Anaesthetic management of lung resection in Covid associated pulmonary mucormycosis: A report of two cases

Khaja Mohideen. S1, Nirmal Kumar. S1, Indupriyadarshini. J1, Mohamed Eliyas. N2

1Consultant Anaesthesiologist, Kauvery Hospital, Cantonment, Trichy

2Registrar – Anaesthesiology, Kauvery Hospital, Cantonment, Trichy

Introduction

Pulmonary mucormycosis (PM) is a relatively uncommon infection that occurs in immunocompromised persons. After the outbreak of Covid-19 infection, more cases of PM are being reported. [1] Early aggressive surgical debridement of infected tissues combined with antifungals is the cornerstone of treatment. [2] We report here the anaesthetic management of two cases of surgical resection for PM associated with Covid-19.

Case Presentation

Case 1

Thirty-year-old male (48kg, known to have diabetes, of American Society of Anaesthesiologists physical status 3) with Covid associated PM, was posted for left upper lobectomy by VATS (video-assisted thoracoscopic surgery). He had a cough with expectoration and hemoptysis. Computed tomography (CT) of the chest showed consolidation with fibrotic changes in bilateral lower lobes. There was also a cavity and air-fluid level in the left upper lobe (Figure 1a, 1b).

Suspecting fungal infection, the patient was started on Amphotericin B. Aseptate branching fungal hyphae with right-angle branching was seen on BAL (bronchoalveolar lavage) specimen. As he had persistent symptoms even after three weeks of treatment, he was posted for lung resection. Postural drainage, gentle physiotherapy, and spirometry were given. Blood investigations and echocardiography were normal.  Room air blood gas analysis showed PaO2 – 80mmHg and PaCo2 – 40mmHg.

Inside the operation theatre (OT), the right IJV (Internal jugular vein) was cannulated with a triple-lumen catheter, and the right radial artery was cannulated. After attaching an electrocardiogram, pulse oximetry, and invasive blood pressure monitors, baseline parameters were noted (heart rate 80/minute, blood pressure 110/70mmHg, room air saturation 94%). The patient was induced with fentanyl 100µg, propofol 100mg, vecuronium 6mg and intubated with 35Fr right DLT (double lumen tube). Lung isolation was confirmed with a fibreoptic bronchoscope (FOB). After 10 minutes, there was fresh bleeding from the tracheal lumen. Bronchial cuff inflation was confirmed and intravenous fluids were rushed. The tracheal lumen was clamped and observed.

The bleeding stopped and there was no hypotension. As FOB showed no active bleeding, we proceeded with VATS. Low tidal volume ventilation (Tidal volume 250-300ml, respiratory rate – 20/minute to maintain peak airway pressure of up to 30 mmHg) was used for one-lung ventilation (OLV). During VATS, there was sudden bleeding from the abscess cavity, probably from rupture of pulmonary vessels beneath the cavity wall. The patient developed hypotension (mean arterial pressure of 50mmHg) and was given crystalloids bolus and noradrenaline (1µg/minute). An emergency thoracotomy was done.

The bleeding pulmonary artery was clamped. Totally 2.5 liters of crystalloids, 4 packed cells, and 4 fresh frozen plasma were given. The left lower lobe was found to be unhealthy and not expanding. There was no hemodynamic collapse after clamping the left pulmonary artery. Hence, we proceeded with pneumonectomy (Figure 1c). FOB confirmed no tracheobronchial injury. Postoperatively the patient was kept on pressure-controlled ventilation. He developed postpneumonectomy pulmonary oedema and pneumonia.

He was treated with Colistin 9 million units and Amphotericin 70 mg. Sputum culture showed MDR Klebsiella sensitive to colistin. Paracetamol 1gm QID and fentanyl 25-50µg/min infusion was used for postoperative analgesia. The repeated T-piece trial was unsuccessful. Surgical tracheostomy was done on postoperative day 5 (Figure 1d). The patient was weaned from ventilator support on postoperative day 10 and discharged home two weeks later.

Case 2

Fifty-year-old male (59 kg, diabetes, ASA 3 status) with Covid–19associated PM , was posted for left upper lobectomy. He had a cough, expectoration, and occasional hemoptysis. CT chest showed bilateral lower lobe ground glass opacity with consolidation in the left upper lobe (Figure 2a). He was started on Amphotericin B. USG-guided transthoracic lung biopsy was done to isolate fungal organisms as transbronchial biopsy (TBLB) by BAL was inconclusive. As he had persistent symptoms despite antifungal therapy, he was planned for lung resection. His blood investigations and echocardiogram were normal. Room air blood gas showed PaO2 – 83mmHg, and PaCo2 – 39mmHg. Inside the OT, baseline vitals like heart rate of 82/min, 120/70mmHg blood pressure, and room air saturation of 96% were recorded. Right IJV was cannulated with a triple lumen catheter and the right radial artery was cannulated.

The patient was induced with fentanyl 100µg, propofol 100mg, and vecuronium 8mg. He was intubated with 37fr right DLT and the position confirmed with FOB. Low tidal volume (Tidal volume 250-300ml, respiratory rate – 20/min to maintain peak airway pressure of up to 30 mmHg) ventilation was used for OLV. The duration of surgery was 5 hours. Blood loss was 500ml. The patient was extubated at the end of surgery. Paracetamol 1gm QID and fentanyl 30-60µg/min infusion was used for postoperative analgesia. His postoperative period was uneventful (Figure 2b).

Discussion

Immune dysregulation caused by COVID-19 along with concurrent administration of steroids, tocilizumab, and the presence of coexisting illnesses like diabetes increases the risk of PM. [3] The hallmark of PM is angio-invasion leading to thrombotic infarction and necrosis of lung parenchyma. Due to its aggressive invasive nature, it can spread locally to surrounding structures and also to distant organs.

Mortality due to PM is high (50%-80% for localized disease and 98% for disseminated disease). Combination of surgical excision and antifungal therapy is the optimal treatment strategy for PM (70% survival with combination therapy vs 61% survival with antifungal therapy alone) [4]. The timing of surgical resection necessary to maximize the outcomes of PM was not defined. However, it depends on the extent of disease involvement and the general condition of the patient [5]. Recently Pulle et al have developed “Centre for Chest Surgery protocol” for effective management of PM. They recommend lung resection surgery in patients with disease localized to one lobe/lung after giving a cumulative dose of 1 to 1.5 gm of Amphotericin B and oral Posaconazole 600mg/day. In patients with bilateral lung involvement, multisystem involvement, and extensive mediastinal involvement antifungal treatment alone is advised. Both of our patients had persistent cough with expectorations even after two weeks of Amphotericin B (cumulative dose of 1.4gm) and had PM localized to the left lung. The principles of surgical resection include aggressive resection of all involved tissue to achieve clear margins. Surgical resection in such cases is really challenging because of two reasons – dense pleural adhesions and angio-invasion. [5] This prolongs the duration of surgery and increases the bleeding. Angio-invasion leads to necrosis of surrounding structures. Our first patient had hemoptysis after a few minutes of placement of DLT, which subsided later. The blood vessel near the necrosed abscess could have ruptured due to positive pressure ventilation and caused the bleeding. Intraoperatively he had bleeding from the abscess cavity due to rupture of pulmonary vessels underneath. PM causes dense pleural adhesions and unclear anatomy which results in the intraoperative decision of pneumonectomy. [5] In our first patient, the decision to do pneumonectomy was made intraoperatively. As we had not done the pulmonary lung functions test preoperatively, we checked the suitability for pneumonectomy by observing the response to clamping of the ipsilateral pulmonary artery. Since there was no hemodynamic collapse after clamping of the pulmonary artery, we proceeded with pneumonectomy.

Preoperative evaluation of pulmonary function includes pulmonary function tests (PFTs), calculation of predicted postoperative PFT, measures of gas exchange, and cardiopulmonary exercise testing (CPET). [6] We could not do PFT as both patients had hemoptysis. Also, V/Q (ventilation/perfusion) scan and CPET were not available at our hospital. Our second patient was able to perform a stair-climbing test. Our first patient was uncooperative with the stair climbing test but was able to perform the Sabrasez single breath count test (35 secs). Hence, we proceeded with VATS for both patients.

Conclusion

The diffuse lung fibrotic changes due to COVID-19 make the preoperative lung function worse resulting in longer periods of preoperative optimisation and difficulty in assessment of predicted postoperative lung function. Hence lung resection for Covid-19 induced PM can pose more anaesthetic challenges.

References

  • Malhotra N, Bajwa SS, Joshi M, Mehdiratta L, Kurdi M. Second wave of COVID‑19 pandemic and the surge of mucormycosis: Lessons learnt and future preparedness: 1. Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement. Indian J Anaesth 2021; 65:427-33.
  • Johnson AK, Ghazarian Z, Cendrowski KD, Persichino JG. Pulmonary aspergillosis and mucormycosis in a patient with COVID-19. Med Mycol Case Rep. 2021; 32:64-67
  • Muthu V, Rudramurthy SM, Chakrabarti A, Agarwal R. Epidemiology and Pathophysiology of COVID-19-Associated Mucormycosis: India Versus the Rest of the World. Mycopathologia. 2021 Aug 19:1–16.
  • Vercillo MS, Liptay MJ, Seder CW. Early pneumonectomy for pulmonary mucormycosis. Ann Thorac Surg. 2015;99: e67-8.
  • Pulle MV, Puri HV, Asaf BB, Bishnoi S, Sharma S, Kumar A. Outcomes of early anti-fungal therapy with aggressive surgical resection in pulmonary mucormycosis. Lung India 2021; 38:314-20.
  • Lederman D, Easwar J, Feldman J, Shapiro V. Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia. Ann Transl Med 2019; 7:356

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