2023 FSA Podium and Poster Abstracts
P035: URGENT SURGERY IN THE SETTING OF DISSEMINATED MONKEYPOX INFECTION
Jessica V Bonilla, DO1; Cameron Howard, MD, MBA, CPE, FASA2; Benjamin Houseman, MD, PhD, FASA2; 1Memorial Healthcare System; 2Memorial Healthcare System and Envision Physician Services
Introduction/Background: The 2022 Monkeypox (MP) outbreak made a once rare infection increasingly prevalent across the United States. MP is characterized by a blister-like rash across the body, accompanied by flu-like symptoms. [1] MP spreads through direct physical contact and respiratory secretions, requiring specific isolation precautions and considerations for administration of anesthesia.[2] The majority of MP infections are mild, but disseminated infection has been reported in patients with compromised immune systems. Here we describe the perioperative management of proctitis in a patient with severe MP and advanced HIV/AIDS.
Methods: A 32-year-old male required anesthesia for urgent examination of anal lesions due to suspected MP proctitis. Preoperatively, he was afebrile with a WBC of 8.5 and mild tachycardia at 101. His absolute CD4 count was 99 a week prior to surgery with an undetectable HIV viral load. On physical exam, the patient was ill-appearing with multiple MP lesions across his torso and face, including the bridge of his nose (Figure 1a). He had a Mallampati score of 2, a thyromental distance >3 finger breadths, full neck ROM and intact dentition with thrush noted around the soft palette and oral mucosa (Figure 1b). Following discussion with the patient and surgeon, we elected to proceed with general endotracheal anesthesia rather than a neuraxial technique. The patient was taken to a negative pressure room, where personnel wore gowns, gloves, eye protection and N95 masks per CDC guidelines. [3-5] Following preoxygenation and administration of propofol and rocuronium, the patient’s trachea was intubated uneventfully using direct laryngoscopy. Anesthesia was maintained with sevoflurane. Dexmedetomidine and esmolol were administered throughout the procedure to treat tachycardia. Ondansetron and sugammadex were administered prior to extubation, and recovery from anesthesia was completed in the same negative pressure room as the procedure.
Discussion: Lesions on the bridge of this patient’s nose made preoxygenation challenging due to discomfort. Fortunately, this case proceeded uneventfully with appropriate infection control precautions. Neuraxial anesthesia might have been considered in this case because there were no lesions in his lower back, but the patient and surgeon preferred endotracheal anesthesia which was not contraindicated.[6] This case would have been more challenging without our experience during the COVID19 pandemic, which prepared our hospital and anesthesia staff to care for patients with these isolation precautions.
