Case report of dextrocardia

1. ANESTHESIA
IMPLICATIONS IN
DEXTROCARDIA
WITH SITUS
INVERSUS
Presenter: Dr Tess Jose (Second Year PG Resident)
Moderator: Dr Giles George

2. INTRODUCTION
Dextrocardia is a rare congenital disorder in
which the heart resides on the right side of the
thoracic cavity.
It is often associated with other development
anomalies and, in most cases, is diagnosed
incidentally.
It can occur by itself or can be accompanied by
a reversal in the position of other organs

3. HEART IS THE FIRST ORGAN
TO DEVELOP IN AN EMBRYO.
FETAL HEART DEVELOPS
FROM AN EMBRYONIC
HEART TUBE, WHICH IS
FORMED BY THE FUSION OF
THE ENDOCARDIAL TUBES.
THE HEART TUBE ATTACHES
TO THE CRANIAL ASPECT TO
THE ARTERIAL TRUNK, AND
THE CAUDAL ASPECT IS
CONNECTED TO THE
VENOUS CHANNELS.
ONCE THE HEART TUBE IS
FORMED, THE NEXT
IMPORTANT STEP IN THE
DEVELOPMENT OF THE
HEART IS LOOPING.
LOOPING DETERMINES THE
POSITION OF THE VENTRICLE
IN RELATIONSHIP TO THE
ATRIA

4. During the embryological development, a 270°
clockwise rotation instead of normal 270°
anticlockwise of the developing thoracoabdominal
organs results in mirror image positioning of the
abdominal and thoracic viscera.
The association of situs inversus totalis with
syndromes, such as Kartagener’s syndrome, cardiac
anomalies, spleen malformations, and other such
clinical entities, makes the clinical scenario extremely
challenging for the concerned anesthesiologist

5. CASE REPORT
• Name: Sadananthan
• Age 45year
• Sex: Male
• Occupation: Farmer
• Address: Kozhencherry
• Presenting complaint
• Swelling in groin on right side for 3 years

6. HISTORY OF PRESENTING ILLNESS:
• The patient was apparently alright 3 years ago when he noticed a
swelling in the right groin which was insidious in onset, and
gradually progressed in size over 2 years to reach the root of the
scrotum.
• It was spontaneously reducible in the first 8-10 months but
presently it is not reducible with/without manipulation.
• Patient also complains of mild intermittent pain in scrotum over 2
years with an increase in severity since 1 month.
• Pain is aggravated on walking and coughing, and relieved on sitting
or lying down position.
• It is dull aching in character and non radiating

7. • No h/o difficulty in initiating micturition, poor stream, increased
frequency, dribbling of urine, stress on micturition, increase or
decrease with straining.
• No h/o constipation.
• No h/o abdominal surgery.
• No h/o vomiting associated with abdominal distention.
• No h/o acute severe pain associated with fever and redness over
swelling.

8. • Past history
• Past medical history
• K/c/o Dextrocardia with situs inversus diagnosed incidentally in
childhood
• No h/o T2DM, Hypertension, CAD, CVA, BA,Seizure disorder,
Bleeding disorder, Thyroid disorder

9. • Drug history
• Not on any regular medication
• No history of drug allergy

10. • Personal history
• Normal bowel and bladder habit
• Mixed diet
• Family history
• No significant history .

11. GENERAL EXAMINATION
• Pt conscious oriented to time place person
• Moderately built and nourished
• No pallor
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• No edema

12. VITALS
• PR -80/min, regular rhythm, volume, and character normal, no radio
femoral delay, condition of vessel wall-no thickening
• Bp-130/70mmHg right arm sitting position
• RR-16/min, Abdominothoracic
• SpO2-98% With room air
• Temp -afebrile

13. AIRWAY EXAMINATION
• No facial dysmorphism
• MO 3 fb
• Tongue, dentition normal
• Mps Grade 2
• Sternomental distance13.5 cm
• No retrognathia
• Neck movement adequate

14. CVS EXAMINATION
• Inspection
• No chest wall abnormalities
• No visible pulsations
• No dilated or engorged veins
• Palpation
• Apex beat felt on 5th Right intercostal space just medial to midclavicular line
• No epigastric pulsations
• No parasternal heave/No thrill
• Auscultation
• SI and S2 were heard on the right side with no murmurs

15. RESPIRATORY SYSTEM
• INSPECTION
• 1. Position of trachea central
• 2. No Chest wall deformity-
• 3. Chest wall symmetrical
• 4. Movements of chest wall
• 5. No intercostal retraction, accessory of respiration.
• 6.Skin over chest wall-dilated veins, pulsations, scar discharging
sinus, intercostals swelling

16. • Palpation
• Trachea central -
• Movement of chest - b/l symmetrical
• no local rise of temperature
• vocal fremitus -equal on both sides
• Percussion
• Resonant note in both lung fields
• Auscultation
• • Air entry bilaterally equal
• • normal vesicular breath sounds no added sound

17. GIT EXAMINATION
• Oral cavity-dental caries present, no loose teeth, no malformed
teeth,
• Tongue -normal size, colour,surface
• No local rise of temperature
• no tenderness
• no guarding or rigidity
• no rebound tenderness
• no organomegaly-liver, spleen not palpable

18. NEUROLOGICAL
EXAMINATION
• Hmf -normal
• Cranial nerves-normal
• Motor system wnl
• Sensory system Wnl

19. INVESTIGATIONS
• Hb-14g/dl, PCV- 45.6, TLC :8040- , platelets :- 2.8lakhs
• S. Cr :0.9mg/dl, urea :32
• S.Na+:141meq/L S.K+ :4.5mg/dl
• PT-INR -1.05, BT-2'10"BT-4'10"
• RBS:-85mg/dl
• LFT-normal
• Blood group: 0 neg
• viral markers –non-reactive

20. ECG
• right axis deviation,
• Global negativity in lead I and
global positivity in aVR
• Absent R wave progression in
precordial leads.

21. • Chest xray
• The cardiac apex pointing
to the right.
• Right-sided aortic arch.
• The right hemidiaphragm
presents at a lower level
compared to the left

22. • Echocardiography revealed dextrocardia Right
ventricular hypertrophy Satisfactory LV systolic
function no septal defects.
• USG abdomen showed malposition of abdominal
organs

23. SUMMARY
• 45 years old gentleman, a farmer by occupation, k/c/o
dextrocardia with situs inversus.
• Presented with swelling in the groin on the right side
for 3 years, initially reducible, now irreducible,
associated with a dull aching pain with an increase in
severity over the last 1 month.
• Posted for laparoscopic Right sided inguinal
hernioplasty.

24. ANESTHESIA MANAGEMENT
An 18 G iv line was placed and patient was pre-medicated
medicated with Metaclopromide 10 mg and Pantoprazole
40 mg intravenously (IV) one hour before surgery.
Standard monitorings were attached. ECG electrodes were
placed in exactly opposite spotes to what is done for
levocardia
Patient’s pulse rate was 70/min, blood pressure was
124/76 mmHg and arterial oxygen saturation was 98% on
room air.

25. In OR patient was preoxygenated for 3
minutes with 100% O2 with FGF 8L/min
Induction of anesthesia was achieved with
fentanyl 2 mcg/ kg and etomidate 0.6 mg/ kg .
Intubation was done using a 8.5 mm cuffed
endotracheal tube.
laryngoscopic view could be best labeled as
Cormack–Lehane grade II
Bilateral air entry was checked and tube was
fixed and maintained with O2 + N2O (50:50)+
sevoflurane (1-1.5MAC)

26. Maintenance of anesthesia was carried out with divided doses of
injection Cisatracurium and Fentanyl infusion.
After tracheal intubation FGF 4L/min O2 2L/min and N2O 2L/min
Ventilation was adjusted to maintain normal arterial oxygen and
ETCO2 at range 30-45 mmHg during anesthesia
Analgesia was maintained with incremental doses of Fentanyl and
Cisatracurium when required
Hemodynamic monitoring was continuously performed during the
course.

27. Intraoperative period was smooth and uneventful
lasted for 2 hours
At the end of surgery ,Inj Neostigmine 0.05 mg/ kg
and Glycopyrolate 0.01 mg/ kg. was administered
after confirming spontaneous breathing.
Extubation was performed only after returing of all
protective airway reflexes and establishment of
regular breathing pattern

28. As a part of multimodal analgesia post operative
pain was managed with Right side Transverus
abdominis plane block Under USG guidance.
Recovery period was uneventful and patient was
discharged post op day 3.

29. DISCUSSION
Patients with situs inversus require certain intraoperative
considerations:
1. Main stem intubation often occurs at left
2.The ECG and pacing or defibrillator pads should be placed
placed in reverse. If not, the polarity change for the ECG can
can erroneously display a picture of perioperative ischemia.
3. Successful cardiopulmonary resuscitation and
defibrillation requires proper knowledge

31. DISCUSSION
4. TEE imaging and interpretation must take into account the
possibility of uncovering abnormalities missed in previous
work-ups
5. Central venous cannulation should occur in the left internal
jugular vein, which provides a direct route to the right atrium
and lessens the incidence of thoracic duct injury
6. In the obstetric patients, uterine displacement should be to
the right

32. DISCUSSION
7. Association of situs inversus with KGS ,mucociliary dysfunction
airway abnormalities etc.. which may predispose to airway
difficulty and pulmonary infections that have considerable
implications during induction of anesthesia and intubation
8.Premedicant drugs that depress ventilation or ciliary activity
should be avoided in dextrocardia with KGS.
9. Sedatives should be used with caution as respiratory acidosis
may increase pulmonary vascular resistance

33. DISCUSSION
10. Numerous cardiac abnormalities such as ASD ,VSD ,TGV,TAPVC
further complicate anesthesia .
11. The associated spinal deformities like split cord, spina bifida,
meningomyelocele, scoliosis etcetera either contraindicate or
make the administration of neuraxial blockade difficult.
12. Insertion of DLT will pose a lot of challenges and successful
intubation and separation of the lung cannot be achieved without
the aid of fibreoptic bronchoscope.

35. CONCLUSION
• The precise diagnosis of situs inversus totalis and a thorough preoperative
evaluation can minimize, to a large extent, the difficulties and the various
potential challenges associated with its anesthetic management.
• It needs modification in technique, proper planning and with cautious
dissection; then the procedure can be safely completed.

36. Thank you