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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 201-205

Recovery from anaesthesia in post-COVID-19 mucormycosis debridement surgery: An observational study


1 Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
2 Department of ENT, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Date of Submission11-Jun-2022
Date of Acceptance06-Jul-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Roopa Sachidananda
Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli - 580 021, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_54_22

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  Abstract 


Background: Mucormycosis has emerged as the most common lethal post-COVID-19 infection. Since the onset of the COVID-19 pandemic, anaesthesiologists have faced the challenge of anaesthetising post-COVID mucormycosis patients, which requires extensive surgical debridement. Various perioperative factors can have an impact on the recovery from the neuromuscular blockade of these patients. Aims and Objectives: This study was undertaken to observe the recovery pattern from the neuromuscular blockade and the impact of various factors on extubation time. Materials and Methods: The retrospective study included all post-COVID-19 mucormycosis patients who underwent debridement surgery under general anaesthesia in a tertiary referral hospital. All the pre-anaesthetic evaluation charts, treatment charts and anaesthetic management charts were reviewed. The following outcome variables at recovery from anaesthesia were noted: duration of surgery, duration of anaesthesia and extubation time. Results: A total of 72 patients underwent post-COVID-19 debridement surgery in the study period, of which 26 patients were excluded from the study and 46 patients were included in the analysis. The median extubation time was 32 min and interquartile range was 7–37 min. Seventeen (37%) patients were extubated in <15 min and 29 (63%) patients were extubated after 15 min. The shortest extubation time was 2 min, whereas the longest was 1440 min. Conclusion: Extubation time was prolonged when post-COVID patients underwent debridement surgery for rhino-orbito-cerebral mucormycosis. Although pre-operative and intraoperative factors can impact recovery from neuromuscular blockade, our study did not demonstrate such findings. Delayed extubation time may be related to the COVID illness rather than pre-operative risk factors.

Keywords: Anaesthesia recovery, COVID-19, extubation, Mucormycosis, muscle weakness


How to cite this article:
Sachidananda R, Ladhad DA, Joshi V, Kurdi MS, Bhat VK, Sarasamma AG. Recovery from anaesthesia in post-COVID-19 mucormycosis debridement surgery: An observational study. Hamdan Med J 2022;15:201-5

How to cite this URL:
Sachidananda R, Ladhad DA, Joshi V, Kurdi MS, Bhat VK, Sarasamma AG. Recovery from anaesthesia in post-COVID-19 mucormycosis debridement surgery: An observational study. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:201-5. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/201/364688




  Introduction Top


Rhino-orbito-cerebral mucormycosis is a fulminant, opportunistic fungal infection most commonly seen in people with diabetes and immunocompromised individuals. The classical features of mucormycosis are angioinvasion, thrombosis, infarction and necrosis. There was an epidemic of mucormycosis following the second wave of COVID-19 in India and many other nations.[1],[2]

Management of such cases includes early diagnosis, high-dose intravenous amphotericin B (AmB), extensive surgical debridement of the necrotic tissue, control of underlying disease and other supportive measures.[3]

The coexistence of sepsis, systemic illnesses like diabetes mellitus (DM), hypertension, ischaemic heart disease, immunosuppression and airway-related morbidities make anaesthetic management even more challenging.

Multiorgan failure, the use of AmB, steroids, intraoperative anaesthetic agents and various other factors can have an impact on the recovery from neuromuscular blockade of these patients. Hence, this observational study was undertaken. The primary objective was to observe the recovery pattern from the neuromuscular blockade and the impact of various factors on extubation time. The secondary objective was to observe the various pre-operative and intraoperative risk factors associated with the recovery from neuromuscular blockade.


  Materials and Methods Top


This retrospective study included all post-COVID-19 mucormycosis patients who underwent debridement surgery under general anaesthesia from 1 July to 31 July, 2021, in a tertiary referral hospital. The institutional ethical committee approved the study (KIMS: ETHICS COMM 429:2021-22 dated 21 September, 2021). The study was registered in the Clinical Trials Registry of India (CTRI/2021/10/037653). All the pre-anaesthetic evaluation charts, treatment charts and anaesthetic management charts were reviewed. Those patients who underwent debridement surgery for non-COVID mucormycosis, or Mucor occurring due to post-transplant immunosuppression, uraemia, burns, malnutrition, malignancy and chemotherapy, pregnant and paediatric patients were excluded from the study.

In all the cases, general anaesthesia was induced using propofol and fentanyl. Succinylcholine was administered to facilitate intubation. Anaesthesia was maintained with atracurium or vecuronium and sevoflurane. Paracetamol infusion was administered intraoperatively in addition to fentanyl as an analgesic. Volume-control or pressure-control mode was used for ventilating the patients. Intraoperatively, crystalloids or blood were transfused as per the requirement. All patients were monitored using an electrocardiogram, non-invasive blood pressure, pulse oximeter and end-tidal carbon dioxide (ETCO2). Neuromuscular monitoring was used for selected patients. Neostigmine was used as a reversal agent. All patients were extubated after assessing for adequate recovery from muscle power using clinical criteria.

The total requirement of propofol, fentanyl, atracurium/vecuronium and reversal agent was noted as mentioned in the records. Following outcome variables at recovery from anaesthesia were noted: duration of surgery: skin incision to end of the surgery; duration of anaesthesia: induction to discontinuation of the anaesthetic agent; extubation time: from the conclusion of surgery to extubation of the endotracheal tube.

Data were entered into Microsoft Excel and statistical analysis was carried out using SPSS software (SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago). Qualitative variables were presented as frequency and percentages. Quantitative variables were presented as mean (standard deviation) or median (range) depending on the data distribution. Extubation time was categorised into binary outcomes (normal extubation – <15 min and delayed extubation of more than 15 min). Laboratory, anaesthetic and surgical parameters were compared between the two groups. Independent t-test or Mann–Whitney test was used based on the normality of the data. P < 0.05 were considered for statistical significance.


  Results Top


A total of 72 patients underwent post-COVID-19 debridement surgery during the study period, of which 26 patients were excluded from the study due to insufficient data and 46 patients were included in the analysis. The demographic profile, pre-operative characteristics, investigations and recovery times are shown in [Table 1], [Table 2], [Table 3]. Thirteen patients underwent revision surgery. Thirty-five patients were male and 11 were female patients. The youngest patient was of age 25 years, whereas the oldest was 80 years. The median extubation time was 32 min and interquartile range was 7–37 min. Seventeen (37%) patients were extubated in <15 min. Of these 17 patients, seven patients were on oxygen and one patient was on non-invasive ventilation for COVID illness. Details of five patients were unavailable while four patients did not require oxygen.
Table 1: Demographic characteristics, surgery time and anaesthesia time

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Table 2: Pre-operative characteristics

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Table 3: Pre-operative investigations

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Twenty-nine patients (63%) were extubated after 15 min. Of these 29 patients, 12 patients were on oxygen therapy and one patient required non-invasive ventilation for COVID illness. Details of five patients were unavailable while 11 patients did not require oxygen.

The shortest extubation time was 2 min, whereas the longest was 1440 min. Extubation time was prolonged with an increased duration of anaesthesia (P = 0.04).

Seven patients from the normal extubation group and 12 patients from the prolonged extubation group had received steroids. Five patients from the regular extubation group and 10 patients from the prolonged extubation group had not received steroids. Details of 12 patients with regard to treatment with steroids were unavailable. Forty-four patients had diabetes, ten of these had hypertension, two were known cases of hypothyroidism and one had a history of stroke.

The comparison of laboratory parameters is shown in [Table 3]. There was no statistically significant difference between the two groups. The mean white blood cell count was 7690 ± 2590.00 cells/mm3 (maximum 14,400, minimum 3300 and median 7050). The mean platelet count was 2.74 ± 1.08 lac cells/mm3 (maximum 6.4, minimum 1.09 and median 2.72).

The anaesthetic parameters are shown in [Table 4]. There was a statistically significant difference between the two groups with respect to total anaesthesia time (P = 0.04). Pre-induction, post-induction and post-extubation haemodynamics are shown in [Figure 1]. There was no statistically significant difference between them at any level of anaesthesia (P value for heart rate was 0.4, systolic blood pressure 0.12 and diastolic blood pressure 0.1).
Figure 1: Comparison between vitals at all levels of anaesthesia. HR: Heart rate bpm, SBP: Systolic blood pressure, DBP: Diastolic blood pressure

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Table 4: Intraoperative anaesthetic requirement

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Mean ETCO2 was 41.71 ± 5.73 mmHg to 47.13 ± 6.12 mmHg (maximum 53 to 58 and minimum 32 to 38 and median 42 to 48).

One patient from the regular extubation group and five patients from the prolonged extubation group required admission to the intensive care unit (ICU). Of these five patients, which required ICU admission, the first patient had pulmonary mucormycosis. The second patient was a 65-year-old female with a history of DM, hypertension and hypothyroidism who needed the support of a ventilator due to extensive disease involvement. This patient had ethmoid, maxillary, frontal and sphenoid sinusitis with infiltrations into the infratemporal fossa and cavernous sinus thrombosis. The third patient was a 60-year-old male with a history of DM and hypertension, who required noradrenaline infusion intraoperatively. The fourth patient was a 50-year-old male with DM who was hospitalised for 1 month for COVID illness, was on non-invasive ventilation and was thrombolysed for pulmonary thromboembolism. The fifth patient was an 80-year-old female with DM, hypertension and ischaemic heart disease.


  Discussion Top


Mucormycosis has emerged as the most common lethal post-COVID-19 infection. Since the onset of the COVID-19 pandemic, anaesthesiologists have faced the challenge of anaesthetising post-COVID mucormycosis patients. In the present study, we have demonstrated variable periods of extubation, with prolonged extubation time in 29 patients who underwent endoscopic debridement of the nose, paranasal sinuses, palate, orbit and even the brain.

Mucormycosis patients were invariably treated with liposomal AmB, which had the side effects such as nephrotoxicity, hypotension, hypokalaemia, hypomagnesaemia and arrhythmias. The altered electrolyte balance and renal function can interfere with the regular activity of the neuromuscular blocking agents, thus leading to prolonged extubation.[4],[5],[6]

However, in our study, many of these pre-operative factors did not have an impact on the extubation time [Table 2] and [Table 3].

The age, body mass index, duration of anaesthesia and surgery, as well as the concentration of volatile inhalant used, have been shown to affect neuromuscular blockade recovery. The same results were demonstrated in our study too.[7],[8] The requirement of neostigmine was significantly more in the prolonged extubation group. Residual paralysis, hypoventilation, hypercarbia, impaired ventilatory response to hypoxia, hypothermia, acidosis and slower clearance of inhalation agents can also affect recovery.[9] Some of these factors could have implications in our patients too; details of which were not available.

COVID-19 has affected all the organ systems in the human body, including the skeletal muscles. Skeletal muscles and muscle cells such as leucocytes, fibroblasts and endothelial cells express angiotensin-converting enzyme receptors. Therefore, skeletal muscles are also susceptible to SARS-CoV-2.[10]

Many of our patients required prolonged hospitalisation, some of them were on oxygen therapy, whereas few required admissions to ICU. Acquired myopathy 1-month post-discharge is a common sequela in ICU-treated COVID-19 patients. The exact aetiology of critical illness myopathy in these patients is not known, but the hallmark of this illness seems to be the loss of myosin filaments.[11],[12]

In these patients, the illness lasted from a few days to months, this could have led to impaired muscle power as a sequel of viral illness. We observed that, although these patients regained consciousness they could not be extubated due to reduced muscle strength.

In a case–control study of patients who died of severe COVID-19 infection, an autopsy of a skeletal muscle sample showed mild-to-severe myositis. The authors presumed that SARS-CoV-2 might be associated with post-infection immune-mediated myopathy.[13]

Persistent fatigue and muscle weakness which is a part of long-COVID or post-COVID fatigue syndrome is a new issue concerning COVID and may reduce muscle strength.[14]

Steroids can also cause neuropathy and myopathy.[15],[16]

We presume that in our study, delayed extubation time which was observed in some patients may be related to the COVID illness rather than pre-operative risk factors.

Limitations of the study

This is an observational study of 46 patients and data regarding a few parameters were insufficient. Future studies may be conducted with a larger sample size correlating inflammatory markers that may reflect muscle injury with the extubation time.


  Conclusion Top


Extubation time was prolonged when post-COVID patients underwent debridement surgery for rhino-orbito-cerebral mucormycosis. Although pre-operative and intraoperative factors can impact recovery from neuromuscular blockade, our study did not demonstrate such findings. Delayed extubation time may be related to the COVID illness rather than pre-operative risk factors.

Acknowledgements

The author would like to thank Dr Milon V Mitragotri Dr Arunima, Dr Amrutha, Dr Athira Dr Srinidi Deshpande Department of Anaesthesia, KIMS Hubli Karnataka, India.

Ethical statement

The study was approved by the institutional Ethics Committee of KIMS Hubballi with registration number KIMS:ETHICS COMM429:201-2022 dated 21st September 2021.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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