Anaesthetic challenges of Post-COVID19 mucormycosis with cerebral & orbital involvement-a case report

Presentation: A 47-year old male patient presented with COVID pneumonia along with right facial swelling, right proptosis and chemosis, right sided facial sensation loss and left hemiparesis on day 8 of hospital admission. He was treated with Inj. Remdesivir 100mg given for 5 days along with Inj. Methylpred 30mg IV bd. He was recently diagnosed with diabetes with evidence of uncontrolled sugar levels. Insulin was started on sliding scale. Diagnosis: The chest X-ray revealed bilateral infiltrates in both lower lung lobes. Nasal suction debris on examination suggestive of fungal hyphae, CECT brain suggestive of peripheral hypodense lesion in bilateral frontal lobe and right gangliocapsular area, orbital cellulitis, frontal and ethmoidal sinusitis and was diagnosed as rhino-orbito-cerebral mucormycosis. Treatment: The patient was treated with Inj phenytoin, 3% Nacl and amphotericin B and planned for emergency surgery. Plan proposed was external approach maxillectomy with orbital exenteration with bifrontal lobectomy. Pre-operative: Patient was kept nil per oral and hydrated, blood sugar was marginally controlled with a fasting level of 173mg/dl and planned for general anesthesia with endotracheal intubation. Intraoperative: Before induction a right IJV central venous cannula and a radial arterial cannula was placed. Patient was induced using modified rapid sequence with Inj Propofol and succinylcholine and intubated with 8mm cuffed endotracheal tube with direct laryngoscopy and connected to mechanical ventilation under volume control mode with high PEEP. Concerns: Intraoperative concerns were blood loss of 1.5 litres and hypotension due to acute sinus bleed which was controlled by inotropes and blood transfusion as well as a surge in blood sugar levels which was modulated by titrated insulin infusion. Hourly ABG and RBS was checked. Conclusion: Patient was shifted to ICU on mechanical ventilation with stable vitals. Early diagnosis and debridement remains the mainstay of treatment.