Recent COVID infection before rectal cancer surgery52-year-old man, 82 kg, for laparoscopic anterior resection of rectal cancer

The patient

The examiner asks

Answer aloud, then press Show.

1. Consider

   What are your concerns?

   Show the answerHide the answer

   • A 52-year-old with COVID four weeks ago and mild asthma, for time-sensitive rectal cancer resection. Patient
   • Four weeks is inside the 7-week window, when his chest and death risks stay raised. Disease
   • His risks of pneumonia, respiratory failure and embolism peak in the first 4 weeks.
   • His persisting cough and fatigue may justify waiting longer than 7 weeks.
   • But this is cancer: delay carries its own risk, so the decision is individual. Surgery

2. Prepare

   How do you decide whether to go ahead?

   Show the answerHide the answer

   • I record when he had COVID, how severe it was, and his vaccination status. Disease
   • I reassess his breathing and exercise tolerance against his pre-COVID baseline.
   • Joint decision with him and the surgeon: cancer progression against perioperative chest risk. Surgery
   • If symptoms are settling, a short wait toward 7 weeks may suit his cancer plan.
   • COVID within 30 days adds to his clot risk; I plan full thromboprophylaxis. Disease
   • Budesonide continues; his asthma must be controlled on the day.

3. Plan

   How will you conduct the anaesthetic?

   Show the answerHide the answer

   • Salbutamol 2–4 puffs, 20–30 minutes before induction. Disease
   • Adequate depth before intubation; volatile agents reduce his airway reactivity. Airway
   • Lung-protective ventilation, 6–8 mL/kg ideal weight with PEEP, during pneumoperitoneum. Surgery
   • Calf compression from induction, then low-molecular-weight heparin afterwards. After surgery
   • Adrenaline drawn up before cefazolin and the relaxant, the commonest anaphylaxis triggers. Crisis

4. Crisis

   Two minutes after the cefazolin, BP is 64/30, HR 136, airway pressure is rising with wheeze, and a rash spreads. What do you do?

   Show the answerHide the answer

   • Anaphylaxis algorithm: hypotension and bronchospasm straight after cefazolin, a severe reaction. (Crisis)
   • Cefazolin stopped, help called, surgeon told to pause, 100% oxygen.
   • Adrenaline 0.5 mg IM now; no response, 0.05–0.1 mg IV slowly, as he is monitored.
   • Crystalloid 1 L bolus for this grade 3 reaction, repeated as needed.
   • His asthma makes the bronchospasm worse: salbutamol 4–8 puffs down the tube.
   • Still low: adrenaline infusion 0.05–0.1 mcg/kg/min, then vasopressin 2–10 units IV.
   • Antihistamine and steroid only after adrenaline; they don't treat his pressure or wheeze.

5. Crisis

   He stabilises after 20 minutes on a low-dose adrenaline infusion. What now?

   Show the answerHide the answer

   • Tryptase within 45–90 minutes of onset, then at 3 hours and 24 hours. (After surgery)
   • Proceed or abandon: I weigh his cancer's urgency against this severe reaction; today, I would postpone.
   • ICU observation; biphasic reactions occur in up to 20%, more after repeated adrenaline.
   • Every exposure documented with times, including chlorhexidine and other non-IV agents.
   • Allergy clinic referral, an adrenaline autoinjector, and the event explained to him.