Anaesthetic Consideration in Mucormycosis Patients Posted for RhinoOrbital-Dental Surgeries

BackgroundMucormycosis, is a rare yet potentially life-threatening fungal infection common in immunocompromised patients. Despite optimal care, mucormycosis in haemato-oncological patients often results in poor outcomes. This case series details the presentations and unique challenges faced during the management of patients with acute myeloid leukemia who developed rhino-cerebral mucormycosis.Case presentationWe present three cases of rhino-cerebral mucormycosis in patients with acute myeloid leukemia: two females aged 35 and 29, and one male aged 42. Symptoms manifested during chemotherapy induction, with all patients experiencing symptoms suggestive of rhino, orbital, or cerebral infection in a background of severe neutropenia (ANC < 0.5). Nasal endoscopy revealed necrotic tissue in all cases, with contrast-enhanced computer tomography (CECT) confirming invasive fungal infection. Rhizopus species were isolated in cultures from the two female patients, and histopathological evidence of fungal invasion was noted in one. Prompt treatment with liposomal Amphotericin B combined with surgical debridement with functional endoscopic sinus surgery (FESS) and treatment of neutropenic sepsis resulted in the survival of two patients, though one succumbed during treatment.ConclusionsThis case series highlights the importance of early clinical suspicion and treatment of mucormycosis in hematological malignancies. Due to mild and atypical presentations and lack of confirmation by microbiological and histological methods, a multifaceted diagnostic approach combining clinical, laboratory, and imaging modalities is essential. A multidisciplinary treatment approach with the management of concomitant complications like neutropenic sepsis is crucial for better outcomes.

Mucormycosis in patients who have COVID-19 or who are otherwise immunocompromised has become a global problem, causing significant morbidity and mortality. Infection is debilitating and fatal, leading to loss of organs and emotional trauma. Radiographic manifestations are not specific, but diagnosis can be made through microscopic examination of materials collected from necrotic lesions. Treatment requires multidisciplinary expertise, as the fungus enters through the eyes and nose and may even reach the brain. Use of the many antifungal drugs available is limited by considerations of resistance and toxicity, but nanoparticles can overcome such limitations by reducing toxicity and increasing bioavailability. The lipid formulation of amphotericin-B (liposomal Am-B) is the first-line treatment for mucormycosis in COVID-19 patients, but its high cost and low availability have prompted a shift toward surgery, so that surgical debridement to remove all necrotic lesions remains the hallmark of effective treatment of mucormycosis in COVID-19. This review highlights the pathogenesis, clinical manifestation, and management of mucormycosis in patients who have COVID-19.

Recent papers relevant to the preoperative evaluation and optimization of patients with severe liver disease will be discussed. The emphasis will be placed on cardiovascular, pulmonary, and renal complications. Other aspects such as preoperative management of hepatitis B and C, other infectious issues, and liver cancer will not be discussed because this rarely involves the anesthesiologist. Dobutamine stress echocardiography has been the cornerstone of cardiac evaluation of liver transplant candidates. Combining liver transplantation with cardiac procedures has been shown to be feasible. While mild hepatopulmonary syndrome is well-tolerated, severe hepatopulmonary syndrome carries a fairly high mortality rate. New treatment modalities of severe portopulmonary hypertension have been introduced, and may have advantages over epoprostenol administration. Hepatic hydrothorax requires similar therapy to ascites [repeated thoracentesis or paracentesis, and transjugular intrahepatic portosystemic shunt (TIPS)], but refractory hydrothorax may require other interventions. Hepatorenal syndrome may improve by increasing renal blood flow through the use of vasoconstrictors (vasopressin, norepinephrine) in combination with albumin administration. Interventional radiologists can now change the flow through an established TIPS. Hepatic encephalopathy may result in some irreversible changes in the brain. It remains difficult to predict whether a patient with acute fulminant failure will recover spontaneously. Support devices that include hepatocytes show early promising results. The coagulation changes in living donors are incompletely understood. Finally, autonomic neuropathy as a complication of severe liver disease results in more hemodynamic instability. Recent advances in preoperative evaluation and optimization are presented and discussed.

Patient: Female, 53Final Diagnosis: Muscular mucormycosisSymptoms: Arm pain • leg pain • swellingMedication: —Clinical Procedure: —Specialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Mucormycosis is a serious, potentially fatal fungal infection caused by species in the Mucorales order. Together with candidiasis and aspergillosis, it is one of the most significant fungal infection that carries a high rate of mortality. Early detection and initiation of antifungal therapy with adequate surgical debridement improves the clinical outcome.Case Report:We describe a case of mucormycosis in a patient with acute myeloid leukemia who developed disseminated lung disease with muscular involvement without any cutaneous manifestation. Successful treatment was achieved with surgical debridement, amphotericin B lipid-complex and posaconazole step-down therapy.Conclusions:Mucormycosis can present in various clinical scenarios. Key to diagnosis depends on tissues diagnosis from the affected system, as was done with lung and muscle biopsy in our patient. Clinicians should maintain high suspicion for early diagnosis and prompt treatment.

Objective: To discuss the clinical significance and value of PRVC by monitoring, comparing and studying pressure control (PC), volume control (VC) and pressure-regulated volume control (PRVC) ventilation modes during pneumoperitoneum. Methods: Ninety patients with laparoscopic cholecystectomy were randomly and equally divided into 3 groups (PC group, VC group and PRVC group). Esophageal pressure (PES), mean airway pressure (PAWM), peak airway pressure (PAP), arterial blood carbon dioxide partial pressure (PaCO 2 ), end-tidal carbon dioxide concentration in the expired air (ETCO 2 ), tidal volume (TV), mean arterial pressure (MAP) and heart rate (HR) were not only detected before pneumoperitoneum, but also in 5, 10, 15 and 20 minutes after pneumoperitoneum. Results: PES after pneumoperitoneum in VC mode was obviously higher than that in PC and PRVC groups. In 10 minutes after pneumoperitoneum, levels of PaCO 2 and ETCO 2 became increased obviously in PC and VC groups ( p < .05); levels of PaCO 2 and ETCO 2 were not only increased in PC group, but also the level of TV after pneumoperitoneum in PC group was significantly lower than that in the other two groups ( p < .05). Levels of PaCO 2 and ETCO 2 were increased in PC and VC groups after pneumoperitoneum, along with the increase of MAP and HR ( p < .05). After pneumoperitoneum, levels of MAP and HR in PRVC group were significantly lower than those in PC and VC groups ( p < .05). Conclusions: PRVC mode can effectively reduce the pneumoperitoneum-induced increase of PAWM, PAP and PES without the unusual increase of PaCO 2 and ETCO 2 during surgery, so as to guarantee the stability of vital signs in perioperative patients.

Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital

The diagnosis and treatment of hilar tumors requires a multidisciplinary approach based on the synergy of radiologists, surgeons, oncologists, and gastroenterologists. Klatskin tumor is a relatively rare disease with a poor prognosis. Currently, the only possible treatment is represented by the removal of the tumor associated with radical surgery, even though its results are still jeopardized by significant morbidity and mortality. A proper preoperative optimization of the patient, including staging laparoscopy, biliary drainage, and portal vein embolization, may improve short-term outcome. The purpose of this study was to evaluate the short- and long-term impact of preoperative optimization in patients affected by hilar cholangiocarcinoma. From January 2004 to May 2012, 94 patients with preoperative diagnosis of Klastkin tumors were candidates for surgery at the Hepatobiliary Surgery Unit of the Hospital San Raffaele in Milan. The data of all patients were prospectively collected and retrospectively reviewed. The outcome was evaluated in terms of perioperative morbidity and mortality and overall and disease-free survival. Short-term outcome of patients undergoing preoperative optimization was compared with outcome of patients who did not undergo it in terms of intraoperative data, morbidity and mortality. Of 94 patients undergoing surgery, 80 underwent hepatic and biliary confluence resection. Fourteen patients were considered unresectable due to the presence of peritoneal carcinomatosis or advanced disease seen during staging laparoscopy or at laparotomy and therefore were excluded from the analysis. Seventy-five (93.7 %) patients underwent major liver resections: in 14 of these, surgery was performed at a distance of 30-40 days from PVE. In 55 patients, biliary drainage was preoperatively placed for palliation of obstructive jaundice. The postoperative morbidity rate was 51.2 % and mortality 6.2 %. The most frequent cause of death was postoperative liver failure. Five-year survival rate was 29 %. Patients undergoing preoperative optimization experienced a significant reduction of postoperative morbidity, especially in terms of infectious related events. Klatskin tumor remains a disease associated with poor prognosis, but a correct preoperative diagnostic and therapeutic management provides tools to perform this type of surgery with acceptable morbidity and mortality, thus improving long-term results.

Preoperative Optimization: A Continued Call to Action.

Preoperative Optimization of the Heart Failure Patient Undergoing Cardiac Surgery

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Main specific interventions for preoperative clinical optimisation of patients undergoing lung cancer surgery include assessment and treatment of comorbidities, minimizing preoperative hospitalization, minimizing preoperative fasting, and optimisation of antibiotic and thrombo-embolic prophylaxis. Preoperative patient optimisation is considered a crucial part of enhanced recovery after thoracic surgery pathways. Potentially, advantages of this fast-track management could be even higher when considering video-assisted thoracic surgery (VATS) major lung resection, because reduced trauma related to minimally invasive techniques is one of the main factors improving postoperative outcome. Literature data and clinical evidences in this setting are reported and discussed.

Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives. As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation. Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again. We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts.

BackgroundAplastic anemia is a hematologic disorder characterized by bone marrow failure and profound neutropenia, which increases the risk of opportunistic infections such as mucormycosis, an aggressive fungal disease. This condition requires early diagnosis and integrated treatment strategies to reduce the high mortality rate. We report a rare case of rhino-orbito-cerebral mucormycosis in a patient with aplastic anemia.Case presentationA 16-year-old Middle Eastern (Persian, Iranian) male with a history of aplastic anemia presented with unilateral right-sided facial swelling. He was initially diagnosed with a bacterial soft tissue abscess and treated with antibiotics. Owing to a lack of response, further imaging and histopathological studies were performed, which revealed invasive mucormycosis. The patient received antifungal therapy, but surgical debridement was not performed because of severe thrombocytopenia. His condition deteriorated, and he was admitted to the intensive care unit. Despite resuscitation efforts, the patient died on day 17 of hospitalization.ConclusionThis case highlights the diagnostic and therapeutic challenges in managing mucormycosis in patients with hematological disorders. A key factor contributing to the unfavorable outcome was the prolonged interval between symptom onset and rhino-orbito-cerebral mucormycosis diagnosis. Physicians should consider invasive fungal infections in all immunocompromised patients, particularly those with aplastic anemia, when they present with facial soft tissue infections.

205. Malnutrition increases risk of complications following posterior lumbar fusion independent of body mass index

The care of the patient with vascular disease can be complicated as these patients are often high risk with multiple comorbidities. They are frequently frail and can have hypertension, diabetes, pulmonary disease, coronary artery disease, congestive heart failure, cerebral vascular disease, delirium, dementia, renal insufficiency, renal failure, peripheral vascular disease, and more. A complete preoperative evaluation and patient optimization will help ensure that the best anesthetic plan is chosen for the patient. Preoperative optimization uses the information that has been gained from the evaluation to ensure that the patient’s medical conditions are as optimized as possible in order to undergo surgery, a procedure, and anesthesia.