Is this patient in respiratory distress? Is this acute or chronic? Why? What difference does it make? How will you evaluate the patient’s oxygenation and work of breathing?

Would those assessments be of any importance to your anesthetic plan? Interpret the CXR findings.

Of what importance is the anemia? What additional information would you like to evaluate the anemia? Does this patient need a platelet transfusion? Are any other laboratory tests indicated? Which ones specifically?

How should his cardiac function be evaluated? What additional information on the echo report will be of importance in planning the anesthetic? What might an ECG show?

This child exhibits signs of respiratory distress such as tachypnea and retractions. Infection with HIV in this case was almost certainly through vertical transmission from mother to child, meaning that he has had HIV/AIDS for 6 months. Retractions are evidence of increased resistance to inspiratory flow, and the tachypnea, in the presence of a smaller tidal volume, indicates decreased pulmonary compliance. Measurement of room air S_pO₂ will give an indication of oxygenation, but if the child is receiving supplemental oxygen, the oxygen saturation measurement can be normal in the face of significantly impaired pulmonary function. This child certainly has pulmonary disease. In addition to an infectious pneumonia, he also may have lipoid interstitial pneumonia (LIP), which can present with bilateral CXR infiltrates, wheezing, tachypnea, and cough [1–3]. The incidence of LIP in HIV-infected children is 20–30 %. The most common opportunistic infection seen in children with AIDS is pneumocystis carinii [4].

Children infected with HIV often have lowered counts of all the formed elements of the blood. As is the case with other chronic diseases, the anemia seen in these children is hypochromic and microcytic with low reticulocyte counts. The causes for the anemia are the disease itself, poor nutrition due to poor appetite, and side effects of the medications used to treat AIDS. Based on the weight of 3.5 kg, it is likely that the infant is failing to thrive. A comparison with the birth weight will give information about the rate of postnatal growth. Thrombocytopenia is also seen commonly in these children. Both impaired production and increased destruction have been seen in HIV/AIDS patients. In addition, a lupus-like anticoagulant has been noted in up to 20 % of HIV children undergoing coagulation testing. Blood products must be available for this child undergoing this procedure. Transfusion should be undertaken after discussion with the child’s primary physician. Only CMV-negative, leukocyte-depleted RBCs should be given to AIDS patients. The need for additional platelets for this case depends upon the exact nature of the procedure. It may be prudent to have platelets available and to use them if the open lung biopsy is performed but withhold them if the bronchoscopy alone is done. Renal dysfunction is common in children with HIV/AIDS. A screening urine analysis will detect proteinuria and hematuria. Given the child’s poor nutritional status and failure to thrive, it is worthwhile to check the serum electrolytes, total protein, and albumin prior to inducing anesthesia. Abnormal sodium or potassium values would be a reason to delay proceeding, and knowledge of low serum protein would affect dosing of medication during the anesthetic.

Approximately 10–12 % of children infected with HIV have significant cardiac involvement [5]. The infant’s resting tachycardia may be due to poor cardiac function from HIV infection. The parent or caregiver should be asked about prior treatment for congestive heart failure (CHF), and signs and symptoms of CHF should be sought when the history is taken. A cardiac ECHO will demonstrate LV hypertrophy and/or systolic dysfunction if present, but diastolic dysfunction may not be apparent on a routine ECHO. An ECG will show sinus tachycardia often seen in these children.

What monitors will you choose? Is an arterial line indicated for this case? What are the risks of central line placement in this patient? Which lead would you choose to monitor on the ECG? Would a transesophageal echocardiogram (TEE) be of any help? Why/why not?

The bronchoscopist requests “a little sedation only.” Do you agree? Why? Why not?

Your colleague stops by and suggests total intravenous anesthesia technique because the “lungs are so sick, and the heart is too.” What do you think? You select an intravenous technique with small incremental doses of propofol; upon withdrawing the needle from the latex hub, you stick yourself and draw blood. What do you do next? Should you continue with the case? Ask someone to take over? Wash your hands in bleach, alcohol, or betadine? Should you request to be started on AZT?

What will be your primary technique be? Why? Will you use nitrous oxide? Why/why not? What is your choice of muscle relaxant? Why?

Assume intubation. During surgery, the patient develops increasing difficulty, and the SpO₂ decreases from 93 % to 87 %. The breath sounds become even more coarse throughout the lungs. What would you do? Why? Blood pressure is 60/40 mmHg with a heart rate of 160/min. How would you manage the vital signs and maintain anesthesia?

Routine ASA monitors are sufficient for the bronchoscopy, washings, and brushings. During these cases, drapes are ordinarily not used, the child is available to the anesthesiologist, and the procedure can stop at any time. If the open lung biopsy is done, an arterial line is important in allowing assessment of blood gases. In this infant with pulmonary compromise, development of a pneumothorax during CVL placement would be very dangerous. If a CVL were planned, placement should certainly be done by the most experienced person, using ultrasound guidance. Lead II of the ECG should be monitored since that lead gives a good indication of the rhythm. TEE would not be particularly helpful in this case. If there is significant cardiac dysfunction and the open lung biopsy is undertaken, placement of a CVP and measurement of filling pressures will give adequate information about cardiac performance.

Sedation is not a good option for this child for several reasons. The infant has respiratory insufficiency; the bronchoscopist will obstruct part of the airway with the scope and will then instill saline into the child’s lungs after which he/she will suction out part of that saline, along with much of the FRC. With administration of general anesthesia through an LMA, a high concentration of oxygen and controlled ventilation can be delivered, if needed. Occupational exposure to the HIV virus is an important consideration in this case. Studies of hundreds of household contacts have confirmed that the risk of transmission from passive contact with an HIV-infected child is practically zero. Seroconversion is not a common occurrence following needle stick exposure. Hollow-bore needles used in drug administration give a much larger inoculum of blood than the solid needles used for suturing. The current risk for seroconversion for health-care personnel after accidental percutaneous exposure to blood is 0.3 %. After a parenteral exposure to a patient with HIV, the health-care worker should undergo postexposure prophylaxis, postexposure treatment, and follow-up [6]. While determining which agents and how many to use or when to alter a postexposure prophylaxis (PEP) regimen is largely empiric (two- or three-drug regimen), the timing is not [7]. Drugs currently used include nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PI). The wound should be immediately and thoroughly washed with saline and the institutional “stick” team called. As prophylaxis is begun, the exposed person should be tested to document the HIV status. This testing should be repeated at 6 and 12 weeks after the exposure.