J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 5, Number 7, July 2014, pages 392-396

Perioperative Management of a Patient With Fontan Physiology for Posterior Spinal Fusion

**Table 1.** Perioperative Care of the Patient With Fontan Anatomy During Posterior Spinal Fusion
Reference number	Outcome
PSF: posterior spinal fusion; TIVA: total intravenous anesthesia; CVP: central venous pressure; TEE: trans-esophageal echocardiography; EBL: estimated blood loss.
[15]	14-year-old boy with Fontan physiology undergoing PSF. Preoperative testing included a trial of anesthetized positive pressure ventilation and position changes without surgical intervention. TIVA to facilitate neurophysiological monitoring. Intraoperative monitoring included arterial cannula, CVP and TEE. Significant hypotension associated with decreased ventricular filling on TEE with no change in CVP. EBL was 1,200 mL. Allogeneic blood transfusion was minimized by using autologous blood donation and intraoperative blood salvage.
[16]	15-year-old boy with Fontan physiology. EBL in excess of 3.5 L, requiring significant intraoperative resuscitation with blood and blood products. This report highlights the potential for significant blood loss in these patients and discusses options to limit this complication.
[17]	Retrospective cohort of seven patients with Fontan physiology for PSF. Average blood loss was 2,942 mL (range: 1,100 - 7,500). Swan-Ganz catheters were used for monitoring. Complication rate of 85.7% including superior mesenteric artery syndrome, acute renal tubular necrosis, pleural effusion requiring chest tube placement, urinary tract infection, Horner syndrome, and a late case of paralysis at 48 h.
[18]	Two adolescents with Fontan physiology. One patient had a pacemaker prohibiting using of motor evoked potentials. The patient experienced ventricular fibrillation requiring cardiopulmonary resuscitation during a wake-up test. The authors theorized that the wake-up test may constitute an increase in cardiac work load that may prove intolerable to patients with palliated congenital heart disease.
[19]	Reported the use of TEE to titrate intraoperative dopamine and epinephrine infusions. Suggested the use of TEE in addition to standard monitors.
[20]	Retrospective analysis of eight patients with Fontan physiology for PSF. Average EBL was 1,520 mL. Although all of the patients required intraoperative blood transfusion, 62% avoided allogeneic products through autologous donation. Postoperative complications occurred in three patients including one death related to hypovolemic shock refractory to treatment and two patients with pleural effusions requiring chest tube placement. The authors stressed the need for a multi-disciplinary team, a thorough evaluation of the patient’s cardiac status and a low threshold for TEE.

Table 1. Perioperative Care of the Patient With Fontan Anatomy During Posterior Spinal Fusion

Reference number

Outcome

PSF: posterior spinal fusion; TIVA: total intravenous anesthesia; CVP: central venous pressure; TEE: trans-esophageal echocardiography; EBL: estimated blood loss.

[15]

14-year-old boy with Fontan physiology undergoing PSF. Preoperative testing included a trial of anesthetized positive pressure ventilation and position changes without surgical intervention. TIVA to facilitate neurophysiological monitoring. Intraoperative monitoring included arterial cannula, CVP and TEE. Significant hypotension associated with decreased ventricular filling on TEE with no change in CVP. EBL was 1,200 mL. Allogeneic blood transfusion was minimized by using autologous blood donation and intraoperative blood salvage.

[16]

15-year-old boy with Fontan physiology. EBL in excess of 3.5 L, requiring significant intraoperative resuscitation with blood and blood products. This report highlights the potential for significant blood loss in these patients and discusses options to limit this complication.

[17]

Retrospective cohort of seven patients with Fontan physiology for PSF. Average blood loss was 2,942 mL (range: 1,100 - 7,500). Swan-Ganz catheters were used for monitoring. Complication rate of 85.7% including superior mesenteric artery syndrome, acute renal tubular necrosis, pleural effusion requiring chest tube placement, urinary tract infection, Horner syndrome, and a late case of paralysis at 48 h.

[18]

Two adolescents with Fontan physiology. One patient had a pacemaker prohibiting using of motor evoked potentials. The patient experienced ventricular fibrillation requiring cardiopulmonary resuscitation during a wake-up test. The authors theorized that the wake-up test may constitute an increase in cardiac work load that may prove intolerable to patients with palliated congenital heart disease.

[19]

Reported the use of TEE to titrate intraoperative dopamine and epinephrine infusions. Suggested the use of TEE in addition to standard monitors.

[20]

Retrospective analysis of eight patients with Fontan physiology for PSF. Average EBL was 1,520 mL. Although all of the patients required intraoperative blood transfusion, 62% avoided allogeneic products through autologous donation. Postoperative complications occurred in three patients including one death related to hypovolemic shock refractory to treatment and two patients with pleural effusions requiring chest tube placement. The authors stressed the need for a multi-disciplinary team, a thorough evaluation of the patient’s cardiac status and a low threshold for TEE.