|Year : 2022 | Volume
| Issue : 3 | Page : 331-335
Perioperative challenges in the management of rhino-orbital cerebral mucormycosis: An observational study from a tertiary care hospital
Pradnya Milind Bhalerao, Shital Mahendra Kuttarmare, Shweta Joshi, Sanyogita Vijay Naik
Department of Anaesthesiology, B. J. Medical College and Sassoon General Hospital, Pune, Maharashtra, India
|Date of Submission||09-May-2022|
|Date of Decision||23-Aug-2022|
|Date of Acceptance||29-Aug-2022|
|Date of Web Publication||09-Dec-2022|
Dr. Shital Mahendra Kuttarmare
B 702, Pinnacle Neelanchal, Near Vibgyor School, Near Yashwin Anand Society, SUS, Pune - 411 021, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Coronavirus disease 2019 (COVID-19) pandemic is the biggest threat of the century. Associated with this disease, are a number of rhino orbital cerebral mucormycosis cases seen as post COVID sequelae. Amphotericin B and surgical debridement are the treatment modalities. Aims: This study aimed to describe the clinical characteristics and perioperative outcomes of patients with ROCM. Settings and Design: This was a prospective, observational study. Materials and Methods: We carried out a study of 238 patients with confirmed ROCM posted for functional endoscopic sinus surgery, craniotomies, maxillofacial surgeries, and orbital exenteration under general anesthesia and the perioperative challenges therein. Statistical Analysis Used: Data were entered in the excel sheet. Descriptive statistics were used to summarize the data. Analysis was done using the Statistical Package for the Social Sciences (SPSS) version 27:0. Categorical variables were expressed as counts and percentages. Results: 78% had diabetes mellitus, 64% had received steroids, 59% had a preoperative oxygen saturation of less than 90%, 86% had a 4–6 zone involvement on chest radiograph, and more than 50% had an anticipated difficult airway. Postsurgery, 13% of patients required intensive care. The 15-day mortality rate was 3% among the operated cases. Conclusion: Post-COVID ROCM is challenging in terms of preoperative poor general condition, difficult airway, intraoperative concerns due to pathophysiology of the disease and its effect on organ systems, and the requirement of postoperative vigilant monitoring.
Keywords: Amphotericin B, coronavirus disease 2019, functional endoscopic sinus surgery, general anesthesia, mucormycosis
|How to cite this article:|
Bhalerao PM, Kuttarmare SM, Joshi S, Naik SV. Perioperative challenges in the management of rhino-orbital cerebral mucormycosis: An observational study from a tertiary care hospital. Anesth Essays Res 2022;16:331-5
|How to cite this URL:|
Bhalerao PM, Kuttarmare SM, Joshi S, Naik SV. Perioperative challenges in the management of rhino-orbital cerebral mucormycosis: An observational study from a tertiary care hospital. Anesth Essays Res [serial online] 2022 [cited 2023 Feb 3];16:331-5. Available from: https://www.aeronline.org/text.asp?2022/16/3/331/363139
| Introduction|| |
Coronavirus disease 2019 (COVID-19) pandemic affected all nations worldwide with our country facing a major brunt of cases. The disease is associated with a wide range of opportunistic bacterial and fungal infections. Recently, an increase in the number of rhino-orbital cerebral mucormycosis (ROCM) had been noted in post-COVID patients. The most common clinical presentations are rhino-orbital-cerebral followed by pulmonary, gastrointestinal, cutaneous, and disseminated., Isolated tracheal and cerebral mucormycosis have also been reported., Mucormycosis disease has a high mortality rate., It poses challenges for an anesthesiologist in terms of difficult airway, post-COVID decrease in lung function, the requirement of oxygen therapy preoperative and postoperative, hypokalemia with amphotericin B (AmB), leading to delayed recovery, deranged blood sugar levels (BSL), and control of associated comorbidities due to myocardial injury, hypercoagulable state, and cerebral involvement.
All these dilemmas have to be dealt without complete optimization in an emergency and have not been documented in the literature.
We present a study of 238 patients operated for mucormycosis in a single tertiary care hospital.
| Materials and Methods|| |
This is an observational, prospective study of 238 patients with a confirmed diagnosis of mucormycosis presenting to a tertiary care hospital from May 15 to July 8, 2021. Written informed consent was obtained from patients for their information to be published in this article. Ethical committee approval obtained from institutional ethical committee (BJGMC/IEC/Pharmac Dept 0621198-198 dated 09/07/2021).
All patients between the age group of 16–85 years of either sex belonging to ASA PS classes III-IV with rhino-orbital-cerebral disease posted for surgery under general anesthesia were included. Past history of COVID-19 infection, requirement of oxygen, and drug therapy including steroids were obtained. A thorough preoperative evaluation was done in the form of ASA PS class, preoperative oxygen saturation (SpO2), arterial blood gas (ABG) analysis, BSL, chest radiograph (CXR) findings, and presence of comorbidities. Preoperative complete blood count, renal function tests, serum electrolyte, and electrocardiography were done for all patients. Echocardiography was done only in patients with a history of cardiac disease or on suspicion of post-COVID cardiac involvement from previous records.
Preoperative Glasgow coma scale (GCS) was assessed to rule out cranial involvement. Most of these patients were diabetic, and hence, preoperative blood sugar was measured on the day of surgery. The time between the history of COVID-19 infection and operative time was noted. Airway examination was done using Mallampatti classification (MPC) and interincisor distance.
On the day of surgery, nil by mouth (NBM) status and written informed consent was confirmed. Electrocardiography, noninvasive blood pressure, end-tidal carbon dioxide, SpO2 and temperature monitor were attached. Central venous line (CVP) was done in all cases. Betadine 0.5% drops were instilled in each nostril 30 min before surgery. All patients received 0.2 μg.kg−1 Glycopyrrolate i.m. 30 min before induction. Midazolam 0.03 mg.kg−1 i.v. and fentanyl 1 μg.kg−1 i.v. was given preinduction. Induction was done with propofol 1-2 mg.kg−1 i.v. Tracheal intubation was facilitated using succinylcholine 2 mg.kg−1 i.v. or rocuronium 1 μg.kg−1 i.v. For tracheal intubation, C-Mac video laryngoscope or Macintosh laryngoscope with large blade was used. Maintenance was done using oxygen, nitrous oxide, isoflurane, vecuronium, or atracurium depending upon the patient's renal function tests. At the end of procedure, patients were extubated after reversal with glycopyrrolate 10 μg.kg−1 and neostigmine 0.05 mg.kg−1. Paracetamol was given intravenously for postoperative analgesia. Postoperative intubated patients were sent to intensive care unit (ICU) for elective ventilation while others to high-dependency unit (HDU) for observation. Patients were monitored till postoperative day 15.
Data were entered in the excel sheet. Descriptive statistics were used to summarize the data. Analysis was done using the Statistical Package for Social Science (SPSS) version 27.0 (SPSS Inc., Chicago II, USA).
Categorical variables were expressed as counts and percentages.
| Results|| |
A total of 238 patients were diagnosed with ROCM during these 2 months out of which 165 were males and 73 females. 76% of patients had eye and sinus whereas 17% of patients had cranial involvement and the rest had only sinus involvement.
29% of patients were aged between 51 and 60 years, 24% were between 41 and 50 years, and 26% were above 60 years. There were 165 males and 73 females.
Out of 238 patients, 231 patients gave a history of COVID-19 infection. 64% of patients had received steroids either in the form of methylprednisolone or dexamethasone. 131 patients required preoperative oxygen [Figure 1]. 59% of patients had preoperative SpO2 less than 90% [Figure 2]. 53% of patients had diabetes mellitus (DM) as comorbidity [Figure 3]. Predictors of difficult airway which includes MPC showed that almost 43% of patients had MPC 3 and 4 [Table 1]. Associated with it, the interincisor distance was less than 2.5 cm in 59% of patients.
147 patients had BSL greater than 160 mg.dL−1 [Figure 4]. 50% of patients had six zones involvement on preoperative CXR [Table 2].
The 25-point chest computerized tomography severity scores were available for all patients which showed that 21% of patients had score more than 15, 36% of patients between 8 and 15, and 38% of patients less than 8.
Out of 238 patients, 17 patients were vaccinated before the development of mucormycosis while 221 patients were not vaccinated.
All patients belonged to ASA PS classes III and IV. Postsurgery, 13% of patients with cerebral involvement, poor GCS, and on high oxygen support required intensive care, out of which six patients succumbed before postoperative day 15, while the rest were shifted to HDU.
| Discussion|| |
Mucormycosis is a fungal infection affecting the paranasal sinuses, brain, and orbit., Uncontrolled diabetes with ketoacidosis, immunosuppression with steroids, posttransplant, oncopathologies and prolonged stay in ICU for COVID-19 infection are probable predisposing factors for the development of ROCM. AmB is the most commonly used antifungal agent for its treatment.
Surgical debridement is done in the form of functional endoscopic sinus surgery, exenteration, enucleation, mandibulectomy, maxillectomy and craniotomies. Retrobulbar injection of AmB showed improvement in orbital cases.
There are a multitude of perioperative concerns in these cases. Preoperative evaluation often reveals post-COVID pulmonary, cardiovascular, renal, and coagulation abnormalities. The patient presents with breathlessness, cough, fatigue, and limited exercise tolerance. ABG, CXR, and SpO2 are thus of utmost importance. In this study, 59% of patients had SpO2 of less than 90% (room air) and almost 86% of patients had 4 zones of lung involvement on CXR [Table 2]. A preoperative ABG showed 34% of patients with partial pressure of oxygen in the range of 60–80 mmHg while 7% with less than 60 mmHg.
AmB used for the treatment of Mucor infection was started in a dose of 1 mg.kg−1 as an infusion over 4–6 h 2–5 days preoperatively. It causes side effects such as infusion-related reactions, electrolyte imbalance (hypokalemia, hypomagnesemia), nephrotoxicity, and thrombophlebitis during infusion. Infusion-related reactions include rigor, chills, headache, nausea, malaise and rashes. Eighty percent of patients presented with hypokalemia, fever, and hypovolemia. Insulin infusions for the treatment of diabetes can also add to hypokalemia. Correction of potassium pre- and intra-operatively, fluid resuscitation with CVP monitoring, and injection paracetamol for fever were thus required. Hypokalemia and hypomagnesemia can lead to delayed recovery from neuromuscular blocking drugs and arrhythmias, and thus, monitoring serum electrolytes is mandatory. Longstanding diabetes leads to diabetic nephropathy and acid–base disturbances which is in addition to the effects caused by AmB and post-COVID renal injury., Four patients had renal dysfunction requiring dialysis in this study. Here, titrated doses of drugs were used and postoperative dialysis was continued. Monitoring urine output and renal function is essential.
Diabetes is one of the major causative factors for this disease, and 78% of patients were diabetics in this study. 55% of patients had BSL in the range of 160–180 mg.dL−1 and 47% of patients had BSL greater than 200 mg.dL−1 on the day of surgery. Perioperative monitoring of blood sugar is thus very important.
In this study, 25% were diabetics with hypertension (HT) and ischemic heart disease (IHD), and 5% and 7% had isolated HT and IHD, respectively. Others were post coronary artery bypass graft (CABG), postangioplasty, had evidence of paroxysmal atrial fibrillation, hypothyroidism, pacemaker in situ, thrombocytopenia, anemia, renal failure, and psychiatric illness.
COVID-19 can have both primary (arrhythmias, myocardial infarction, myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. This can lead to dysrhythmias and ischemia and nonischemic cardiomyopathy. Therefore, continuous electrocardiography monitoring is required. Preoperative echocardiography is desirable.
The patients are on anticoagulants immediate post-COVID. A majority of the patients were either on tablet rivaroxaban or low molecular weight heparin (LMWH) which were stopped 24 h and 12 h prior respectively as per the guidelines.
Patients with associated IHD were on clopidogrel and aspirin. Tablet clopidogrel was stopped 5 days prior and so was tablet warfarin for a patient with a stent in situ. These patients were given bridge therapy with LMWH. Thus, blood loss may be a concern. However, in this study, no case had a major blood loss.
Anemia may be present due to prolonged illness with poor nutrition due to edema and pain. Preoperative transfusion is often required. 12% of patients had hemoglobin less than 8 g/dL and needed blood transfusion for optimization.
Facial and supraglottic edema, fungal debris in the oropharyngeal region, and palatal perforation lead to difficult mask ventilation, laryngoscopy and endotracheal intubation. Mouth opening may be restricted due to pain and joint erosion along with joint stiffness associated with DM. In this study, almost 43% of patients were MPC grade 3 and 4 with inter incisor distance less than 2.5 cm in 59% of patients. Endotracheal intubation was facilitated using a large Macintosh laryngoscope blade or a C-Mac video-laryngoscope with the aid of a stylet to guide the endotracheal tube. Where palatal perforation was present, a gauze pack was kept to aid laryngoscopy. Loose teeth were often a concern and had to be taken care of during laryngoscope insertion. Difficult extubation is also a concern in view of delayed awakening, electrolyte and acid–base imbalance, hypothermia, poor lung and central nervous system (CNS) involvement, and nasal packing besides removal of palate and maxilla.
Since FESS and endotracheal intubation are aerosol-generating procedures, the use of personal protective equipment is desired.
All the patients were reverse transcriptase polymerase chain reaction (RT-PCR) negative at the time of surgery. The timing between the COVID infection and operative procedure is important. Ideally, one must wait for at least 4–6 weeks before taking up any COVID-infected patient for surgery. However, as these patients were emergency cases, they had to be done within 2 weeks of COVID-negative status.
Propofol for induction of anesthesia was preferred considering a hyperreactive respiratory tract and probable anticipated difficult intubation. Short-acting depolarizers suxamethonium for intubation and atracurium for maintenance of muscle relaxation were preferred considering the difficult airway and renal dysfunction, respectively.
Total intravenous anesthesia (TIVA) for FESS is also a good option. However, we preferred inhalational anaesthetic isoflurane for maintenance considering delayed awakening due to continuous infusion in these critically ill patients. A possible antibacterial and antifungal action of isoflurane has been suggested.
Intraoperative-induced hypotension was avoided in these already hypovolaemic and often hypotensive patients.
All patients need postoperative care in the high-dependency care unit or ICU in view of postoperative edema, nasal pack, palatal dissection, preoperative poor lung function, a poor GCS preoperatively, and often oxygen requirement. Besides blood glucose, potassium, urine output, SpO2 and acid–base status need to be monitored.
We were not able to do follow-up of patients after 15 days to determine the outcome of the patient, which was a limitation of this study.
Perioperative uncontrolled diabetes with hypokalemia, preoperative oxygen requirement, extent of mucormycosis, post-COVID or non-COVID disease, duration from COVID infection to surgery, and their relationship with the postoperative outcome can be a hypothesis for further research.
| Conclusion|| |
This study of 238 patients posed a major challenge to the anesthesiologists, and we successfully conducted these cases with thorough knowledge of the pathophysiology of the disease and perioperative vigilance. We need to be prepared for a myriad of patients with other post-COVID sequelae in the future.
We thank the Department of Otorhinolaryngology, Neurosurgery, and Ophthalmology, BJ Government Medical College and Sassoon General Hospitals, Pune.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]