Anesthetic Management for Dental Treatment in a Child with Tricuspid Atresia (after Bi-directional Glenn Surgery)

Abstract

  We performed anesthetic management for dental treatment in a 6-year-old boy with mental retardation and tricuspid atresia (TA) after a bidirectional Glenn surgery. He had not yet undergone a Fontan surgery because of moderate renal disfunction. Therefore, he had cyanosis, and pulse oximetry showed an Spo₂ of 85% to 90% oxygen saturation with room air in everyday life. The patient had normal cardiac function, but his hemodynamics had not been recently evaluated using a cardiac catheter examination because of the moderate renal dysfunction. TA is a congenital heart disease (CHD) with tricuspid valve closure, and systemic and pulmonary circulation depends on a single ventricle with parallel circulation. In this patient with cyanosis, it was important to lower the pulmonary vascular resistance and to maintain pulmonary blood flow, so special attention was paid to the following matters during the anesthesia management : 1) maintaining an Spo₂ 90% or higher by setting a high Fio₂, 2) maintaining a low Paco₂ (about 30 mmHg) and alkalosis, 3) maintaining a low airway pressure (approximately 10 cmH₂O), 4) maintaining a proper systemic vascular resistance. General anesthesia was induced with fentanyl and midazolam and was maintained with remifentanil and sevoflurane in oxygen (Fio₂, 0.8). We administered an α₁-adrenoceptor agonist to cope with the intraoperative hypotension, and we tried to adjust the ventilation to improve acidosis and to maintain a low Paco₂. Also, we administered fentanyl to avoid cyanosis arising from emergence agitation before and/or after extubation. In this manner, we were able to perform safe anesthetic management by paying attention to the maintenance of pulmonary blood flow.