A Challenging Cancer Case with Multiple Anaesthetic Drug Allergies Successfully Operated at KIMS Cancer Center

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A 57 year old lady presented herself at the OPD of a premier Medical College Hospital in Odisha for her right lower neck swelling in March this year. Evaluation was suggestive of Papillary carcinoma of her thyroid gland with metastasis to lymph nodes in her neck.

She was taken up for planned surgery (Total Thyroidectomy, Central compartment clearance, Right Selective neck dissection ( neck levels II-V) on 6th May, 2024 at the hospital but surgery was deferred due to persistent thick mucus coming from airway which made it difficult to ventilate her. She was posted for surgery again at the same institution on   24th May 2024, but fell in oxygen saturation, which was encountered during induction. Bronchoscopy revealed thick mucus plugs. Surgery was deferred.On improvement, she was discharged and referred to one of the Premier Medical College & Hospitals of India in Delhi, where she remained hospitalized for about a month in June-July 2024. She was dermatologically tested for hypersensitivity to drugs. She was found to have hypersensitivity to many anaesthetic agents including induction agents, muscle relaxants etc. Hypersensitivity was found to a total of 8 drugs including drugs commonly used for general anesthesia, potent analgesic and an antibiotic.( Atracurium, cis-atracurium, ketamine, thiopental, succinylcholine, cefuroxime, morphine, ketorolac). She then returned to Odisha.She presented herself at KIMS Cancer Center on 31st August, 2024 to Dr. Sabyasachi Parida, Senior Consultant, Surgical Oncology. On re- evaluation, she was found to have imaging suggestive of bilateral enlarged neck nodes. This precluded possibility of any surgery under local anaesthetic.She was then referred to the Anesthesia Team at KCC. The team was headed by Senior Anaesthetist Dr. T. Rajmohan Rao evaluated the Patient, discussed the plan and gave consent to go ahead with surgery. The Surgeon and Chief Anaesthetist discussed the case again followed by a presentation in the Tumor Board. A Plan was made to take her up for surgery under high risk. The Surgical plan was modified to Total Thyroidectomy, central compartment clearance and bilateral selective neck dissection.

She was posted as the sole case in a designated OT. Check lists were prepared separately for her in addition to usual check lists. Staff were sensitized and prepared to handle the procedure. Chief of Anesthesia at KSS & CC, Dr. T. Rajmohan Rao took up the case. Clear instructions were given on what to do and what not to do. Three peripheral lines, one arterial line were placed. Central venous line was not placed in the neck due to planned bilateral neck dissection.Induction and intubation was smooth, however hypotension was encountered which was managed with vasopressors. Other senior members of the Anesthesia Team also remained available and kept constant watch on the patient. Surgery was difficult due to high vascularity which made it difficult to progress rapidly. However, all the planned steps were completed by Dr. Sabyasachi Parida, assisted by Scrub Nurse: Anuradha, Sarojini, Monalisha and senior OT assistant Mikina.The procedure was completed successfully in about 5 hours, safeguarding the vocal nerves, parathyroid glands of both sides.

She was extubated on a table, shifted to ICU for observation. Feeds commenced the same night. Diet advanced from the next day. She was shifted back toward where her recovery was uneventful. Minimal drugs were employed in view of known multiple drug hypersensitivity. She was discharged after removal of neck drains.This case, other than being challenging, is one of rarest cases in view of hypersensitivity to multiple anaesthetic agents. Careful planning, precise execution and teamwork ensured optimal outcomes for the Patient despite challenging conditions.

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