Peri-operative and anesthesia considerations for patient recovered from COVID-19 scheduled for radical cancer surgery

Daljeet Singh; Uma Hariharan; Anumeha Joshi; Ganesh Nandan

doi:10.4103/BJOA.BJOA_198_20

CASE REPORT

Year : 2021 | Volume : 5 | Issue : 2 | Page : 115-117

Peri-operative and anesthesia considerations for patient recovered from COVID-19 scheduled for radical cancer surgery

Daljeet Singh, Uma Hariharan, Anumeha Joshi, Ganesh Nandan
Department of Anesthesiology and Intensive Care, Dr. Ram Manohar Lohia Hospital, ABVIMS and PGIMER, New Delhi, India

Date of Submission	26-Aug-2020
Date of Decision	17-Nov-2020
Date of Acceptance	22-Nov-2020
Date of Web Publication	16-Apr-2021

Correspondence Address:
Dr. Uma Hariharan
Associate Professor, [MBBS, DNB, PGDHM, CCEPC, FICA, DESA, MNAMS, FIMSA], BH 41, East Shalimar Bagh, Delhi - 110 088
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_198_20

Abstract

The current COVID-19 pandemic has affected the health-care system worldwide. While there is a plenty of literature in recent times regarding the anesthetic management of COVID-positive patients for various surgeries, there is a paucity of publications on the concerns and anesthetic implications of COVID-19 recovered patients, posted for major oncology surgery. We, hereby, present a geriatric case of post-COVID-19 recovered patient posted for radical cystectomy following chemotherapy. These patients are immunosuppressed due to cancer per se as well as because of concurrent chemotherapy, and hence, they may have a stormy course of COVID-19 infection. Since, COVID-19 affects multiple organs, preoperative evaluation must thoroughly investigate all the systems. Anesthetic management and operating theatre preparedness for such cases is discussed in brief.

Keywords: Aerosol, immunosuppression, oncology surgery, preanesthetic evaluation, recovered

How to cite this article:
Singh D, Hariharan U, Joshi A, Nandan G. Peri-operative and anesthesia considerations for patient recovered from COVID-19 scheduled for radical cancer surgery. Bali J Anaesthesiol 2021;5:115-7

How to cite this URL:
Singh D, Hariharan U, Joshi A, Nandan G. Peri-operative and anesthesia considerations for patient recovered from COVID-19 scheduled for radical cancer surgery. Bali J Anaesthesiol [serial online] 2021 [cited 2023 Mar 22];5:115-7. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/115/313880

Introduction

Health infrastructure has been under unprecedented duress in these times of global pandemic of SARS Coronavirus 2 (SARS-CoV-2). Owing to the pathology of the underlying disease, the oncological surgeries cannot be delayed beyond a certain point of time or we risk adverse impact on the survival. A wide number of case reports have been published and various guidelines issued for the management of COVID-19 positive/suspected surgical patients. However, publications on the management of COVID-19 recovered patient posted for radical cancer surgery are scarce. In this case report, we attempt to outline the management of such cases by amalgamation of previous knowledge and recent experiences.

Case Report

A 60-year-old male with high-grade epithelial urinary bladder tumor was posted for radical cystectomy. The patient was a chronic smoker (recently quit smoking) and hypertensive for the past 10 years, on regular treatment (calcium channel blockers). He had undergone six cycles of chemotherapy (Gemcitabine and Cisplatin).

The patient was diagnosed to be COVID-19 positive 2 months back by the reverse transcriptase polymerase chain reaction (RT-PCR), for which he was hospitalized for a period of 14 days requiring intermittent oxygen therapy through face mask, along with other standard treatment regimes. As per the institutional protocol, he was discharged after two negative COVID-19 reports, 24 h apart. He was planned for radical cystectomy with ileac conduit bladder reconstruction.

Preoperative baseline 2D-Echocardiography revealed ejection fraction of 45%–50%, dilated left atrium, mild global hypokinesia, Grade III left ventricular diastolic dysfunction, mild mitral regurgitation, mild tricuspid regurgitation, and mild pulmonary artery hypertension. Complete blood count, kidney function tests, liver function tests, and blood gas values were unremarkable. Chest radiograph at the time of COVID-19 infection had bilateral and peripheral ground-glass opacities involving the lower lung zones. The recent chest radiograph [Figure 1] had consolidation patch in the right lower lung zone.

Figure 1: Chest radiograph depicting right lower zone consolidation

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Pulmonary function tests revealed a restrictive lung pattern with forced expiratory volume in 1^st second to forced-vital capacity ratio of 74%. Respiratory medicine opinion was sought in view of deranged pulmonary function tests and chest radiograph findings. Chest condition was optimized with physiotherapy, incentive spirometer, appropriate antibiotics, and nebulization. In view of previous COVID-19 positive status, only limited personnel, in personal protection equipment (PPE) kits and N95 masks were allowed inside the theater.

We wheeled the patient into the operating theater (OT) with mask put on. Standard monitors were attached, and 18G intravenous line was secured. Under all aseptic precautions, right radial artery was cannulated for continuous blood pressure monitoring. Lumbar epidural catheter was secured at L2–L3 level for perioperative analgesia. Airway was secured after adequate preoxygenation and rapid sequence induction, with the help of a video-laryngoscope. Intubation box was used to limit the aerosol spread. The endotracheal tube was connected to the closed circuit system with HME filter attached to expiratory limb. After checking correct tube placement, nostrils and mouth were covered with wet sterile drapes. Right-sided internal jugular vein was cannulated with triple-lumen catheter under ultrasound guidance. Complete asepsis was followed in all the procedures. Low flow anesthesia was administered.

The total blood loss of approximately 3,000 ml was managed with transfusion of blood, blood products, crystalloids, and colloids. Intraoperative hemodynamic was maintained with the brief use of vasopressors (noradrenaline infusion) to maintain perfusion pressure and renal blood flow, which were eventually tapered-off. The perioperative blood gases, blood sugar, and serum electrolytes were maintained within the normal limits. Surgery lasted for about 5 h. The patient was shifted to postoperative surgical intensive care unit (ICU) for overnight elective mechanical ventilation and was extubated the next morning. The postoperative course was uneventful. The patient was later shifted to the ward and discharged in a stable condition.

Discussion

Radical cystectomy with pelvic lymphadenectomy remains the most effective and widely used surgical intervention for muscle invasive bladder cancer and is considered the gold standard treatment.^[1],[2]

COVID-19 infection predisposes the survivors to a plethora of on-going and irreversible insults to various body systems. Recovered patients are at greater risk of having myocarditis (myocardial inflammation) and coronary thrombosis thereby accentuating the risk for perioperative cardiovascular events. The viral infection leads to a prolonged hypercoagulable state, thereby increasing the chances of embolism, cerebrovascular infarcts, and deep-vein thrombosis. In view of the aforementioned effects of the viral infection on the cardiovascular system, a thorough preoperative evaluation was carried out with two-dimensional echocardiogram, contrast-enhanced computed tomography (CECT-chest), cardiac enzyme levels (Troponin T and I), and complete coagulation profile.

The restrictive respiratory pattern on pulmonary function tests was confirmed on CECT imaging [Figure 2] in the form of necrosis and scarring of lung tissue. Our patient had persistent fatigue and the other symptom of post-COVID-19 syndrome such as diffuse myalgia, depressive symptoms, and nonrestorative sleep, were absent. Persistence of viral RNA in respiratory samples 6 weeks after the onset of symptoms in clinically cured patients has been documented.^[3] Hence, all precautions to curtail aerosol generation and spread were carried out, such as anti-sialagogues (glycopyrrolate), preoxygenation over two-ply surgical mask, rapid sequence intubation, use of intubation box, video laryngoscope, covering the nostrils, and oral cavity with wet sterile drapes as well as complete asepsis in all procedures.

Figure 2: Contrast-enhanced computed tomography scan depicting the bilateral postero-basal pleural thickening and reticular opacities (left more than right)

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Invasive monitoring was done in view of major radical surgery involving massive fluid shifts. Immunosuppressive factors such as drugs or pathological conditions as in present case could contribute to impaired viral clearance and favor SARS-CoV-2 reactivation.^[4] Coupled with reactivation/reinfection, the extended duration of surgery puts the operation theater staff and doctors at risk of getting infected in the present scenario of SARS COV 2 pandemic. Hence, we attempted to minimize the number of personnel entering the operation theater, and all were advised to wear complete PPEs.

Wen and Li, described in brief the anesthesia procedures for emergency surgery in patients with suspected or confirmed COVID-19.^[5] They stated that a thorough preoperative examination and epidemiologic investigation are essential for all surgical patients to assess suspected COVID-19 cases. For patients with suspected or confirmed COVID-19, elective surgical procedures should be cancelled. For emergency operations in suspected or confirmed patients, anesthesiologists should be protected according to level three protection. Currently, no evidence-based guidelines exist for PPE usage in a COVID recovered case posted for radical oncosurgeries. This unique case attempts to highlight the judicious usage of PPE along with anesthetic management in a case of radical cystectomy. Keeping in mind, anticipated extended duration of surgery, major fluid shifts, blood loss, need of invasive procedures for monitoring, and preexisting chest condition, the patient was transferred to the ICU and observed for any complications.

Although several articles related to obstetric, pediatric, and cardiac anesthesia have been published, there is a dearth of literature on anesthetic management of post-COVID recovered patient in radical oncologic surgeries in the era of COVID-19 pandemic.^{[3],[6],[7],[8],[9],[10]}

Conclusion

In-depth preoperative evaluation is the cornerstone to establish the systemic effects of COVID-19 infection, thereby guiding the peri-operative outcomes. RT-PCR should be carried out to rule out the viral reactivation/re-infection in such immunosuppressed individuals. Underlying chest and cardiac condition should be optimized for a favorable result. Finally, in addition to the routine precautions for onco-surgery, complete asepsis, aerosol limitation, and minimum essential and experienced personnel with PPE should be involved in the patient care.

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 understand, that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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