Second wave of COVID-19 pandemic and the surge of mucormycosis

Abstract

PREAMBLE The Indian Society of Anaesthesiologists (ISA) issues the following advisory and position statement pertaining to the second wave of coronavirus disease-2019 (COVID-19) in India, the lessons learnt and future preparedness. The months of April and May 2021 have been extremely challenging for all, especially the anaesthesiologists. In the second wave of COVID-19 pandemic, very large numbers of patients were infected in a very short span of time. The medical facilities were overburdened with patients leading to scarcity of oxygen, COVID beds, intensive care unit (ICU) facilities, essential drugs and other resources. Besides taking care of COVID and non-COVID clinical work, the anaesthesiology fraternity during this period was intensely focussed on arranging more and more beds and oxygen for the COVID patients and delivering oxygen from liquid medical oxygen (LMO) tanks, medical gas cylinders, oxygen concentrators or splitting the central oxygen supply (only as dire emergency measures). The clinical, administrative, psychological and social stresses were aptly handled by the anaesthesiologists. As the understanding of COVID-19 is improving, the guidelines and recommendations are also being updated regularly; nevertheless, this ISA advisory and position statement is also subject to change and updation in the coming days. INDIAN SOCIETY OF ANAESTHESIOLOGISTS POSITION STATEMENT The sudden increased demand of medical oxygen led to its extreme shortage. To overcome this shortage, 93% ± 3% medical oxygen can be used for COVID-19 pandemic patients through the use of medical oxygen generation plants. These oxygen generation plants work on pressure swing adsorption (PSA) technology involving molecular sieve (Zeolite). Use of 93% ± 3% medical oxygen (oxygen 93) is approved by the Indian Pharmacopoeia (IP), United States Food and Drug administration and the European Union. Anaesthesiologists should ensure optimal utilisation of oxygen by guiding all hospital staff in implementing zero leaks at all oxygen ports When there is scarcity of oxygen, use regional anaesthesia techniques for the surgical procedure, wherever feasible. For surgery under general anaesthesia, use low-flow anaesthesia technique. Use oxygen judiciously in the post-operative period Different modes of oxygen delivery and ventilatory support for COVID-19 patients are nasal prongs, face masks, non-rebreathing bag masks, non-invasive ventilation, invasive ventilation, etc., to keep the target oxygen saturation to 94%. The high-flow nasal oxygenation should be used very selectively Anaesthesiologists, being experts in critical care, successfully managed many critically ill COVID-19 patients in the ICUs. The expertise in critical care which the anaesthesiologists possess and the huge number of working hands of our anaesthesiology post-graduates and consultants helped tremendously in managing such a large number of COVID-19 patients and saving many lives A large number of anaesthesiology residents and faculty/consultants were infected with COVID-19 in the second wave, thus decreasing the number of working hands; nevertheless, many of those infected returned to COVID-19 duties as soon as they tested negative and were asymptomatic. This is appreciable and they should continue to render their valuable and skilled services to the cause of this pandemic Management of COVID-19 patients should be as per the standard guidelines, such as those laid down by the Ministry of Health and Family Welfare, Government of India and the respective state governments. The anaesthesiologists managing critically ill COVID-19 patients in the ICU should administer corticosteroids judiciously, when indicated There are specific indications for the usage of drugs remdesivir and tocilizumab in COVID-19 patients. The shortage of these drugs in the intensive care management of COVID-19 patients should be managed by well-laid institutional mechanisms to make the availability of these drugs for the selective patients in the hospitals The institutes and hospitals that have facilities for extracorporeal membrane oxygenation (ECMO) should utilise this technique judiciously in severely ill COVID-19 patients. ECMO ICUs should be set up in tertiary care institutes There is a sudden surge in mucormycosis cases and anaesthesiologists are involved in the multidisciplinary management of mucormycosis in COVID-19 patients as these patients often require surgery under anaesthesia The COVID-19 patients suffering from mucormycosis often have coexisting comorbidities such as diabetes mellitus (DM), oncopathologies and immunosuppression therapies. Meticulous attention must be paid to glycaemic control. Apart from these comorbidities, mucormycosis may make the airway management difficult. In addition, administration of injection amphotericin B (AmB) can have significant adverse effects which are of concern to the anaesthesiologists. Moreover, COVID-19 itself affects different organs of the body Future preparedness for COVID-19 pandemic includes up-gradation of hospital oxygen supplies, alternative sources of oxygen generation, adequate number of good-quality working ICU ventilators and monitors, sufficient quantity of drugs used in the ICU management of COVID-19 patients, setting up ECMO ICUs and most importantly ensuring 100% vaccination for the anaesthesiologists The ISA through its national/state/city units shall continue to train more doctors of other clinical specialities in teaching the basics of mechanical ventilation. The training has to be hands-on training on the ventilators actually available in different civil and general hospitals. The training can be conducted online, if physical training is not feasible The two waves of COVID-19 have exposed the gross deficiencies in terms of availability of nursing staff and more so that of ICU trained nursing staff. The anaesthesiologists can take a lead in providing training to the nursing staff in critical care so that the care improves if and when a third wave occurs The anaesthesiologists should be mentally relaxed and strong because, at times, they have to do duties on two fronts: managing patients in ICUs and also looking after their family members who are infected with COVID-19 The SARS-CoV-2 vaccination may cause mild symptoms in a very few individuals like fever, chills, myalgias, pain at injection site, headache, etc. These symptoms may mimic common post surgical conditions but resolve within 2-3 days. So, elective surgery/interventions can be done under anaesthesia upon resolution of these symptoms, if any (usually one week after vaccination) in consultation with a qualified anaesthesiologist. The post-graduate students have been busy in COVID-19 duties. They should be adequately taught and trained in the designated fields of the subject of anaesthesiology and supervised compassionately in completion of thesis and examinations that should be conducted in stress-free environment. INDIAN SOCIETY OF ANAESTHESIOLOGISTS ADVISORY Mucormycosis in COVID pandemic and the anaesthesiologist Since the last few months, there are increasing case reports of rhino-orbito-cerebral mucormycosis in patients with COVID-19. Mucormycosis can also involve lung (pulmonary), gastrointestinal tract, skin, heart, kidney and mediastinum (invasive type). The symptoms appear during the recovery from COVID-19. An environment of low oxygen (hypoxia); high glucose (diabetes, new-onset hyperglycaemia, steroid-induced hyperglycaemia); acidic medium (metabolic acidosis, diabetic ketoacidosis); high-iron (ferritin) levels; lymphopenia, neutropenia; malnutrition; decreased phagocytic activity of white blood cells due to immunosuppression (SARS-CoV-2-mediated, steroid-mediated or background comorbidities) and contaminated oxygen therapy and delivery devices favours the growth of the fungus. Management of mucormycosis aims at early diagnosis, a reversal of underlying predisposing factors, early administration of systemic antifungal therapy (intravenous liposomal AmB) and broad surgical debridement of infected tissue. The pathophysiologic profile of mucormycosis has numerous clinical and anaesthetic implications. Anaesthetic management of post-COVID mucormycosis These patients pose several challenges because it is usually a post-COVID illness population. The surgical procedures usually involve debridement, functional endoscopic sinus surgery, maxillectomy, mandibulectomy, exenteration, enucleation, palatal debridement, craniotomy, etc., and for which general anaesthesia has to be administered. The timing of taking up for surgery is another debatable issue. Those with active COVID-19 infection are being taken up for debridement in some institutes, whereas others wait for a negative reverse transcription polymerase chain reaction (RT-PCR) report before taking up for surgery. Endoscopic sinus surgery is an aerosol-generating procedure with high risk of transmission of the coronavirus. Use of personal protective equipment, barrier devices and instillation of pre-procedure povidone iodine drops in the nose are recommended in the patients with positive reports. However, majority of patients are RT-PCR negative at the time of hospital admission for mucormycosis. Preoperatively, one has to carefully screen the patients for post-COVID pulmonary and cardiovascular residual dysfunction. The peripheral oxygen saturation should be checked, and the patient may be on some means of oxygenation (by nasal prongs/face mask/others). Complete biochemical work-up of renal functions, electrolytes and coagulation profile should be done in patients receiving AmB therapy. Optimisation and control of blood glucose including shifting over to insulin are important. Patients may be on heparin or on long-acting post-COVID oral anti-coagulants. Heparin is withheld before surgery and has to be restarted post-operatively. The decision to stop or continue oral anticoagulant has to be taken after multidisciplinary discussion, weighing the risk against benefit of stopping the drug. In cases with prosthetic cardiac valves or deep vein thrombosis, it may not be advisable to stop the anti-coagulants. A written informed consent should be taken depending upon patient's clinical condition, present comorbidities and surgical procedure which can be disfiguring at times. The multi-organ effects of COVID-19 and DM, a weakened post-COVID body state and the systemic effects of AmB administration including decrease in renal function can have serious perioperative implications. Perioperative hypotension and arrhythmias due to AmB, post-COVID adrenal suppression and myocardial dysfunction have been frequently reported. Maintenance of an adequate mean arterial pressure, cardiac output and normovolaemia while concomitantly avoiding further renal insults is of paramount importance. The tissue that is debrided is dead tissue and hence not much bleeding has been reported intra-operatively. However, intra-operative bleeding can be an issue in redo debridement. Electrolyte disturbances such as hypokalaemia and hypomagnesemia due to AmB can interfere with neuromuscular blocking drugs, leading to problems such as delayed recovery. When administering neuromuscular blockers such as succinylcholine, the possibility of hypokalaemia due to AmB and hyperkalaemia due to critical illness-induced myopathy should be kept in mind. Serum potassium and blood glucose levels should therefore be closely monitored peri-operatively. The patients can have a difficult airway because of epiglottitis, sub- and supra-glottic oedema, restricted mouth opening due to jaw erosion and pain, palatal ulcers which bleed on touch, palatal perforations, crusts in the nose, oroantral fistulas and DM-induced joint stiffness. Facial swelling, proptosis and perioral wounds due to the use of tight fitting non-invasive ventilation masks during COVID treatment can hinder mask ventilation. An oral polyvinyl chloride/flexometallic endotracheal tube (of smaller size, if required) can take care of the airway; nonetheless, the difficult airway cart should be kept ready. Post-operative ICU care may be required due to the presence of comorbidities, post-COVID respiratory problems and airway-related issues. Wide excisions will warrant future flap reconstructive surgeries, which may pose as anticipated difficult airway. Thus, a patient scheduled for mucormycosis surgery should be thoroughly screened for effects of mucormycosis on airway besides, multi-organ effects of COVID and DM, and systemic effects of AmB administration. Adequate oxygen supply and optimal utilisation Oxygen supply to hospitals In India, The Central Drugs Standard Control Organisation (CDSCO) under the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, monitors the manufacture and use of the medical gases. The medical oxygen should be of medical grade IP 2010 that is certified safe for human use. Medical oxygen is oxygen that is free from any contamination, generated by an oil-free compressor and is odourless. It has carbon monoxide less than 5 parts per million (PPM) and carbon dioxide not more than 300 PPM. It should be free from halogen, polymer and oxidising substance and moisture. It should not cause any damage to the materials of cylinders, gas pipeline, anaesthesia machines and ventilators and most importantly to the patients. LMO, compressed gas cylinders, oxygen plants and oxygen concentrators are the sources of medical oxygen in health-care facilities. Any of these sources can be chosen depending upon the amount of oxygen needed at the health-care facility, the available infrastructure, cost, capacity and supply chain for local production (and delivery) of medicinal gases, reliability of electricity, access to maintenance services and spare parts, etc. Up-gradation of central oxygen supply and medical gas pipeline system (MGPS) should be done based upon anticipated future requirements. There should be provision for monitoring oxygen delivery pressure with functional alarms and isolation of oxygen supply to different hospital areas. All big hospitals should have full-time dedicated biomedical engineer for planning, installation, monitoring and maintenance. Liquid medical oxygen Bulk liquid oxygen is generated off-site and stored in a large cryogenic tank: vacuum-insulated evaporator (VIE). The boiling point of oxygen is −183°C. In the VIE, it is kept at −160°C at 5–10 atmospheric pressure. This is much below its critical temperature of −118.4°C, the temperature above which no amount of pressure can hold oxygen in liquid state. At 15°C, 1 L liquid oxygen can lead to the production of 842 L of gas at one atmospheric pressure. A full 10 KL LMO tank is approximately equal to 1200 “D” type cylinders of 7000 L. Liquid oxygen is highly concentrated, so more oxygen can be stored in a smaller tank. The cryogenic storage tank is refilled periodically by a truck from a supplier. Oxygen generator plant The oxygen generator plant generates 93% oxygen (±3%) for medical use according to the IP, the remainder consisting mainly of argon and nitrogen. It generates oxygen by PSA with molecular sieve technology (Zeolite). It operates on the principle of adsorbing under pressure, gases other than oxygen in the atmosphere onto the surface of an adsorbent material, termed as Zeolite (aluminium silicate). After adsorption, those gases except oxygen are vented out. This process, also called as fractional distillation, ensures that only oxygen is the The carbon dioxide and carbon monoxide in oxygen should not 300 and 5 PSA oxygen generator atmospheric and of storage and The oxygen generation capacity usually from to L per at pressure. PSA oxygen generator should oxygen and at pressure. The oxygen ± is monitored by a oxygen The PSA grade adsorbent should last for at 10 It is for and use and should have 100% as per the and It civil work, work, training to plant and to the It is advisable to not only have a provision for over from to generator up but also have cylinders as a supply in the The of oxygen generation plant is that it is in oxygen production with the of supply The of oxygen generator plant is that its output may be less than the oxygen during the of its use in the In addition, the generates of Thus, ventilation and for the and the are environment increased on the of and ventilation are issues when these plants. Moreover, the oxygen generation plant can be a of significant There is provision of of oxygen The of gases, of cylinders and gas is done are by The of cylinders and and to and compressed gas in cylinders are The Medical in its April 2021 has that all medical hospitals are also required to have a dedicated PSA oxygen supply in to supply from liquid oxygen which is to be and within Anaesthesiologists have used medical oxygen The anaesthesia and ICU ventilators are to work with the They will require when 93% medical the oxygen may not to the demand of oxygen in big hospitals and It is to have a to these oxygen and this oxygen can be used for those of the hospital which have oxygen beds The and ICUs can keep on receiving oxygen supply from LMO The hospitals should not on a medical gas pipeline from a This type of supply can be during A system and a gas supply should be to oxygen supply and the of the and of pipeline and should be conducted A hospital should have supply oxygen to last for a of and oxygen supply to last for days. The use of oxygen and in the hospital should be A to this should be and oxygen should be done Oxygen concentrators An oxygen is a medical to oxygen from concentrators available an oxygen and when within Oxygen concentrators can in and and they can be clinical or set up as in patient areas. They should be one from the in a of the They oxygen by The from L For COVID-19 patients, oxygen concentrators that are to 5–10 L of 93% ± 3% oxygen per are They are for and can oxygen for a for but some may require a of The of oxygen concentrators is A oxygen supply is The maintenance includes of for and oxygen delivery The and other are two patients use and as per the concentrators are available with oxygen Oxygen concentrators a low pressure output which is not for positive airway oxygen The oxygen from the of oxygen and of cylinders, and most it is not like medical oxygen can be generated by or oil-free oil-free are for oxygen that can be to the health-care There can be the presence of in oxygen cylinders which can cause of Thus, oxygen should be used for medical of and are treatment for COVID-19 patients The anaesthesiologists managing critically ill COVID-19 patients in the ICU should use corticosteroids There are very specific indications of the drugs remdesivir and tocilizumab in COVID-19 patients. These drugs are approved under the emergency use The shortage of these drugs in the intensive care management of COVID-19 patients should be managed by well-laid institutional mechanisms to make the availability of these drugs for the selective patients in the hospitals. The institutes and hospitals that have facilities for ECMO should utilise this technique judiciously in severely ill COVID-19 patients. ECMO ICUs should be set up in tertiary care Apart from the recommended for COVID-19 patients, few more are also therapy therapy a of and has been approved by the and the Drugs General of India for emergency use for the treatment of COVID-19 and in those at high risk of COVID-19. and are that are against the of to the and human two against of a multidisciplinary or a consisting of the involved in COVID-19 patient care should the use of therapy. The therapy is most for COVID-19 patients who the such as body renal DM, receiving of with cardiovascular or or pulmonary respiratory with for their and or or or or or a or positive pressure ventilation to or airway or other respiratory that for control. It should not be in patients with more than 10 from if the of is patient is due to patient has oxygen due to or those who require an in oxygen due to COVID-19 and in those on oxygen therapy due to underlying is on the use of this drug. The in India is a of 1200 of and of as a in over at different as soon as after positive for is to be used for two patients. After the is to be stored at and can be used within therapy A glucose has emergency use in India for use as an to standard of care in the treatment of COVID-19 It by the and the of the SARS-CoV-2 the cells and effects by the of from It is available in in and in in the of up to 10 or is The has through and clinical and patients have early clinical by with from The of many of the are to be The of the is not India is the in for the treatment of COVID-19. of the have and it is available in some hospitals. The is to be in COVID-19 The above is an advisory and position statement based on the and It is to state that is and guidelines are being support and of There are no of to of Indian Society of Anaesthesiologists, especially ISA and ISA on COVID-19 COVID-19 especially and and and for their valuable and

Topics & Concepts