A 38-year-old male presented with left-sided hydrocele and indirect inguinal hernia of long duration. His medical history included repeated upper respiratory tract infection requiring frequent hospitalization in childhood and was diagnosed to have a ventricular septal defect (VSD) and situs inversus at the age of 7 years. On examination, the apical impulse was felt in right 5th intercostal space with right precordial bulge. A holosystolic murmur (Grade 3/6) was heard in the right 2-4th intercostal spaces with a loud P2 and normal vesicular breath sounds. The hemoglobin of 16.3 g/dl and platelets of 2,30,000/mm3 were noted on blood investigations. Chest X-ray showed dextrocardia and a right-sided “stomach bubble” []. Situs inversus of abdominal organs was seen on the ultrasound. Echocardiogram (ECHO) revealed dextrocardia, subaortic VSD, mildly dilated right ventricle and atrium, moderate tricuspid regurgitation, and pulmonary arterial hypertension (60 mmHg). ECG was consistent with mirror image dextrocardia.\nA combined spinal epidural anesthesia (CSEA) was planned for hernioplasty and hydrocelectomy. The patient was premedicated with pantoprazole and ondansetron on the morning of surgery. A 20G arterial line was secured for invasive pressure monitoring. Continuous ECG, invasive blood pressure, and pulse oximeter was instituted. With strict asepsis and the patient in sitting position, an 18-gauge epidural catheter was placed at L1-L2 interspace. Using a 25-gauge spinal needle, subarachnoid block was performed with 1.8 ml of 0.5% bupivacaine and 25 μg fentanyl at L3-L4 interspace. The patient's heart rate, blood pressure, and oxygen saturation remained stable during the intraoperative period. Fentanyl 50 μg and graded doses of 0.2% Ropivacaine was administered epidurally to achieve segmental anesthesia for the subsequent operative period. Further intraoperative course was uneventful. In the first 24 hours postoperatively, patient was monitored in the ICU. Buprenorphine 120 mcg twice daily was administered for epidural analgesia. Further postoperative period was uneventful and subsequently, the patient was discharged home.
A 44-year-old man was admitted to the Ear, Nose, and Throat department of our hospital in August 2019 with chronic nasal obstruction, postnasal drip, chronic sinusitis, and chronic non-productive cough for FESS. During history-taking, the patient stated that his heart was on the right side of his chest. A chest roentgenogram and a high﻿-resolution chest and abdomen computed tomography (CT) scan identified dextrocardia (), situs inversus (), and chronic bronchitis and bronchiectasis involving both lung bases ( and ). CT sinuses showed mucosal thickening of bilateral maxillary and ethmoid and sphenoid sinuses (). KS was diagnosed based on the presence of the classical triad.\nOn admission, the patient’s vital signs, including blood pressure (systolic 112, diastolic 74 mmHg), heart rate (80 beats per minute), respiratory rate (19/min), and the peripheral capillary oxygen saturation (SpO2; 94%), were within normal range. The complete blood count and renal and liver function test results were unremarkable. The 12-lead electrocardiogram (ECG) with reversal of the limb and precordial leads showed sinus rhythm and a normal tracing. The patient had a known allergy to acetylsalicylic acid (Aspirin®) and nonsteroidal anti-inflammatory drugs, and an allergy panel was performed, which revealed positive hazelnut antibodies. Since crepitations and wheezes were heard over bilateral lung fields, the patient was prescribed oral prednisolone (50 mg, once daily (QD), oral lansoprazole (30 mg, QD), oral levofloxacin (500 mg, QD), and 0.1% xylometazoline hydrochloride nasal spray (every 8 h). Intensive chest physiotherapy and supportive care prior to surgery were provided to prevent worsening of the lung function. Additional hypertonic saline nebulizer (every 8 h) and salbutamol nebulizer (5 mg, twice daily) were provided during pre-anesthetic evaluation in order to prepare the patient for safe anesthesia and surgery. The METs estimated by preoperative history at the preoperative evaluation visit were approximately 4 with moderate-intensity activities. He could walk on a flat surface for one or two blocks and up to two flights of stairs.\nIn the operating theater, an intravenous (IV) access, neuromuscular monitoring, and routine monitors (ECG, non-invasive blood pressure, and pulse oximetry for SpO2) were established. The patient was pre‑oxygenated with a face mask for 3 minutes. General anesthesia was induced with 2 µg/kg IV fentanyl and 2–2.5 mg/kg IV propofol. Neuromuscular blockade was achieved with 0.5 mg/kg atracurium. The trachea was intubated in a single attempt using a single-lumen cuffed tube of internal diameter 8.0 mm. The anesthesia was maintained with 50% O2, N2O, and isoflurane. Remifentanil was given continuously with a syringe infusion pump (Perfusor® Space; B. Braun, Germany) at a rate of 0.1 µg/kg/min adjusted per the patient’s heart rate.\nThe patient’s lungs were ventilated with a 50% fraction of inspired oxygen. A tidal volume of 7–10 mL/kg and respiratory rate of 10–12 breaths/min were adjusted to maintain the End-tidal CO2 between 30 and 36 mmHg. To increase the lung functional residual capacity a small amount of PEEP (5 cmH2O) was applied during the mechanical ventilation of the patient. A single dose of IV cefotaxime 1 g was administered intraoperatively.\nAbout 20 minutes before the end of the surgery, 1 g paracetamol with 100mg tramadol was infused for 15 minutes. Dexamethasone 8 mg and metoclopramide 10 g were also given intravenously.\nThe duration of FESS with bilateral frontal polypectomy was 95 minutes. All hemodynamic parameters were stable, and no additional muscle relaxant or fentanyl was required throughout the procedure. At the end of the surgery, the residual neuromuscular block was reversed with IV neostigmine 0.05 mg/kg and IV atropine 1 mg.\nLungs suctioning through the endotracheal tube and oral suctioning were performed gently. Tracheal extubation was performed when the patient was able to open the eyes and ventilate spontaneously. The emergence from anesthesia was smooth and without complications. After ~20 minutes in the post-anesthesia care unit, the patient was fully awake and pain-free (pain scale 2). The patient was then transferred to the surgical intensive care unit for 8 hours, and subsequently to the ward. An arterial blood gas analysis on room air showed pH = 7.419, oxygen concentration (PaO2) = 70 mm Hg, carbon dioxide concentration (PaCO2) = 36 mm Hg, bicarbonate ion concentration (HCO3−) = 23 mmol/L, O2 saturation = 94%, and base excess = −1 mmol/L. The postoperative period was uneventful. The patient felt subjectively “very well” and was discharged from the hospital on the ﻿second postoperative day.