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| LETTER TO EDITOR |
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| Year : 2018 | Volume
: 19
| Issue : 2 | Page : 92-93 |
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Dextrocardia with situs inversus totalis: Anesthetic implications and considerations
Teena Bansal, Jatin Lal
Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
| Date of Web Publication | 15-Nov-2018 |
Correspondence Address:
Dr. Teena Bansal
19/6 J, Medical Campus, PGIMS, Rohtak - 124 001, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/TheIAForum.TheIAForum_18_18
How to cite this article:
Bansal T, Lal J. Dextrocardia with situs inversus totalis: Anesthetic implications and considerations. Indian Anaesth Forum 2018;19:92-3 |
Sir,
Situs inversus totalis is an uncommon genetically determined positional anomaly characterized by transposition of abdominal and thoracic viscera, and the predicted incidence is 1 in 10,000 among the general population.[1] It can also exist as part of the Kartagener's syndrome. Kartagener's syndrome is a congenital autosomal recessive disorder that includes situs inversus totalis, sinusitis, and bronchiectasis. We hereby present a case of situs inversus totalis posted for emergency laparotomy.
A 45-year-old male presented in emergency operation theater for laparotomy because of acute pain in the left iliac fossa which was diagnosed as burst appendix on ultrasonography. Ultrasound abdomen indicated situs inversus. Medical and surgical history was unremarkable. Blood pressure was 90/60 mmHg and heart rate was 120/min. Systemic examination revealed normal heart sounds but on the right side. Chest was bilaterally clear. Airway examination was unremarkable. Spine was normal. Electrocardiography (ECG) displayed inverted P waves in Leads I and aVL suggestive of dextrocardia. Chest X-ray revealed cardiac shadow and gastric bubble on the right side. A diagnosis of situs inversus with dextrocardia was made. Echocardiography revealed dextrocardia with normal cardiac anatomy. Other relevant laboratory investigations were within normal limits. General anesthesia was planned for the procedure. In the operating room, standard monitors were attached. After preoxygenation, induction of anesthesia was done with fentanyl 2 μg/kg, thiopentone sodium 5 mg/kg, and rocuronium 1 mg/kg. Endotracheal intubation was done which was confirmed by bilateral air entry and capnography. Anesthesia was maintained with isoflurane in 67% nitrous oxide. Heat moisture exchanger was used for humidification of inspired gasses. Intraoperatively, there were secretions in the endotracheal tube which were suctioned out. Surgery lasted for 1 hour. At the end of surgery, residual neuromuscular blockade was reversed with neostigmine and glycopyrrolate and the trachea was extubated awake. Postoperative course was uneventful.
Situs inversus may involve many systems such as cardiovascular system, airway, spine, and alimentary tract of which involvement and abnormalities of cardiovascular system are most important. In normal population, the prevalence of congenital heart disease is <1%, whereas in patients of situs inversus totalis, it may go up to 3%–5%. Various anomalies associated with situs inversus either singly or in combination in the cardiovascular system include atrial septal defects, ventricular septal defects, transposition of great vessels, absent coronary sinus, double outlet right ventricle, total pulmonary anomalous venous defect and pulmonary valve stenosis.[2]
Association between situs inversus and spinal cord malformations has been reviewed by Dwarakanath et al.[3] Scoliosis, split cord, spina bifida, meningomyelocele, and tethered spinal cord have been described. A diligent neurological examination and palpation of the spine are essential to detect these problems. Goldenhar syndrome, aglossia, hypoglossia, and craniodiaphyseal dysplasia have also been reported in these patients. Hence, the patient should be evaluated thoroughly by history, examination, and investigations and optimized preoperatively.
ECG demonstrates sinus rhythm and inversion of the P wave in Leads I and aVL. ECG with reversed leads shows no abnormalities. An echocardiography may help in confirming the absence of major defects preoperatively, and the monitoring should be individualized based on the severity of the cardiac disease.
Local and regional anesthetic techniques are preferred over general anesthesia with the rapidity, density, and reliability of the subarachnoid block and the flexibility of continuous epidural to extend duration of analgesia. Combined spinal-epidural anesthesia is an effective choice in these patients.[4] However, we avoided regional anesthesia as the patient's blood pressure was 90/60 mmHg, and regional anesthesia could result in further lowering of blood pressure.
The main anesthetic considerations among patients with Kartagener's syndrome are related to the pulmonary function which includes testing of preoperative respiratory infections due to associated bronchiectasis.[5] Bronchodilators, chest physiotherapy, postural drainage, antibiotics, and incentive spirometry are mandatory in optimizing the pulmonary status before any surgical procedure. It is often necessary to delay surgery if respiratory infection is present.
Premedication drugs that depress ventilation or ciliary activity should be avoided in dextrocardia associated with Kartagener's syndrome. Prolonged paralysis after the use of succinylcholine has been reported with situs inversus totalis and ranitidine-induced bradycardia in a patient with dextrocardia. Hence, we avoided succinylcholine and used rocuronium. Inspired gasses should be humidified due to inspissation of secretions. ECG electrodes and defibrillation pads should be placed in reverse manner. Left internal jugular vein cannulation is preferred to avoid thoracic duct injury and to ensure direct access to the right atrium in case of inversion of great vessels. The anatomy of the bronchi should be considered before selecting a double-lumen tube in thoracic surgery.
In conclusion, management of a patient with situs inversus totalis is important for both surgeon and anesthesiologist due to different anatomical structures as these patients require meticulous planning.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Bajwa SJ, Kulshrestha A, Kaur J, Gupta S, Singh A, Parmar SS, et al. The challenging aspects and successful anaesthetic management in a case of situs inversus totalis. Indian J Anaesth 2012;56:295-7.  [ PUBMED] [Full text] |
| 2. | Winer-Muram HT. Adult presentation of heterotaxic syndromes and related complexes. J Thorac Imaging 1995;10:43-57. |
| 3. | Dwarakanath S, Suri A, Garg A, Mahapatra AK, Mehta VS. Adult complex spinal dysraphism with situs inversus totalis: A rare association and review. Spine (Phila Pa 1976) 2005;30:E225-8. |
| 4. | Abraham B, Shivanna S, Tejesh CA. Dextrocardia and ventricular septal defect with situs inversus: Anesthetic implications and management. Anesth Essays Res 2012;6:207-9. [Full text] |
| 5. | Reidy J, Sischy S, Barrow V. Anaesthesia for Kartagener's syndrome. Br J Anaesth 2000;85:919-21. |
| This article has been cited by | | 1 |
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| Kaitlin E. Woods,J. W. Awori Hayanga,Daniel Sloyer,Roy E. Henrickson,Lawrence M. Wei,Heather K. Hayanga,Anjan Trikha | | Case Reports in Anesthesiology. 2020; 2020: 1 | | [Pubmed] | [DOI] | |
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