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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 126-135

The New Normal Anesthesiologist and the Challenging Post-COVID-19 Mucormycosis Patients − Our Experience


1 Department of Anesthesia and Critical Care, Maulana Azad Medical College, New Delhi, India
2 Department of Anesthesia and Critical Care, Lok Nayak Hospital, New Delhi, India

Date of Submission04-Jul-2021
Date of Decision07-Jul-2021
Date of Acceptance14-Jul-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Dr. Sonia Wadhawan
Department of Anesthesia and Critical Care, Maulana Azad Medical College, S-18, Greater Kailash, New Delhi 110048
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_71_21

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  Abstract 


Rhino-orbital-cerebral mucormycosis (ROCM) is an aggressive, lethal, angioinvasive fungal infection that has presented as an opportunistic infection in the backdrop of a highly infectious and severe second coronavirus disease 2019 (COVID-19) wave in India. The dominant delta strain during the second wave led to an unprecedented rise in hospital admissions with moderate to severe COVID-19 illness. A working staging system is helpful in triaging these patients to prioritize surgical debridement and liposomal amphotericin B induction therapy. The evaluation and optimization of post-COVID-19 sequelae becomes a cornerstone in achieving a favorable perioperative outcome. As anesthesiologists, we share our experience in managing this novel subset of patients. Post-COVID-19 sequelae with a prothrombotic state and multisystem involvement, challenging and shared airway, and amphotericin B-related complications are being the key concerns.

Keywords: Airway, amphotericin B, anesthesia, post-COVID sequelae, prothrombotic, mucormycosis


How to cite this article:
Wadhawan S, Husain F, Agarwal M. The New Normal Anesthesiologist and the Challenging Post-COVID-19 Mucormycosis Patients − Our Experience. MAMC J Med Sci 2021;7:126-35

How to cite this URL:
Wadhawan S, Husain F, Agarwal M. The New Normal Anesthesiologist and the Challenging Post-COVID-19 Mucormycosis Patients − Our Experience. MAMC J Med Sci [serial online] 2021 [cited 2021 Dec 6];7:126-35. Available from: https://www.mamcjms.in/text.asp?2021/7/2/126/324742




  Introduction Top


Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi became a dedicated center for managing patients with post-coronavirus disease 2019 (COVID-19) mucormycosis during the second wave of the pandemic. We started the post-COVID-19 mucormycosis OT on May 22, 2021 for patients to undergo surgical debridement under general anesthesia and have anesthetized over 100 cases.

Rhino-orbital-cerebral mucormycosis (ROCM) is an aggressive, lethal, angioinvasive fungal infection that has presented as an opportunistic infection[1] in the backdrop of a highly infectious and severe second COVID-19 wave in India. The dominant delta strain during the second wave led to an unprecedented rise in hospital admissions with moderate to severe COVID-19 illness. Virus-induced damage to the respiratory epithelium resulting in mucociliary dysfunction allowed the fungus to invade. The increased frequency of ROCM has been attributed to host factors such as poorly controlled diabetes, use of corticosteroids in severe COVID-19 pneumonia, and anti-interleukin 6 therapy (tocilizumab) in hospitalized patients, primary or secondary immunodeficiency, hematologic malignancies, solid organ transplantation, iron overload, etc.[2],[3]

The presence of signs and symptoms makes ROCM a “Possibility” [Table 1]. The “Probability” is further confirmed by nasal endoscopy findings along with computerized tomography (CT) scan or magnetic resonance imaging findings suggestive of the mold. Clinicoradiologic features, coupled with microbiologic confirmation (direct microscopy/culture/histopathology), are essential to categorize a patient as “Proven” ROCM.[4].{Table 1}

Therefore, a working staging system is helpful in triaging these patients to prioritize surgical debridement and liposomal amphotericin B induction therapy [Table 2].[4] In probable and proven cases of mucormycosis, early initiation of amphotericin B along with urgent surgical debridement becomes mandatory to ensure better outcomes in this rapidly progressive disease.[4],[5] Amphotericin B is the proven medical treatment of choice[6] but use of combination therapy with posaconazole and isavuconazole, still warrants further clinical trials and studies. Liposomal amphotericin B is the preferred and least toxic modality of pharmacotherapy; however, due to limited availability of this drug, other preparations such as amphotericin B deoxycholate and amphotericin B lipid complex may be utilized. Posaconazole is being used as a replacement to amphotericin B or as a step-down therapy in the present scenario.{Table 2}

Most patients who present to the hospital with mucormycosis need surgical debridement under general anesthesia on a semi-emergency basis.

Addressing the Anesthetic Concerns in Patients with Post-COVID Mucormycosis

A detailed preanesthetic workup of these patients with emphasis on the following issues:
  1. Post-COVID-19 sequelae with suboptimal functional status
  2. Difficult airway due to mucormycosis or inherent causes
  3. Amphotericin B-related complications
  4. Surgery-related problems
  5. Associated comorbidities


Post-COVID-19 Sequelae with Suboptimal Functional Status

A recently recovered patient with COVID-19 can present with multiple short- and long-term sequelae including chronic pulmonary dysfunction, myocardial inflammatory states, renal impairment, psychologic distress, chronic fatigue, and musculoskeletal deconditioning.[7] The perioperative challenges in the patients with post-COVID mucormycosis and the anesthetic concerns are multifold[8] and need to be addressed with a multidisciplinary approach involving otorhinolaryngology, ophthalmology, internal medicine, neurology, anesthesiology, cardiology, radiology, microbiology, and pathology teams. Wang et al. reported in their study that 94% of patients with COVID-19 discharged from the hospital had residual disease on their last CT scans.[9]

To ensure that perioperative outcome is devoid of complications, it is very important to clinically evaluate and investigate the patient to optimize their functional status [Table 3].{Table 3}

Difficult Airway due to Mucormycosis or Inherent Causes

As the disease is predominantly in the rhino-nasal areas, the nasal access for airway management is not available to the anesthesiologist. A ROCM may present with difficult bag and mask ventilation or difficult intubation because of reduced mouth opening that maybe attributed to pain or swelling. Additionally, these patients may have an inherent difficult airway due to submucous fibrosis, obesity, macroglossia, ankylosed temporomandibular joint, neck contractures, etc. Keeping the above in mind, tracheostomy maybe the only method for securing the airway in some of these patients. Hence, a front of neck access (FONA) assessment becomes an essential part of the preanesthetic evaluation.

Amphotericin B-related Complications

Liposomal amphotericin B is the drug of choice for ROCM, but it may cause electrolyte disturbances leading to hypokalemia and hypomagnesemia. The low potassium levels can lead to problems such as life-threatening arrhythmias, prolonged muscle relaxation leading to delayed or inadequate reversal. Hence, continuous electrocardiogram (ECG) monitoring of lead 2 and the use of neuromuscular monitoring become essential in these patients. Being semi-emergency procedures, these patients may be taken up with ongoing intravenous (IV) potassium and magnesium supplementation to prevent this perioperative complication.

Surgery-related Problems

Surgeries for management of patients with ROCM range from endoscopic procedures to extensive debridement. Some patients may also present for redo surgeries if the disease progresses to newer areas despite initial debridement and ongoing drug therapy. ROCM with intracranial extension such as cavernous sinus involvement or post-COVID-19 thrombotic cerebral infarcts also forms a challenging class of patients where the judicious role of opioids, relaxants, and cerebral decongestants become extremely important. Extensive surgery with significant blood loss and postoperative airway compromise may lead to the requirement of postoperative ventilation and intensive care unit (ICU) care. The need for postoperative ventilation will also be determined based on the extent of airway compromise due to handling of tissues and hence it is important that the anesthesiologist is aware about the surgical plan [Table 4], [Figure 1],[Figure 2],[Figure 3].{Table 4}{Figure 1}{Figure 2}{Figure 3}

Associated Comorbidities

The ROCM is mostly observed in patients with diabetes and other immunocompromised states. Perioperative blood sugars should be kept in the range of 140 to 180 mg/dl using an insulin infusion to promote adequate wound healing and prevent postoperative wound infections. Antihypertensives, cardio-protective drugs, bronchodilators, etc., need to be continued for preoperative optimization so as to optimized. A major cause of concern is the possibility of perioperative cardiac and thrombotic events especially in patients with a recent history of infarcts (myocardial infarction, MI). Hence, a multidisciplinary approach to anticoagulation maybe sought on a patient-to-patient basis.

Case Series and Our Experience

Keeping all the above concerns in mind, optimization became the key to a good perioperative outcome in these patients. As majority of these patients were belonging to ASA class III and above, a written informed high-risk consent was taken and wherever anticipated, the patient was counseled about the need for postoperative ventilation and ICU care. Here, we share our anesthesia experiences with a case series of five challenging cases.

Case 1: Preoperative optimization of a patient with post-COVID-19 with a backdrop of multiple comorbidities − a successful outcome



CPAP, continuous positive airway pressure; NSAID, Nonsteroidal anti-inflammatory drugs; RR, respiratory rate; TLC, total leucocyte count.

Case 2: Redo surgical debridement: a mammoth task.



Cases 3 and 4: The prothrombotic patients with recent MI and stroke.



LMWH, Low molecular weight heparin; Trop-I, troponin -I.

Case 5: Giving general anaesthesia (GA) to the significantly hypokalemic patient.



RR, respiratory rate.


  Conclusion Top


To manage this novel subset of patients, we became new normal anesthesiologists, and “experiential learning’ and “hypervigilant monitoring” became the cornerstone of our anesthetic techniques. To make the anesthesiologist more aware about the concerns in this challenging patient population, we have formulated guidelines for perioperative anesthetic management which are attached as Annexure 1.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.













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  References Top

1.
Salehi M, Ahmadikia K, Badali H, Khodavaisy S. Opportunistic fungal infection in the epidemic area of COVID-19: a clinical and diagnostic perspective from Iran. Mycopathologica 2020;185:607-11.  Back to cited text no. 1
    
2.
Sergrelles-Calvo G, Araujo GR de S, Frases S. Systemic mycoses: a potential alert for complications in COVID-19 patients. Future Microbiol 2020;15:1405-13.  Back to cited text no. 2
    
3.
Skied A, Pavleas I, Drogari-Apiranthitou M. Epidemiology and diagnosis of mucormycosis: an update. J Fungi (Basel) 2020;6:265.  Back to cited text no. 3
    
4.
Honavar SG. Rhino-orbito-cerebral mucormycosis − guidelines for diagnosis, staging, and management. Indian J Opthalmol 2021;69:1361-5.  Back to cited text no. 4
    
5.
Nithyanandam S, Jacob MS, Battu RR, Thomas RK, Correa MA, D’Souza O. Rhino-orbito-cerebral mucormycosis. A retrospective analysis of clinical features and treatment outcomes. Indian J Ophthalmol 2003;51:231-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Rhino-Orbito-cerebral Mucormycosis − Prevention and treatment in COVID-19 patients − Protocol based Management − AIIMS Patna, May 2021.  Back to cited text no. 6
    
7.
Wang F, Kream RM, Stefano GB. Long term respiratory and neurological sequelae of COVID 19. Med Sc Monit 2020;26:e 928996.  Back to cited text no. 7
    
8.
Hoyler MM, White RS, Tam CW, Thalappillil R. Anesthesia and the “post-COVID syndrome”: perioperative considerations for patients with prior SARS-CoV-2 infection. J Clin Anesth 2021;72:110283.  Back to cited text no. 8
    
9.
Wang Y, Dong C, Hu Y et al. Temporal changes of CT findings in 90 patients with COVID-19 pneumonia: a longitudinal study. Radiology 2020;296:E55-64.  Back to cited text no. 9
    
10.
Leo F, Wormanns D, Grohe C. COVID-19: a pulmonologist point of view-long term sequelae of COVID-19-implications for follow-up in respiratory medicine. Dtsch Med Wochenschr 2020;145:1086-92.  Back to cited text no. 10
    
11.
George PM, Wells AU, Jenkins RG. Pulmonary fibrosis and COVID-19: the potential role for antifibrotic therapy. Lancet Respir Med 2020;8:807-15.  Back to cited text no. 11
    
12.
Zhang T, Sun LX, Feng RE. Comparison of clinical and pathological features between severe acute respiratory syndrome and coronavirus disease2019. Zhonghua Jie He He Hu Xi Za Zhi 2020;43:496-502.  Back to cited text no. 12
    
13.
Yusuff H, Zochios V, Brodie D. Thrombosis and coagulopathy in COVID-19 patients requiring extracorporeal membrane oxygenation. ASAIO J 2020;66:844-6.  Back to cited text no. 13
    
14.
Wu CT, Lidsky PV, Xiao YH et al. SARS-CoV-2 infects human pancreatic â cells and elicits â cell impairment. Cell Metab 2021 May 18;S1550-4131(21)00230-8.  Back to cited text no. 14
    
15.
Chamchad D, Horrow JC, Nakhamchik L et al. Prophylactic glycopyrrolate prevents bradycardia after spinal anesthesia for Caesarean section: a randomized, double-blinded, placebo-controlled prospective trial with heart rate variability correlation. J Clin Anesthesia 2011;23:361-6.  Back to cited text no. 15
    




 

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