Bain's circuit as continuous positive airway pressure device in a postoperative COVID-19 associated mucormycosis patient with type-1 respiratory failure: a case report

Abstract

The surge in coronavirus disease of 2019 (COVID-19) pneumonia cases has brought about a wave of COVID-19 associated mucormycosis, especially in patients with diabetes and those on immunosuppressive drugs. In addition, the antifungal therapy and the residual cardiopulmonary illness bring about an array of challenges in the perioperative period. Most often, such patients are far from optimized and need urgent surgical intervention. Regardless to say, many need some form of respiratory assistance in the postoperative period as well. With the pandemic already throttling the existing resources, such as ventilators and oxygen supply, it may be prudent to use devices from an anesthetist's armamentarium to aid patient's oxygenation and ventilation in the perioperative period. The authors describe one such case using Bain's circuit and a noninvasive ventilation mask to function as a continuous positive airway pressure device.

Full text

Bain’s circuit as continuous positive airway pressure device for COVID-19 patients
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Original Article - Case Study
Bain’s circuit as continuous positive airway pressure device in a
postoperative COVID-19 associated mucormycosis patient
with type-1 respiratory failure: a case report
Snigdha Kumari1, Habib Md Reazaul Karim1,*, Prateek Arora1, Arshad Nadirsha1
1Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences
Raipur, India.
* Corresponding author: Habib Md Reazaul Karim, MD, DNB, IDCCM, FNIV. Faculty Room A001, Block
A, AIIMS Raipur Hospital Complex, GE Road, Tatibandh, Raipur, 492099, India. Email:
drhabibkarim@gmail.com
Submitted: June 17, 2021; Revised and Accepted: June 30, 2021; Published: June 30, 2021.
Citation: Kumari S, Karim HMR, Arora P, Nadirsha A. Bain’s circuit as continuous positive airway pressure
device in a postoperative COVID-19 associated mucormycosis patient with type-1 respiratory failure: a case
report. Discoveries Reports 2021, 4: e22. DOI: 10.15190/drep.2021.7
ABSTRACT
The surge in coronavirus disease of 2019
(COVID-19) pneumonia cases has brought about a
wave of COVID-19 associated mucormycosis,
especially in patients with diabetes and those on
immunosuppressive drugs. In addition, the
antifungal therapy and the residual
cardiopulmonary illness bring about an array of
challenges in the perioperative period. Most often,
such patients are far from optimized and need
urgent surgical intervention. Regardless to say,
many need some form of respiratory assistance in
the postoperative period as well. With the
pandemic already throttling the existing resources,
such as ventilators and oxygen supply, it may be
prudent to use devices from an anesthetist's
armamentarium to aid patient's oxygenation and
ventilation in the perioperative period. The
authors describe one such case using Bain's circuit
and a noninvasive ventilation mask to function as
a continuous positive airway pressure device.
Keywords
COVID-19, fungi, mucormycosis, anesthesia;
artificial respiration.
INTRODUCTION
Mucormycosis is a rare, life-threatening infection
caused by a fungus called mucormycetes and has
been described in patients with medical conditions
where immunity is compromised1. The coronavirus
disease of 2019 (COVID-19) pandemic has
unleashed havoc worldwide, and the use of steroids,
monoclonal antibodies, and broad-spectrum
antibiotics are rampant in the management of
COVID-19 patients. Steroid use leads to
hyperglycemia and negatively impacts glycemic
control, even in diabetic patients. Furthermore,
immune dysregulation in COVID-19 is also now
well-known2. All these factors provide a congenial
environment to the opportunist fungus3, and
COVID-19 associated mucormycosis is becoming an
added challenge in this pandemic4. As the patients'
lungs are often in a bad condition due to COVID-19,
perioperative respiratory failure management
remains difficult.
CASE REPORT
A 46-year-old gentleman, weighing 65 kg, was
posted for debridement of sino-nasal lesions of
COVID-19 associated mucormycosis. The patient
DISCOVERIES REPORTS 2021, 4: e22
DOI: 10.15190/drep.2021.7

Bain’s circuit as continuous positive airway pressure device for COVID-19 patients
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Figure 1. Computed tomography (axial section) of rhinoorbital region showing soft tissue swelling in
the infraorbital region, maxillary sinus and nasal cavity of the right side
Figure 2. Chest x-ray showing bilateral diffuse, multifocal, nonhomogeneous opacities predominantly
over the mid and lower lobe

Bain’s circuit as continuous positive airway pressure device for COVID-19 patients
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had fever, cough, breathlessness and was diagnosed
with COVID-19 four weeks back. He received low-
molecular-weight heparin, remdesevir,
methylprednisolone, broad-spectrum antibiotics, and
oxygen therapy by non-rebreathing mask. His
condition improved, and he tested negative for
COVID-19 on the 21st day. However, he
subsequently developed swelling and pain over the
right infraorbital region, upper jaw, and headache
two days before the COVID-19 negative report. The
cough and exertional breathlessness persisted
throughout. Clinical findings, microbiological study,
and computed tomography (Figure 1) confirmed the
diagnosis of COVID-19 associated mucormycosis.
He is a known case of diabetes for the past two years
and was on oral hypoglycemics. During COVID-19
hospitalization, insulin was initiated, and blood
sugar was maintained between 150-200 mg/dl.
Following the diagnosis of COVID-19 associated
mucormycosis, he received the first dose of
liposomal amphotericin B. He was conscious,
oriented, butanxious, having tachypnoea and a room
air saturation of 91%. Crepitations over the right
basal lung field were present. Gingival mucosa
discoloration, a few loose teeth, pus discharge, right
infraorbital swelling, lid edema, and conjunctival
congestion were also present. No neurological
deficit was noted. His preoperative hemoglobin,
platelet counts, serum creatinine, and blood urea
were within normal limits, but a mild hypokalemia
(K+ 2.7 mEq/L) was present. Chest X-ray showed
bilateral diffuse, multifocal, nonhomogeneous
opacities, predominantly over the mid and lower
lobe (Figure 2). Preoperative arterial blood gas
measurements showed pH 7.49, pCO2 27 mmHg,
pO2 60 mmHg and HCO3 level of 20 mEq/L.
With informed and written consent, the patient
was taken for surgery. The American Society of
Anesthesiologists standard monitoring was applied,
and the right radial arterial line was secured and
transduced. He was premedicated with midazolam
injection 1 mg, the general anesthesia was induced
with fentanyl injection 100 microgram and propofol
injection 100 mg. After confirming bag-mask
ventilation, injectable vecuronium 5 mg was used to
facilitate tracheal intubation. A 7.5 mm inner
diameter (ID) flexometallic tube was used to secure
the airway. Balanced low flow anesthesia was
maintained with isoflurane in air and 50% oxygen.
The age adjusted minimum alveolar concentration of
potent inhalational agent was maintained at 1+/-0.1..
Injection vecuronium as a muscle relaxant,
nalbuphine injection 4 mg, and paracetamol 1 gm
were administered as analgesic. Intraoperative
arterial blood gas measurements showed pH 7.46,
pO2 111 mmHg, pCO2 35 mmHg and HCO3 level
of 22 mEq/L. The surgery lasted for three hours, and
the intraoperative course was uneventful. Thus, the
inhalational agent was cut-off, and pressure support
ventilation mode indicated good efforts.
Neostigmine injection 2.5 mg and glycopyrrolate 0.5
mg were used to reverse neuromuscular blockade.
He was extubated uneventfully and was put on a
face mask 8 L/min. However, despite having a good
respiratory pattern and depth, his saturation
remained below 94%. Therefore, he was shifted to a
post-anesthesia care unit, put on a noninvasive
ventilation mask connected to Bain’s circuit with an
adjustable pressure limiting valve (Figure 3), and
maintained a SpO2 of 99 to 100% with O2 8 L/min.
His condition improved over the next 12h and
arterial blood gas measurements showed pH 7.40,
pCO2 32 mmHg, pO2 110 mmHg and the HCO3
level of 19 mEq/L. The patient was weaned to face
mask and subsequently to room air and maintained
SpO2 of 96-98% without respiratory distress by the
next day.
DISCUSSION AND CONCLUSION
Our patient posed a few challenges apart from
airway management, perioperative glycemic, and
hemodynamics control. While medical management
using antifungals is ubiquitous, successful treatment
of rhino-cerebral mucormycosis often includes
surgical modalities requiring perioperative care.
Recent literature recommends liposomal
amphotericin B and surgery wherever possible, as
the first line and posaconazole as the second line
pharmacological agent5. On the other hand, these
antifungal affect serum K+ and renal function6,
impacting anesthesia management and perioperative
outcome7. Therefore, pre-anesthetic evaluation of
such patients should be meticulously performed, and
appropriate correctible and optimizing strategies are
crucial, especially for the correction of
dyselectrolytemia and prevention of further kidney
injury.

Bain’s circuit as continuous positive airway pressure device for COVID-19 patients
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Over and above dyselectrolytemia, our patient
also had a type-1 respiratory failure with terrible
lung status due to a recent COVID-19 infection.
While it is advised to time the elective surgeries in
post-COVID-19 patients8,9, patients with COVID-19
associated mucormycosis cannot wait, and urgent
surgery is required. Residual shortness of breath
from cardiopulmonary dysfunction also requires
special consideration during perioperative
management9. Furthermore, invasive ventilation
increases the risk of ventilator-associated
pneumonia. On the other hand, noninvasive positive
pressure ventilation after extensive sino-nasal
surgery is not without risk. The nostril is usually
packed in such patients, and a high-flow nasal
cannula in such a scenario is also not feasible.
Therefore, we decided to use indigenously adapted
Bain's circuit as a continuous positive airway
pressure device where the APL valve of the Bain's
circuit was slightly closed to provide approximately
3-5 cm H2O resistance. It worked for the patient, and
the patient maintained both oxygenation and
ventilation well (as evidenced from arterial blood
gas measurements), and even clinical condition
improved over the next 12h.
COVID-19 associated mucormycosis is emerging
as another havoc. Most cases are being reported
from India10. Many patients will require
perioperative O2 therapy, including artificial
respiratory support. In developing countries where
health resources and funds are limited, this modified
low-cost aid might be helpful in selected patients.
Conflict of Interest
The authors declare no conflict of interest.
Figure 3. Showing the application of Bain’s circuit as continuous positive airway pressure device in the
postoperative period

Bain’s circuit as continuous positive airway pressure device for COVID-19 patients
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Acknowledgements
We would like to acknowledge that all the devices and
manpower required were provided by the All India
Institute of Medical Sciences Raipur. Informed written
consent for publication was obtained from the patient.
In the authors' institute, case reporting does not require
institute research board approval.
References
1. Ibrahim AS, Spellberg B, Walsh TJ, et al.
Pathogenesis of mucormycosis. Clin Infect Dis.
2012 ;54 Suppl 1(Suppl 1):S16-22. doi:
10.1093/cid/cir865.
2. Tahaghoghi-Hajghorbani S, Zafari P, Masoumi E,
et al. The role of dysregulated immune responses in
COVID-19 pathogenesis. Virus Res.
2020;290:198197. doi:
10.1016/j.virusres.2020.198197.
3. John TM, Jacob CN, Kontoyiannis DP. When
Uncontrolled Diabetes Mellitus and Severe
COVID-19 Converge: The Perfect Storm for
Mucormycosis. J Fungi (Basel). 2021;7(4):298. doi:
10.3390/jof7040298.
4. Rabagliati R, Rodríguez N, Núñez C, et al. COVID-
19–Associated Mold Infection in Critically Ill
Patients, Chile. Emerg Infect Dis. 2021;27(5):1454-
1456.
5. Brunet K, Rammaert B. Mucormycosis treatment:
Recommendations, latest advances, and
perspectives. J Mycol Med. 2020;30(3):101007.
doi: 10.1016/j.mycmed.2020.101007.
6. Takazono T, Tashiro M, Ota Y, et al. Factor
analysis of acute kidney injury in patients
administered liposomal amphotericin B in a real-
world clinical setting in Japan. Sci Rep.
2020;10(1):15033.
7. Arora P, Pourafkari L, Visnjevac O, et al.
Preoperative serum potassium predicts the clinical
outcome after non-cardiac surgery. Clin Chem Lab
Med. 2017;55(1):145-153. doi: 10.1515/cclm-2016-
0038.
8. El-Boghdadly K, Cook TM, Goodacre T, et al.
SARS-CoV-2 infection, COVID-19 and timing of
elective surgery: a multidisciplinary consensus
statement on behalf of the Association of
Anaesthetists, the Centre for Peri-operative Care,
the Federation of Surgical Specialty Associations,
the Royal College of Anaesthetists and the Royal
College of Surgeons of England. Anaesthesia 2021.
Epub 18 March. doi: 10.1111/anae.15464
9. Ortoleva J. Anesthetic Considerations for
Recovered COVID-19 Patients. J Cardiothorac
Vasc Anesth. 2021;35(2):376-377. doi:
10.1053/j.jvca.2020.10.032.
10. Singh AK, Singh R, Joshi SR, et al. Mucormycosis
in COVID-19: A systematic review of cases
reported worldwide and in India. Diabetes Metab
Syndr. 2021 May 21. Epub-ahead-of-print. doi:
10.1016/j.dsx.2021.05.019
This article is an Open Access article distributed under
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License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original
work is properly cited and it is not used for commercial
purposes; 2021, Kumari S et al., Applied Systems and
Discoveries Journals.