CASE REPORT |
https://doi.org/10.5005/jp-journals-10049-2041 |
Anesthetic Challenges in an Elderly Patient with Rhino-orbital Mucormycosis, Uncontrolled Diabetes Mellitus, and Cardiac Autonomic Dysfunction for Emergency Surgical Debridement
1–4Department of Anesthesiology and Critical Care, Command Hospital Air Force, Bengaluru, Karnataka, India
Corresponding Author: Manimaran P, Department of Anesthesiology and Critical Care, Command Hospital Air Force, Bengaluru, Karnataka, India, India, Phone: +91 9003968784, e-mail: dr.manimaran@gmail.com
Received: 02 December 2023; Accepted: 26 March 2024; Published on: 26 July 2024
ABSTRACT
This case report outlines the successful anesthetic management of a 78-year-old patient with rhino-orbital mucormycosis, uncontrolled diabetes mellitus (DM), cardiac autonomic neuropathy (CAN), and coronary artery disease (CAD) who underwent an emergency surgical debridement. The challenges included an anticipated difficult airway due to fungal debris, palatal perforation, and glottic edema, exacerbated by the patient’s complex medical history. The presence of CAN heightened the risk of perioperative cardiovascular complications. The successful approach involved invasive monitoring, careful administration of medications, and a multidisciplinary strategy to address both anatomical and physiological airway difficulties. This report contributes to the understanding and preparation for anesthetic challenges in similar emergency scenarios involving elderly patients with multiple comorbidities.
How to cite this article: Mishra SK, Sapra A, Bhatti P, et al. Anesthetic Challenges in an Elderly Patient with Rhino-orbital Mucormycosis, Uncontrolled Diabetes Mellitus, and Cardiac Autonomic Dysfunction for Emergency Surgical Debridement. Res and Innov Anesth 2024;9(1):24–27.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Cardiac autonomic neuropathy, Case report, Diabetes mellitus, Rhino-orbital mucormycosis.
PATIENT PARTICULARS AND CLINICAL HISTORY
A 78-year-old patient with rhino-orbital mucormycosis, uncontrolled diabetes mellitus (DM) [glycated hemoglobin (HbA1c) 13.8], cardiac autonomic neuropathy (CAN), and coronary artery disease (CAD) presented for emergency surgical debridement. The patient’s medical history included a 30-year history of diabetes, CAD with regional wall motion abnormalities, moderate pulmonary artery hypertension (PAH), and chronic kidney disease (CKD) stage 3. The anesthetic plan involved general anesthesia with invasive monitoring.
PATIENT’S MEDICAL HISTORY AND COMORBIDITIES
The patient had uncontrolled DM (HbA1c 13.8) along with CAN. Random blood sugars were recorded at 446 mg/dL, and urine ketones were negative, leading to the initiation of insulin infusion on a sliding scale. The patient has been a known diabetic for 30 years with poor compliance with medications.
The patient’s uncontrolled DM and CAN presented challenges in maintaining hemodynamic stability. Rhino-orbital mucormycosis complicated airway management. We expected a difficult airway, so the difficult airway cart was kept on standby, but the patient had an uneventful intubation. The administration of amphotericin B required careful monitoring due to potential side effects. Intraoperatively, the patient experienced bradycardia and hypotension attributed to diabetic CAN, necessitating prompt interventions.
In addition, the patient had a history of CAD spanning 20 years. Two-dimensional echocardiography findings indicated regional wall motion abnormality in the left anterior descending territory-severe hypokinesia and right coronary artery territory with mild hypokinesia. The left ventricular (LV) ejection fraction was 35–40%. Other cardiac conditions included moderate PAH, mild tricuspid regurgitation, and a sclerosed aortic valve. The electrocardiogram showed LV hypertrophy with ventricular premature contractions and desynchrony.
Furthermore, the patient was diagnosed with CKD stage 3, with serum creatinine at 2.2 mg/dL and blood urea at 98 mg/dL, uncontrolled hypertension, managed with irregular medications for 3 decades, and electrolyte imbalance (potassium 2.9 mEq/sodium 129 mEq/L) added to the patient’s complex medical profile. Considering these factors, the patient was classified as American Society of Anesthesiologists (ASA) class IV E. The anesthesia plan encompassed general anesthesia with invasive arterial line monitoring.
ANESTHESIA CONCERNS
The patient’s uncontrolled DM coupled with CAN presented a major anesthetic challenge—maintaining hemodynamic stability in the presence of reduced physiological reserve and CAN.1 Additionally, the goal was to mitigate the risk of adverse outcomes such as perioperative myocardial ischemia/infarction, arrhythmias, heart failure, postoperative cognitive dysfunction, and stroke factors that could escalate perioperative morbidity and mortality.2,3
The presence of severe rhino-orbital mucormycosis introduced further complexity. The anticipated difficulties in mask ventilation and intubation due to fungal debris at the laryngeal inlet, palatal perforation, and glottic edema posed considerable anesthetic challenges.4 The administration of amphotericin B, the drug of choice for mucormycosis, aimed to limit disease progression. Careful attention was necessary due to its potential side effects, including hypokalemia, hypomagnesemia, and hyperchloremic metabolic acidosis. The drug was administered through a central venous catheter to avoid phlebitis. Before starting infusion, volume expansion with 500 mL of 0.9% sodium chloride was done to reduce a decrease in glomerular filtration rate. However, volume expansion should be done cautiously in patients with decreased ejection fraction or preexisting renal disease, as in this case.5,6
ANESTHETIC MANAGEMENT
Upon transfer to the operating table, monitors were attached in accordance with ASA minimum standards. Preinduction vitals included a pulse rate of 90–95 beats per minute (bpm) with normal sinus rhythm, occasional ventricular premature contractions (<3/minute), blood pressure (BP) of 90/50 mm Hg measured in the right arm supine posture, respiratory rate of 26/minute, and room air oxygen saturation of 88–90%.
Right radial artery cannulation was performed under strict asepsis using a 20G cannula to monitor invasive BP and pulse pressure variation. Additionally, a working 7.5 French triple-lumen catheter was already in place in the right internal jugular vein. Inotropes, including adrenaline (2 mg in 50 mL normal saline) and noradrenaline (4 mg in 50 mL normal saline) were initiated (Fig. 1).
Figs 1A and B: Images of an elderly patient with rhino-orbital mucormycosis; (A) Depicting the patient under general anesthesia and mechanical ventilation; (B) Patient in the postoperative period after extubation
Induction involved administering injection (inj) etomidate (0.3 mg/kg) and inj fentanyl (1 µg/kg), followed by intubation facilitated with inj atracurium (0.5 mg/kg). To maintain a mean arterial pressure above 70 mm Hg, inj phenylephrine was administered in titrated doses [0.3–0.6 µg/kg intravenous (IV)].
Around 15 minutes postinduction, during sterile drape placement, the patient experienced an episode of bradycardia and hypotension due to diabetic CAN. The heart rate (HR) dropped from 98 to 50 and then to 40 bpm, while the systolic BP plummeted from 90 to 50 to 30 mm Hg. Simultaneously, the central venous pressure (CVP) surged from 8 to 16 cm of water (Fig. 2).
Fig. 2: Presents a visual representation of ASA standard monitoring parameters, encompassing HR, BP, oxygen saturation, waveform capnography, and ventilator parameters
An inj atropine (1.2 mg IV bolus) was ineffectual, prompting the administration of 2 mL of 1:10,000 adrenaline IV, followed by adrenaline infusion (0.005 to 0.01 µg/kg/minute IV) and a noradrenaline infusion (0.05 µg/kg/minute). The interventions led to an increase in HR (from 40 to 100 bpm), an elevation of systolic BP (to 120 mm Hg), and a decrease in CVP (from 16 to 10 cm of water).
Throughout the approximately 2-hour intraoperative period, the patient encountered two more instances of bradycardia and hypotension; both managed with titrated doses of phenylephrine and adrenaline while maintaining inotropic support.
In addition to inotropes, the patient received inj magnesium sulfate (1 gm IV) and inj frusemide (20 mg IV). Arterial blood gas analysis indicated a potassium level of 3.2, which was addressed through replacement, and a base excess of −6, requiring an IV infusion of sodium bicarbonate (50 mL).
Before extubation, meticulous optimization of the patient’s condition, full reversal of the neuromuscular blockade, and adequate warming and oxygenation were ensured. Extubation was successfully carried out, and the patient was transferred to the intensive care unit for postoperative hemodynamic monitoring, urine output surveillance, blood sugar level optimization, and observation of oxygen desaturation due to potential fluid overload or pulmonary edema, considering the preexisting moderate PAH.
CONCLUSION
Managing a geriatric patient with a known case of CAD accompanied by severe (LV) dysfunction, moderate PAH, and diabetic CAN coming for major surgery, such as endoscopic debridement of mucormycosis, poses a significant challenge to the anesthesiologist. When dealing with a patient having uncontrolled DM and preexisting CAD, the potential presence of CAN should always be considered.
Utilizing invasive lines, such as a central venous catheter for central venous pressure (CVP) monitoring, CVP-guided vasoactive drug administration, and an arterial line for invasive beat-to-beat BP monitoring and pulse pressure variation monitoring, is essential. This is due to the rapid occurrence of hemodynamic changes in such patients, necessitating goal-directed fluid therapy in the context of severe LV dysfunction and moderate PAH. Such measures are pivotal in preventing fluid overload and hypoxia. Preparedness with inotrope infusions, emergency cardiac medications, and a defibrillator is essential for a prompt response to unforeseen emergencies.
An appropriate ventilation strategy, coupled with the readiness of a difficult airway trolley, is recommended to avert hypoxia and hypercarbia. Given that these patients are susceptible to both anatomical and physiological difficult airways, a comprehensive approach involving multiple disciplines is imperative and should be consistently applied to ensure successful outcomes for these high-risk anesthesia patients.
ORCID
Manimaran P https://orcid.org/0009-0008-6566-5210
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