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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 136-138

Post-COVID rhino-cerebral mucormycosis: Lidocaine infusion for stable peri-operative hemodynamic


Department of Anaesthesia, Indra Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Submission16-Aug-2021
Date of Decision22-Oct-2021
Date of Acceptance05-Nov-2021
Date of Web Publication6-Dec-2021

Correspondence Address:
Nidhi Arun
E/302, Jalalpur Heights, Mansarovar Colony, RPS More, Patna - 801 503, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jigims.jigims_34_21

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  Abstract 


Mucormycosis emerged as major post COVID complication in India. Its management involves Amphotericin B and surgical debridement. Anaesthesia becomes challenging in such patients due to compromised patients, extensive surgery and side effects of Amphotericin B. We present the successful management of a rhino-cerebral mucormycosis patient with lidocaine infusion.

Keywords: Amphotericin B, COVID-19, lidocaine, mucormycosis


How to cite this article:
Arun N, Choudhary A. Post-COVID rhino-cerebral mucormycosis: Lidocaine infusion for stable peri-operative hemodynamic. J Indira Gandhi Inst Med Sci 2021;7:136-8

How to cite this URL:
Arun N, Choudhary A. Post-COVID rhino-cerebral mucormycosis: Lidocaine infusion for stable peri-operative hemodynamic. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Jan 23];7:136-8. Available from: http://www.jigims.co.in/text.asp?2021/7/2/136/331749




  Introduction Top


Second wave of coronavirus disease (COVID) was associated with increasing number of cases of post-COVID complications such as shortness of breath, easy fatigability, chest pain, joint pain, disturbed sleep pattern, and fungal infection. Post-COVID mucormycosis was most devastating among them. India alone contributed around 71% of total global cases.[1] The most common presentation is rhino-orbital-cerebro involvement.

Apart from the challenges such as preexisting comorbidities, COVID-associated damages, prolonged extensive surgery, difficult airway, and massive fluid shift, renal and cardiac side effects of amphotericin B therapy were our major concerns, while anesthetic management of these patients. Here, we present the successful management of a 58-year-old male with rhinocerebral mucormycosis, posted for open surgical debridement under general anesthesia. As per our previous experiences, incidence of intraoperative arrhythmia was found to be quite high in such cases. Intravenous (IV) lidocaine is widely used for the treatment of intraoperative arrhythmia. Thus, we used IV bolus and infusion of lidocaine to prevent intraoperative arrhythmia.


  Case Report Top


A 58-year-old male weighing 70 kg, with a medical history of diabetes mellitus (DM) type II and coronary artery disease (CAD) since 10 years and COVID-19 infection, diagnosed with rhinocerebral mucormycosis, was posted for open surgical debridement [Figure 1]. The patient was on amphotericin B and insulin apart from antibiotics, low-molecular-weight heparin, aspirin, atorvastatin, and isosorbide dinitrate. On evaluation, his echocardiography shows that right wall motion abnormality with ejection fraction of 40% and 25% points computed tomography of chest severity score was 18/25, metabolic equivalent was <4, and breath holding time was 10 s. Laboratory investigations revealed anemia (hemoglobin [Hb]-7.8 mg dl−1) and hypokalemia (potassium (K+)-2.7 mEq L−1). Other biochemical parameters were within normal limits. Measures were taken to correct hypokalemia and anemia. Informed high-risk consent was taken, and the patient was taken up for surgery.
Figure 1: Computed tomography brain showing rhinocerebral mucormycosis

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The patient was kept fasted for 8 h before surgery. Morning dose of insulin was omitted. On the day of surgery, his serum K + was 3.2 and Hb was 8.9 mg dl−1. In operation theater, standard monitors such as noninvasive blood pressure, electrocardiogram, pulse oximeter (SP02), temperature, and end-tidal carbon dioxide (EtCO2) were attached. The patient was premedicated with injection (inj) midazolam 2 mg, injection glycopyrrolate 0.2 mg, and injection fentanyl 140 μg. Preoxygenation was done with 100% oxygen for 3 min. Anticipating difficult airway, difficult airway cart was kept ready. Before induction, IV bolus of 5.25 ml lidocaine (1.5 mg kg−1) followed by infusion at the rate of 7 ml/h (2 mg kg−1 h−1) was started. Induction was done with 100 mg of injection propofol. Injection rocuronium (84 mg) was administered after checking ability to perform positive pressure ventilation (PPV), and airway was secured with cuffed endotracheal tube. Anesthesia was maintained with intermittent positive-pressure ventilation with O2 and N2O (50:50), isoflurane and cisatracurium infusion. Throat was packed with wet gauze ribbon. Under ultrasound guidance, the right subclavian venous cannulation was done with 7F triple lumen catheter. The right radial artery was cannulated with 20G catheter. Along with all basic monitoring, bispectral index, central venous pressure (CVP), invasive blood pressure, temperature, hourly arterial blood gas analysis and random blood sugar (RBS), and urine output were monitored. Glucose–insulin–potassium solution was started and titrated to keep RBS below 180 mg dl−1. CVP-guided balanced isotonic fluid was administered to keep CVP around 8–10 cm of H2O. Surgery was extensive involving complete removal of fungus-affected necrotic tissue over 4 h. Blood loss while surgery was monitored and replaced by transfusion of 2 units of cross-matched packed red blood cells. IV paracetamol (1 g) was given for analgesia. Vital parameters remained stable throughout the surgery. After the end of surgery, infusion lidocaine was stopped. The patient was reversed, extubated, and shifted to intensive care unit and monitored for 48 h. IV paracetamol (1 g) thrice a day was used for postoperative analgesia. IV morphine (0.05 mg k−1) was decided to be used as rescue analgesia. Numerical rating scale was <4, and there was no need of rescue analgesia. Postoperative period was uneventful.


  Discussion Top


COVID-associated mucormycosis is convergence of uncontrolled blood sugar and immunodeficiency caused by COVID infection and use of steroids.[2] The treatment of mucormycosis is amphotericin B and surgical debridement. Amphotericin B use is associated with multiple side effects.

Even after getting recovered from COVID infection, residual organ damage has been seen. Based on available evidence, the bulk of post-COVID-19 complications seem to be associated with the cardiopulmonary systems. The cardiac post-COVID-19 manifestations include myocarditis, arrhythmia, and ischemia. In a study by Wang et al., 7.2% of patients had either elevated troponin levels or new electrocardiography or echocardiography abnormalities suggestive of cardiac injury.[3] Blood pressure abnormalities can also be seen in response to the illness.[4] In addition, palpitations due to arrhythmia have been observed.[5] The most common pulmonary complications reported are bacterial pneumonia, pneumothorax, and pleural effusion. Other systemic post-COVID-19 symptoms often noted include fatigue, headache, body pains, dyspnea, and anxiety/depression.[6]

Associated DM and CA D with damages caused by COVID infection in prolonged extensive type of surgery, make anesthetic management of this case challenging. Our goal was (a) preoperative optimization, (b) invasive monitoring, (c) stable intraoperative hemodynamic, (d) prevention of arrhythmia, (e) maintenance of fluid, electrolyte, and blood loss, (f) blood sugar control, and (g) postoperative pain management.

Amphotericin B impairs renal function and causes hypokalemia, hypomagnesemia, and hypotension which contribute to high incidence of intraoperative arrhythmia.[7] Thus, it becomes necessary to maintain an adequate mean arterial pressure, cardiac output, and fluid electrolyte balance to prevent any arrhythmia which can cause further renal insults.

IV lidocaine has been highly effective in preventing and terminating ventricular premature beats and ventricular tachycardia occurring during surgery without decreasing ventricular contractility, cardiac output, arterial pressure, or heart rate.[8] In addition, lidocaine has analgesic, antinociceptive, immunomodulating, and anti-inflammatory properties.[9],[10] Therefore, lidocaine infusion has been studied in various surgeries for hemodynamic stability, prevention and management of arrhythmia, attenuation of propofol-associated pain at injection site, sedation, analgesia, sparing of opioid and other anesthetic agents, and shorter hospital stay.[11],[12] The use of lidocaine infusion as a component of opioid-sparing multimodal analgesia under careful monitoring is also recommended in enhanced recovery after surgery protocols.

Infusion lidocaine offered various advantages without any toxicity. We observed that bolus lidocaine nullified the laryngoscopy-induced sympathetic response which was very crucial in this patient in view of associated CAD.[13] Further, the infusion spares opioid consumption, which led to early recovery. It has synergistic analgesic effect and prevents development of any chronic pain by its anti-inflammatory action on central neurons.[14] In a study by Kranke et al., lidocaine infusion was found to be not only effective in the reduction of postoperative pain but also expedited gastrointestinal recovery time, reduced postoperative nausea/vomiting, reduced opioid usage, and a reduction in hospital length of stay.[15]


  Conclusion Top


Infusion lidocaine was one point solution of all issues in our patient. We suggest usage of IV lidocaine in therapeutic dose with vigilant eye for any signs of toxicity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prakash H, Chakrabarti A. Global epidemiology of mucormycosis. J Fungi (Basel) 2019;5:26.  Back to cited text no. 1
    
2.
John TM, Jacob CN, Kontoyiannis DP. When uncontrolled diabetes mellitus and severe COVID-19 converge: The perfect storm for mucormycosis. J Fungi (Basel) 2021;7:298.  Back to cited text no. 2
    
3.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 3
    
4.
Khashkhusha TR, Chan JS, Harky A. ACE inhibitors and COVID-19: We don't know yet. J Card Surg 2020;35:1172-3.  Back to cited text no. 4
    
5.
Liu K, Fang YY, Deng Y, Liu W, Wang MF, Ma JP, et al. Clinical characteristics of novel coronavirus cases in tertiary hospitals in Hubei Province. Chin Med J (Engl) 2020;133:1025-31.  Back to cited text no. 5
    
6.
COVID-19 (Coronavirus): Long-Term Effects. Mayo Clinic. Available from: https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351. [Last accessed on 2021 May 10].  Back to cited text no. 6
    
7.
Wong KC, Schafer PG, Schultz JR. Hypokalemia and anesthetic implications. Anesth Analg 1993;77:1238-60.  Back to cited text no. 7
    
8.
Collinsworth KA, Kalman SM, Harrison DC. The clinical pharmacology of lidocaine as an antiarrhythymic drug. Circulation 1974;50:1217-30.  Back to cited text no. 8
    
9.
Yardeni IZ, Beilin B, Mayburd E, Levinson Y, Bessler H. The effect of perioperative intravenous lidocaine on postoperative pain and immune function. Anesth Analg 2009;109:1464-9.  Back to cited text no. 9
    
10.
Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: A new therapeutic indication? Anesthesiology 2000;93:858-75.  Back to cited text no. 10
    
11.
Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH, Hahnenkamp K, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018;6:CD009642.  Back to cited text no. 11
    
12.
Picard P, Tramèr MR. Prevention of pain on injection with propofol: A quantitative systematic review. Anesth Analg 2000;90:963-9.  Back to cited text no. 12
    
13.
Jain S, Khan RM. Effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia. Indian J Anaesth 2015;59:342-7.  Back to cited text no. 13
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14.
Challapalli V, Tremont-Lukats IW, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev 2005;2005:CD003345.  Back to cited text no. 14
    
15.
Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015;(7):CD009642.  Back to cited text no. 15
    


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