Deep Sedation for Palate Alginate Impression Procedure in a Post-Fontan Procedure Patient with Mental Retardation

The Fontan operation is a heart operation used to treat complex congenital heart defects like tricuspid atresia, hypoplastic left heart syndrome, pulmonary atresia and single ventricle. A single ventricle is dedicated to pumping oxygenated blood to the systemic circulation and the entire systemic venous return reaches the pulmonary arterial system without the direct influence of a pumping chamber. In the patient with Fontan operation, it is important to achieve adequate pulmonary blood flow and cardiac output in anesthetic management. In this case, a 10-year-old boy (19.6 kg, 114 cm) with cleft palate, cerebral palsy and severe mental retardation, who underwent a Fontan operation when he was 4 years old, was presented for deep sedation. Because he was suffering from eating disorder with cleft palate, the orthodontist and the plastic surgeon planned to insert intraoral orthodontic device before cleft palate repair. But it was impossible to open his mouth for alginate impression procedure. After careful pre-anesthesia evaluation we planned to administer deep sedation with propofol infusion. After Intravenous catheter insertion, we started propofol intravenous infusion with the formula of a loading dose of 1.0 mg/kg followed by an infusion rate of 6.0 mg/kg/hr with syringe pump. His blood pressure was remained around 80/40 mmHg after loss of consciousness, but he could not maintain his airway patent. So we lowered the infusion rate to 3.0 mg/kg/hr, immediately. The oxygen saturation was maintained above 95% with nasal oxygen supply, and blood pressure was maintained around 100-80/60-40 mmHg. After the sedation of 110 minutes with propofol (the infusion rate to 3.0-5.0 mg/kg/hr), he fully regained consciousness, and was discharged without complication after 1 hour observation. In case of post-Fontan patient, intravenous deep sedation with propofol was safe and effective method of behavioral management during dental treatment.

[1]  M. Ramsay,et al.  Dexmedetomidine sedation for pediatric post-Fontan procedure patients , 2009, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[2]  Joseph P Cravero,et al.  The Incidence and Nature of Adverse Events During Pediatric Sedation/Anesthesia With Propofol for Procedures Outside the Operating Room: A Report From the Pediatric Sedation Research Consortium , 2009, Anesthesia and analgesia.

[3]  Soo-jin Kim,et al.  Outcome of 200 patients after an extracardiac Fontan procedure. , 2008, The Journal of thoracic and cardiovascular surgery.

[4]  Jesse D. Roberts,et al.  Inhaled Nitric Oxide A Selective Pulmonary Vasodilator Current Uses and Therapeutic Potential , 2004 .

[5]  W. Williams,et al.  Anesthetic Considerations for Adult Cardiac Surgery Patients with Congenital Heart Disease , 2003 .

[6]  Hartzell V Schaff,et al.  The modified Fontan procedure: early and late results in 132 adult patients. , 2003, The Journal of thoracic and cardiovascular surgery.

[7]  T. Short,et al.  The use of propofol infusions in paediatric anaesthesia: a practical guide , 1999, Paediatric anaesthesia.

[8]  B. Reitz,et al.  Arrhythmias and thromboembolic complications after the extracardiac Fontan operation. , 1998, The Journal of thoracic and cardiovascular surgery.

[9]  E. Bos,et al.  Specific sequelae after Fontan operation at mid- and long-term follow-up. Arrhythmia, liver dysfunction, and coagulation disorders. , 1993, The Journal of thoracic and cardiovascular surgery.

[10]  F. Beynen,et al.  The modified Fontan procedure: physiology and anesthetic implications. , 1992, Journal of cardiothoracic and vascular anesthesia.

[11]  R. Prielipp,et al.  Vasodilator Therapy in Microembolic Porcine Pulmonary Hypertension , 1990, Anesthesia and analgesia.

[12]  P. Julsrud,et al.  The modified Fontan operation for asplenia and polysplenia syndromes. , 1988, The Journal of thoracic and cardiovascular surgery.

[13]  E. Blackstone,et al.  The Fontan operation. Ventricular hypertrophy, age, and date of operation as risk factors. , 1986, The Journal of thoracic and cardiovascular surgery.

[14]  R. Abella,et al.  Late results of extracardiac Fontan repair. , 1999, Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual.

[15]  D. Harrison,et al.  Challenges posed by the adult patient with congenital heart disease. , 1996, Advances in internal medicine.