureus [MRSA]), and tuberculosis remain important infectious causes of respiratory failure, but non-HIV causes, such as asthma and emphysema, are increasingly common, since patients with HIV infection are living longer. Respiratory failure can also result from immune econstitution syndromes to pneumocystis pneumonia, tuberculosis, or other mycobacterial disease after the initiation of antiretroviral therapy. The immune reconstitution syndrome for these pathogens is manifested as paradoxical worsening of the underlying respirator y disease. The syndrome occurs days to weeks af ter the init iat ion of antiretroviral therapy and is caused by an exuberant inflammatory response to pneumocystis or mycobacterial antigens. The diagnosis of the immune reconstitution syndrome requires the exclusion of other causes of respiratory decompensation. Treatment includes corticosteroids; even patients with severe cases of the syndrome are able to continue antiretroviral therapy.
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Pulmonary Disease
Since the beginning of the AIDS epidemic, respiratory failure has been the most common indication for ICU admission among patients with HIV infection. However, the proportion of ICU admissions caused by respiratory failure has declined (Fig. 1). Pneumocystis pneumonia, bacterial pneumonia (including that due to methicillin resistant Staphylococcus aureus [MRSA]), and tuberculosis remain important infectious causes of respiratory failure, but non-HIV causes, such as asthma and emphysema, are increasingly common, since patients with HIV infection are living longer. Respiratory failure can also result from immune econstitution syndromes to pneumocystis pneumonia, tuberculosis, or other mycobacterial disease after the initiation of antiretroviral therapy. The immune reconstitution syndrome for these pathogens is manifested as paradoxical worsening of the underlying respirator y disease. The syndrome occurs days to weeks af ter the init iat ion of antiretroviral therapy and is caused by an exuberant inflammatory response to pneumocystis or mycobacterial antigens. The diagnosis of the immune reconstitution syndrome requires the exclusion of other causes of respiratory decompensation. Treatment includes corticosteroids; even patients with severe cases of the syndrome are able to continue antiretroviral therapy.
Journals for full download on the link below
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BalasHapusFROM U.S.A