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.
A 55-year-old female patient presented to surgical out-patient department (OPD) with chief complaints of pain and left hypochondrium for the last 3 days accompanied by nausea and vomiting. She presented a big dilemma to the attending surgeon as all the clinical signs and symptoms pointed towards symptomatic cholelithiasis, but the pain in the left hypochondrium totally contradicted the diagnosis. It was only with the help of radiological investigation reports that we were able to confirm it as a case of situs inversus totalis. Her chest X-ray typically depicted dextrocardia and spiral computed tomography (CT) scan showed transposition of all major abdominal organs. Echocardiography was carried out and revealed normal cardiac parameters with an ejection fraction of 60%.\nPre-anaesthetic evaluation revealed Mallampatti class II patient with a slight retrognathia, a pulse rate of 74/min, blood pressure of 130/78 mmHg and normal profile of laboratory investigations. She had a history of intermittent respiratory tract infections, especially during the winter season. At present, the patient had no systemic complaint pertaining to any organ system except for the gall bladder disease. A decision to operate the patient was taken and she was posted for open cholecystectomy.\nTablet ranitidine 150 mg and tablet alprazolam 0.25 mg were administered as premedication a night before and 1 h prior to the surgical procedure with a sip of water. In the operation theatre, a good intravenous (IV) access was secured with a wide bore cannula. Induction of anaesthesia was achieved with O2, isoflurane, propofol 120 mg, butorphanol 1 mg and succinylcholine 100 mg. During induction, we encountered masseter spasm immediately after the administration of succinylcholine, which lasted for approximately 45 s, and disappeared spontaneously, but we were able to ventilate the patient with bag and mask during this episode. Intubation was extremely difficult as the larynx was placed quite anteriorly and the laryngoscopic view could be best labelled as Cormack Lehane grade-III. Maintenance of anaesthesia was carried out with injection vecuronium and low concentration of isoflurane in oxygen and nitrous oxide mixture. The peri-operative period was characterized by frequent copious secretions from the respiratory tract that had to be cleared regularly for smooth ventilation. Inj. Hydrocortisone 100 mg was given prophylactically to prevent any bronchospasm. The surgical procedure was smooth and uneventful, and lasted for about 1 h. At the end of surgery, inj. Neostigmine and glycopyrrolate were administered but extubation was delayed as the patient developed prolonged post-operative apnoea. Therefore, extubation was performed only after establishing the return of all protective airway reflexes and establishment of regular breathing pattern. Infiltration of surgical incision site was carried out with 8 ml 0.375% of ropivacaine. The recovery period and hospital stay were uneventful and the patient was discharged in a satisfactory condition on the eighth post-operative day and was called for follow-up after 2 weeks.