Parin Lalwani

Abstract

Introduction: During the second wave of COVID -19 Indian subcontinent suffered another pandemic of covid associated mucormycosis (CAM) which further burderned the already overexhausted health care infrastructure. Objective: To share our experience of anaesthetic management of eighteen patients with covid associated mucormycosis who underwent surgical resection of necrotized tissues at a tertiary care hospital of North India. Material and Methods: Eighteen patients with COVID-19 infection or previous history of COVID-19 infection based on RT-PCR and histopathologically proven rhino orbital mucormycosis, presented for endoscopic and open surgeries during May and June 2021. According to institutional protocol, institutional ethical committee clearance was not required for a case series. Data regarding the demographic details, clinical manifestations, COVID-19 course, laboratory parameters, imaging reports, pre-operative evaluation, airway management, intraoperative and postoperative management, and complications were collected. Results: Out of eighteen patients 12(66.7%) were male and six (33.33%) were female, with a median age of 51 years. Six patients (33.33%) had a past history of COVID-19, twelve patients had concurrent COVID-19 (66.66%). Most of the patients presented with unilateral facial swelling, retro-orbital pain, ptosis and headache. Fifteen (83.33%) patients had high blood sugars, seven (46.66%) were known type 2 diabetics and eight (53.33%) developed new-onset diabetes after taking prolong systemic corticosteroids. All eighteen patients received antifungal treatment, and eight (44.44%) patients had derranged renal function tests with raised serum creatininine (2.4-2.8) and normal blood urea nitrogen. Eight (44.44%) of them had difficult airway because of swelling on face and limited mouth opening, two patients were reoperated (n=2/18). Three (27.27%) patients deveoped arrythmias and ST changes intraoperatively, two(n=2/18) patients were extubated next day after surgery, one patient was tracheostomised in view of preoperative difficult airway and extensive surgery. One fifty-five year old covid positive female patient died on fifth postoperative day. Discussion: In our case series, all 18 patients had covid associated rhino-orbital mucormycosis, most of them had diabetes and hypertension, cerebrovascular accident, coronary artery disease, asthma and post KTP status. Twelve patients were covid positive and 6 had recent history of covid. One patient developed hemiparesis and one patient died because of intracranial extension of mucormycosis. Disseminated or cerebral mucormycosis, severe covid, elderly age group, associated comorbidities like uncontrolled diabetes and renal failure have been found to increases mortality in CAM patients. Conclusion: Physicians caring for covid associated mucormycosis patients must be aware of the severity of the covid-19 as well as mucormycosis, associated comorbidities and various side effects of the medications used for treatment. Early diagnosis and timely medical and surgical management are necessary to improve outcome in covid associated mucormycosis.   Keywords: Insulin, Surgical debridement, Amphotericin- b, Personal protective equipment, Diabetes, Steroid, Rhno- orbito-cerebral, Difficult airway, Mucormycosis, COVID- 19.

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Abstract

Background: The COVID-19 pandemic resulted in nationwide lockdown followed by phased unlock to break the chain of transmission of the SARS-CoV-2 virus in India. Management of emergency trauma patients has been particularly challenging for anaesthesiologists in order to treat these high risk group of patients and preventing cross infection to healthy patients as well as health care personnel. Materials and Methods : It is a single centre retrospective observational cohort study conducted at tertiary care hospital in North India in the patients who underwent emergency trauma surgeries during 31 March 2020-31 May 2020(Lockdown) and compared with data from 1 June 2020-31 July 2020(Unlock). Primary Objective: To compare the effect of lockdown and unlock during first wave of Covid-19 pandemic on the volume of emergency trauma surgical patients operated within 24 hours of admission. Secondary Objective: To evaluate the difference between the two periods of lockdown and unlock a) in the mortality rates b) covid status c) the length of hospital stay d) the mechanism of injury e)severity of injury f)proportion of aerosol generating procedures (AGP) utilized and g)demographics of the patients. Our anaesthesia experience of managing the patients differently in the pandemic, identify areas for improvement, particularly in terms of minimising exposure and optimising resource usage in the management of such emergency patients in the event of a future healthcare crisis is also discussed. Results: Over the 2 periods of lockdown and unlock there was no statistical difference in number, age or sex distribution of the patients presenting for emergency trauma surgery. Number of covid positive patients were slightly higher during unlock but it was statistically insignificant (p=0.07) and the number of patients died during unlock was also higher during unlock as compared to lockdown but statistically insignificant(p=0.3). The median injury severity score and length of stay was also not statistically significant between two periods. Road traffic accidents were most common type of injury in both the groups, self-inflicted injury occurred in 5 patients during lockdown and zero during unlock, none of these showed a significant difference (p > 0.06). General anaesthesia was the most common anaesthesia technique used in both the periods. Conclusion: Emergency trauma surgeries will continue to occur even in different phases of pandemics, anaesthesiologists should plan and prepare appropriately to provide anaesthesia and emergency care to these patients and prevent cross infection in healthy patients and health care workers.   Keywords: Pandemic, COVID- 19, Lockdown, Unlock, Anaesthesia.

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