Intraoperative Hemodynamic Instability Research Articles

Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia

TIPS is a percutaneous procedure which diverts blood from the portal to the systemic circulation preventing rebleeding from varices and stopping or reducing the formation of ascites. The choice of the anaesthetic technique is still a matter of debate. Since January 2003, 150 consecutive TIPS were performed using total intravenous anesthesia (TIVA), (propofol/fentanyl or remifentanil), endotracheal intubation and mechanical ventilation. Sixty-one patients were classified as ASA 2, 73 ASA 3, and 16 ASA 4. According to CHILD classification, 96 patients were in Class A, 48 in Class B, 6 in Class C. Mean duration f the procedure was 100+/-62 min. After TIPS placement Portal vein pressure decreased from 30+/-10 to 14+/-4 mmHg while RAP increased from 8+/-4 to 12+/-6 mmHg. Intraoperative fluid management included mainly crystalloids (750+/-200 ml, 5.4+/-1.5 ml/kg/h). Fresh frozen plasma (median 2 units, range 1-3) was given in 20 patients (13%) if PT INR was >2. Packed red cells (median 2 units, range 1-5) were transfused in 35 patients (23%) to keep haematocrit >25%; platelets were administered before the procedure if platelet count was <50,000x10(-9) (20 patients, 13%). Urine output was kept above 4 ml/kg/h with loops diuretics (mean diuresis 700+/-200 ml, 5+/-1.5 ml/kg/h). Ten patients (6.6%) required ICU after the procedure, because of intraoperative hemodynamic instability. Three patients (2%) died in the early postoperative period because of multiple organ failure associated with the acute deterioration of an already marginal hepatic function.

Acute Kidney Injury After Liver, Heart, and Lung Transplants: Dialysis Modality, Predictors of Renal Function Recovery, and Impact on Survival

Recipients of nonrenal organ transplants including the liver, heart, and lung are at risk for developing acute kidney injury (AKI) and chronic kidney disease (CKD). Underlying hepatic or cardiopulmonary failure, prolonged intraoperative hemodynamic instability, and the use of calcineurin inhibitors and nephrotoxic medications have all been suggested to be contributory. The incidence of perioperative AKI has been reported to occur in 17% to 95% in liver transplant recipients, 5% to 30% in heart transplant recipients, and 5% to 60% in recipients of lung transplants. Among those who develop AKI, renal replacement therapy is required in 5% to 35%, 5% to 15%, and 8% to 10% in liver, heart, and lung transplant recipients, respectively. The current article presents an overview of the literature on the choice of dialysis modality and its associated advantages and disadvantages in the management of AKI after liver, heart, and lung transplants. Predictive factors for renal function recovery and the impact of AKI and CKD on survival will also be discussed.

American Association Of Clinical Endocrinologists And American Association Of Endocrine Surgeons Medical Guidelines For The Management Of Adrenal Incidentalomas

American Association Of Clinical Endocrinologists And American Association Of Endocrine Surgeons Medical Guidelines For The Management Of Adrenal Incidentalomas

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: Executive Summary of Recommendations

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: Executive Summary of Recommendations

Epidural Anesthesia and Analgesia in Liver Resection and Living Donor Hepatectomy

Parenteral analgesics are still diffusely administered for postoperative pain after major liver resection, while epidural analgesia is widely criticized because of possible changes in the postoperative coagulation profile. The safety of regional anesthesia in liver resections is based on appropriate timing of needle placement and catheter removal and on the individual's skill in performing both the puncture and the catheterization. In the absence of liver failure or in cases of only moderate hepatic dysfunction, the risk of neurologic complications and spinal hematomas does not appear greater than when an epidural is performed for routine abdominal or thoracic surgery. Various anesthetic strategies have been adopted to prevent bleeding during liver resection, such as fluid restriction, diuretic administration, and vasodilator drugs. Lowering central venous pressure (CVP) seems to play a prominent role in prevention of bleeding since an elevated CVP may be associated with increased blood loss at various phases of liver resection. However, a low CVP may not be tolerated by all patients: intraoperative hemodynamic instability may, in fact, easily ensue because of the cardiovascular depressant effects of anesthetics, surgical blood losses, and manipulation of the inferior vena cava. We suggest combining intraoperative epidural anesthesia with general (light) anesthesia as a useful strategy to keep the CVP low during liver resection without vasodilators or diuretics. Epidural anesthesia does not lead to changes in intravascular volume, but only promotes redistribution of blood, decreasing both venous return and portal vein pressure, thus contributing to reduced hepatic congestion and surgical blood loss.

Prospective randomized comparison of laparoscopic versus open adrenalectomy for sporadic pheochromocytoma

Laparoscopic adrenalectomy for pheochromocytoma remains subject of debate, owing to the systemic consequences of pneumoperitoneum in patients with catecholamine-secreting tumors. A prospective randomized study was conducted (2000-2006), evaluating cardiovascular instability during open (n = 9, group A) or laparoscopic (n = 13, group B) adrenalectomy for pheochromocytoma. Haemodynamic parameters were recorded by invasive monitoring. Haemodynamic instability was observed in 3/9 (group A) and 6/13 patients (group B), with a mean of 1.8 and 2.2 hypertensive peaks per patient (p = n.s.). Blood loss (164 +/- 94 cc versus 48 +/- 36 cc, p < 0.05) and operative time (180 +/- 40 versus 158 +/- 45 min, p = n.s.) favored laparoscopic procedures. Postoperative morbidity and mortality were nil. Hospital stay was shorter in group B (p < 0.05). Long-term follow-up was always normal. Laparoscopic approach for pheochromocytoma can be as safe as open surgery; intraoperative haemodynamic instability, although usually controlled with success, remains a source of concern.

Diabetic Cardiomyopathy and Anesthesia

Diabetic Cardiomyopathy and Anesthesia

Intra-operative refractory hypotension in patient chronically treated with renin-angiotensin system antagonists - A case report -

Chronic treatment with renin-angiotensin system antagonists frequently causes deleterious hypotension during anesthesia. We present a case of marked intra-operative refractory hypotension in a 61-year-old male patient undergoing elective total thyroidectomy. He has been chronically treated for hypertension with angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and atenolol, which were taken until the morning of surgery. After induction of anesthesia, marked hypotension which was refractory to fluid therapy occurred and did not respond to ephedrine administration. After continuous norepinephrine infusion, blood pressure increased and remained stable during the anesthesia period. Before extubation, norepinephrine was discontinued and recovery took place without complications. We discuss the anesthetic implication of chronic renin-angiotensin system antagonists treatment and intra-operative hemodynamic instability.

Surgical Hemorrhage, Damage Control, and the Abdominal Compartment Syndrome

The morbidity and mortality associated with surgical hemorrhage are considerable, particularly when relaparotomy is necessary. This complication can usually be avoided with comprehensive preoperative patient evaluation and meticulous surgical technique. The damage control sequence is a useful surgical strategy when severe intraoperative coagulopathy or hemodynamic instability is present. Abdominal compartment syndrome is a potentially lethal phenomenon that can occur following laparotomy or large-volume fluid resuscitation, or both. Early recognition and intervention are critical to survival of the patient when this syndrome occurs.

Morbidly Obese Patients are Hemodynamically Stable During Laparoscopic Surgery: A Thoracic Bioimpedance Study

Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable. In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI > or = 35 kg/m(2)) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40-50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP < or = 60 and MAP > or = 130 mmHg or HR < or = 50 and HR > or = 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI. Heart rate was higher in obese patients in head-up position (79 +/- 15 mmHg vs. 65 +/- 12 mmHg - P=0.011). SVR was higher in the nonobese group with head-up position (1978 +/- 665 dynes s cm(-5) vs. 1394 +/- 496 dynes s cm(-5) P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP < or = 60 and > or =130 mmHg or HR < or = 50 and > or =110 bpm in either of the groups. Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

The influence of xenon on regulation of the autonomic nervous system in patients at high risk of perioperative cardiac complications

As xenon anaesthesia (XE) does not produce haemodynamic depression its use may be of benefit in patients at high risk of intraoperative haemodynamic instability and perioperative cardiac complications. XE (n=22) was compared with total i.v. anaesthesia (TIVA, n=22) for differences in autonomic regulation, peri- and postoperative performance. Patients undergoing abdominal aortic surgery were studied at five events: T1: baseline awake; T2: anaesthesia induction; T3: before aortic cross-clamping; T4: after aortic cross-clamping; T5: after aortic declamping. T3-T5: end-tidal xenon concentration 60 (5)%. Intraoperative analysis: heart rate, heart rate variability, blood pressure and cardiac output. Postoperative analysis: 24 h Holter ECG, intensive care unit and hospital stay, and patient's outcome after 6 months. XE in contrast to TIVA increased parasympathetic and decreased sympathetic activity. Median low to high frequency decreased significantly in the XE group after start of XE (P<0.05) and remained significantly lower during all events after start of XE as compared with TIVA (P=0.0001). After start of XE heart rate of these patients was significantly lower as compared with TIVA (P=0.04). Cardiac output increased significantly in TIVA after aortic declamping (P<0.05). Outcome parameters did not differ significantly between groups. XE patients demonstrated lower sympathetic and higher parasympathetic activity as compared with TIVA patients. This was reflected by significant differences in haemodynamics but did not correlate with a better postoperative outcome. Thus, it remains controversial whether XE provides benefits in high risk patients.

Outcome after anaesthesia and emergency surgery in patients over 100 years old

Deteriorated organ function and reduced stress response in very old patients may cause post-operative morbidity and mortality. We wanted to identify immediate and longer-term outcome after anaesthesia and surgery in the oldest of the old patients. We analysed retrospectively anaesthesia and hospital records of patients who were over 100 years old when undergoing major emergency surgery in our hospital during 1990-2004. Altogether, 12 patients (median age 101 years) underwent 14 operations (nine for hip fracture, four for lower extremity circulatory problems and one for peritonitis). During anaesthesia, invasive arterial pressure was monitored in eight patients while central venous pressure (CVP) was monitored in only one patient. Spinal anaesthesia with bupivacaine was given as a continuous technique in six and as single-shot spinal anaesthesia in five cases. Both spinal (11) and general (3) anaesthesias were characterized by marked drops in arterial pressure. Haemodynamics was managed with intravenous (i.v.) fluids and vasopressors. Five patients had post-operative delirium. Mortality at 30 days, 6 months and 1 year was 25%, 42% and 50%, respectively. Within 15 days of the operation, three patients had died (pneumonia, cerebral infarction and myocardial infarction). Nine patients returned home and six of them lived in their pre-operative mental and physical state for at least a year. Independently of the anaesthetic method, marked drops in blood pressure occurred, requiring pharmacological intervention. We assume that in most of the patients, hypovolaemia explains the intra-operative haemodynamic instability. A 25%, 30-day mortality may be regarded as acceptable and, overall, these very old patients tolerated emergency surgery quite well.

Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery

Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL x kg(-1) x h(-1) and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL x kg(-1) x h(-1)) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.

Preoperative Dobutamine Stress Echocardiography, Intraoperative Events, and Intraoperative Myocardial Injury in Liver Transplantation

Introduction The appropriate method of screening for coronary artery disease in patients who present for liver transplantation is currently uncertain. Methods We assessed the utility of a screening protocol using dobutamine stress echocardiography (DSE) in 119 patients who underwent liver transplantation. Patients with cardiac risk factors had DSE performed, and those with positive results were referred for coronary angiography. Outcome was myocardial injury during liver transplantation determined by an elevation of cardiac troponin T measured after transplantation. Results Seventy-three patients had DSE performed; eight were reported as positive for inducible ischemia. Seven of these patients underwent coronary angiography, and one had significant coronary artery disease. Postoperative troponin elevation occurred in 14 patients. There was no significant difference in the prevalence of troponin elevation in those patients with positive DSE versus those with negative DSE. No significant difference was identified in the prevalence of troponin elevation when comparing those patients with cardiac risk factors who underwent DSE with those patients with no risk factors and no DSE performed. DSE had a sensitivity of 0.2 and a specificity of 0.9 for myocardial injury. The prevalence of intraoperative hemodynamic instability was significantly higher in patients who had evidence of myocardial injury, but hemodynamic instability was no more common in patients who had a positive DSE. Conclusion When used in accordance with our protocol a positive DSE does not reliably identify patients at high cardiac risk during liver transplantation, but a negative DSE is strongly predictive of no myocardial injury.

Off-Pump Bypass Surgery—Ready for the Big Dance?

EVERY SPRING, COLLEGE BASKETBALL TEAMS FROM around the United States gear up for a competition to determine the best team of the year. This tournament is often referred to as the “big dance,” and it represents the ultimate challenge of peer against peer. In this contest, dominance in prior years is no guarantee of continued success. In medicine, new technologies are continuously being developed to challenge the champions of prior years, but there is no calendar marking when a new therapy is ready for its “big dance”—the large multicenter randomized trial that can determine whether it should displace the reigning champion of conventional care in clinical practice. If the assessment comes too early as the therapy is still evolving, a promising treatment may be inappropriately discarded. If the assessment comes too late, practitioners may have already decided to adopt the therapy based on less rigorous evidence and may refuse to enroll patients into a trial based on “ethical grounds.” Over the last few years, much interest has focused on the evolving contest between coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass and offpump coronary artery bypass (OPCAB) surgery. Observational data suggest significant outcome advantages for the newcomer, OPCAB, yet it remains controversial. Many senior surgeons have resisted abandoning the CABG procedure they have performed comfortably for decades in favor of an unproven new procedure that is substantially more difficult for the surgeon and the anesthesiologist. Thus, the contest between conventional CABG with cardiopulmonary bypass and the newer OPCAB has all the makings of a classic matchup. But is OPCAB ready for its “big dance”? Before answering this question, consideration of some additional background is appropriate. The development of cardiopulmonary bypass using the heart-lung machine is a watershed accomplishment of medicine in the 20th century. With varying details, CABG with cardiopulmonary bypass has been used for more than 30 years and has evolved into a safe procedure that is performed in more than 300000 patients each year in the United States. However, research has shown that routing the patient’s circulation through the bypass machine activates a number of undesirable pathogenic processes that have been implicated in major complications following surgery. Looking to improve patient outcomes, pioneering cardiac surgeons began attempting bypass grafting on a “beating” heart. Early OPCAB procedures identified some important challenges to this approach, including intraoperative hemodynamic instability during manipulation of the heart, difficulty providing complete revascularization (particularly of the lateral and posterior walls), and higher risks for anastomotic failures. Since these early days, OPCAB has rapidly evolved with better devices for stabilizing the heart, anesthetic techniques, and improved surgeon experience. As the technique has been refined, its proponents have ventured to compare it directly with CABG with cardiopulmonary bypass in randomized trials. However, these initial trials have a number of important limitations. They generally have been small, single-center (and often singlesurgeon) trials. Additionally, these early trials have tended to exclude severely ill patients as demonstrated by mortality rates that are 2-fold to 3-fold lower than national norms in both the CABG with cardiopulmonary bypass and OPCAB patients. Nonetheless, some trials observed benefits in OPCAB including reduced perioperative myocardial damage (elevations in creatinine kinase levels) and lower rates of renal dysfunction, atrial fibrillation, stroke, sternal wound infection, and need for transfusion. The OPCAB procedure has also been associated with reduced postoperative ventilation time, shorter hospital stays, and lower costs. However, the available trials have not been uniformly supportive of the OPCAB approach. One area in which the newer procedure may be less satisfactory is in completeness and durability of revascularization. On these points, recent trials have reached different conclusions. At one end are the re-

Longitudinal gastrectomy as a treatment for the high-risk super-obese patient.

Bariatric surgery in patients with significant co-morbid conditions is associated with increased perioperative risk. From 1995-2001, 795 patients were operated upon at our institution for the diagnosis of morbid obesity. Of these, 671 (84.4%) had the duodenal switch (DS) procedure. Longitudinal gastrectomy (LG) entails a greater curvature linear gastrectomy creating a gastric tube with a volume of 100 ml along the lesser curvature of the stomach. This procedure was performed for 21 patients (median age 50.5, median BMI 56). 9 patients were offered LG preoperatively because of their known high perioperative risks. 12 patients were initially planned for DS, but the procedure was limited to LG alone because of either unexpected intraoperative findings (n=9) or intraoperative hemodynamic instability (n=3). 5 patients developed complications, and there were no deaths. 19 out of 21 patients were available for a median follow-up of 17.5 months (6.25-20.25). Median weight loss and median %EWL at 12 months were 44.5 kg and 45.1%, respectively. Estimated daily dietary volume at 1 year was 35% of preoperative values. Of 10 patients followed for >or= 1 year, 4 of 10 achieved more than 50% EWL and 8 patients were taking less or were completely off medications for diabetes, hypertension and congestive heart failure. Weight loss plateaued at 1 year for the majority of patients. LG is a safe and effective option for high-risk morbidly obese patients. Weight reduction is accomplished by limitation of caloric intake. LG can be offered to high-risk morbidly obese patients as an interim procedure to help decrease perioperative risk before DS.

A Comparison of Open and Laparoscopic Approaches to Adrenalectomy in Patients with Phaeochromocytoma

We compared the perioperative profiles of patients undergoing unilateral phaeochromocytoma resection performed by open adrenalectomy with those performed by laparoscopic adrenalectomy. Data was collected prospectively on 24 patients (12 open, 12 laparoscopic). All patients underwent extensive preoperative medical preparation with phenoxybenzamine and beta-blockers. The final preoperative dose of phenoxybenzamine was similar in each group (laparoscopic 119+/-60 mg/day, open 100+/-25 mg/day). Intraoperative haemodynamic instability was assessed by the requirement for therapeutic intervention. More haemodynamic instability was observed in the laparoscopic group but the differences were not statistically significant. Sodium nitroprusside use to treat hypertension (systolic blood pressure >180 mmHg) was more frequent and the duration of the infusions longer in the laparoscopic group; high dose beta-blocker therapy with atenolol and/or esmolol to treat intraoperative tachycardia (heart rate >90) was also more frequent in the laparoscopic group. The small sample size of the study limited the ability to detect a true difference. Blood loss was greater in the open adrenalectomy group but the difference was not significant. The operating time was significantly longer (236+/-78 vs 147+/-47 min, P<0.01) but the duration of postoperative hospitalization was significantly shorter (5+/-2 vs 11+/-4 days, P<0.01) in the laparoscopic group. Postoperative complications were not significantly different. There were no perioperative deaths. Overall, we observed more haemodynamic instability in patients undergoing laparoscopic resection but were unable to demonstrate a statistically significant difference. In our experience, laparoscopic adrenalectomy has the advantage of a shorter time to discharge from hospital.

Perioperative implications of heart transplant

Over the past 30 years, heart transplantation has evolved into a definitive therapy for patients with end-stage cardiomyopathy. However, perioperative management of patients undergoing heart transplantation remains a challenge for anesthesiologists. The presence of biventricular failure, arrhythmias and associated multisystem organ dysfunction may contribute to significant intraoperative hemodynamic instability prior to the initiation of cardiopulmonary bypass (CPB). Even after an uneventful transplantation, weaning from CPB may be difficult. Acute right ventricular failure can develop in the recipient secondary to pre-existing pulmonary hypertension. Treatment options frequently focus on therapeutic interventions directed towards decreasing pulmonary vascular resistance and improving right ventricular contractility. Intraoperative use of transesophageal echocardiography (TEE) enables the anesthesiologist to diagnose acute right ventricular failure early on and guide therapy. Concurrent pathology including kinking of the pulmonary artery anastomosis or valvular insufficiency in the transplanted heart can also be recognized and addressed. The number of patients undergoing cardiac transplantation is continually increasing. In addition, the use of more effective immunosuppressive agents has curtailed transplant rejection and permitted longer survival. Consequently, heart transplant recipients are more frequently presenting for non-cardiac surgical procedures. Thus, an understanding of physiological and pharmacological implications associated with heart transplantation is crucial for managing these patients in the perioperative period.

Laparoscopic bilateral partial adrenalectomy for pheochromocytoma

Introduction To describe the technique of transperitoneal laparoscopic bilateral synchronous partial adrenalectomy in a patient with bilateral adrenal pheochromocytoma. Technical considerations An 81-year-old woman with bilateral adrenal pheochromocytoma underwent bilateral laparoscopic partial adrenalectomy. A three-port transperitoneal approach was used for each side, with an additional port for liver retraction during right partial adrenalectomy. Laparoscopic flexible ultrasonography was invaluable for localizing the adrenal tumor and for precise planning of the line of excision. The right main adrenal vein was preserved. Dissection and enucleation of the adrenal tumor and parenchymal hemostasis was achieved effectively using a harmonic scalpel. The total operative time was 2 and 2.5 hours for the left and right adrenal gland, respectively. No major intraoperative hemodynamic instability was noted. The total blood loss was 150 mL, and the hospital stay was 4 days. Pathologic examination confirmed bilateral adrenal pheochromocytoma. Conclusions Laparoscopic partial adrenalectomy for pheochromocytoma is safe and technically feasible. Intraoperative ultrasonography is helpful to accurately plan resection of the tumor. If tumor location permits, the main adrenal vein should be preserved to ensure adequate vascularity for the adrenal remnant.

Low Complication Rate Associated with Cesarean Section under Spinal Anesthesia for HIV-1–Infected Women on Antiretroviral Therapy

Elective cesarean section decreases the likelihood of vertical human immunodeficiency virus (HIV) transmission from mother to infant. This study aimed to determine whether cesarean section done with spinal anesthesia on HIV-1-infected pregnant women taking antiretroviral therapy is associated with intraoperative hemodynamic instability, postoperative complications, or changes in immune function or HIV-1 viral load. A case-controlled study was conducted over a 3-year period in a London academic hospital. Forty-four women infected with HIV-1 and a control group of 45 HIV-negative women undergoing cesarean sections were included. The main outcome measures included intraoperative blood pressure, heart rate, blood loss, and ephedrine requirements, and postoperative infective complications, blood transfusion, changes in blood HIV-1 viral load and lymphocyte subsets, and time to hospital discharge. There were no differences in hemodynamic stability and postoperative complications between the HIV-infected group and the controls. There was an acute postoperative increase in the CD4T lymphocyte count (P = 0.01), but the CD4T:CD8T ratio and viral load did not change. Elective cesarean section under spinal anesthesia for women infected with HIV-1 taking antiretroviral therapy was not associated with intraoperative or postoperative complications.