What is “oppositional” disorder and autism? What are the implications for your anesthetic? What are the strategies available to calm this child or begin the induction process in the preoperative area?

What are the implications of the history of a VSD on your anesthetic management of this child? How would you determine this? Does this child require antibiotics prophylaxis for this procedure?

Behavior and psychological disorders are overrepresented in the dental population undergoing anesthesia. Oppositional defiant disorder (ODD) describes an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with a child’s day-to-day functioning. Symptoms can include temper tantrums and excessive arguing with adults. Autism is a condition that is present early in childhood that is characterized by difficulty in communicating (language) and forming interpersonal relationships. These patients tend to be inflexible in their adherence to routines. Changes in their daily schedule imposed by fasting, new environments, and new people can result in significant agitation and severe anxiety. Most are unable to communicate their concerns. In light of these issues, all attempts should be made to work with parents to bring in familiar objects or toys to their surgical encounter. Nursing personnel in the preoperative and postoperative areas should be made aware of a patient with ODD or autism so that special arrangements can be made for private, quiet space and extra personnel to help with management. Often a specific video or musical recording is helpful, and this information should be solicited and accommodated to whatever degree it is possible. In spite of these efforts, it can be very difficult to gain cooperation from this population of patients, and premedication is often necessary. Oral midazolam (0.5 mg/kg) can be effective but may be associated with paradoxical agitation in approximately 10 % of patients. For patients who are completely uncooperative, IM ketamine 4 mg/kg is used produce a dissociated state that will allow induction to proceed. The “dissociated state” refers to the dissociation of the thalamus from the cortex. The child’s midbrain is not anesthetized – so airway reflexes and respiratory drive are preserved. Onset of ketamine sedation is heralded by lateral nystagmus and a quiet state with eyes open and breathing/airway tone intact. It is important to warn parents and family members about what the sedated state will look like, or it can be alarming to those present during this process. At this point, an inhaled or IV induction can take place without requiring excessive physical restraint. It is particularly important to involve the parents in management of these patients and allow them to give insight into which techniques have worked in the past. In addition, I would involve the child life specialists to assist in finding comfort items and a plan that will be agreeable to the family and result in the best possible behavioral outcome.

The history of a repaired VSD would generally not affect the planning of anesthesia to a great degree. The most important issue would be the presence of any residual defect and continued intracardiac shunting. If there were a residual shunt, in this case it would usually be left to right and result in relative pulmonary overcirculation. If the shunt was significant, it would be critical to limit physiologic changes that would encourage further increases in pulmonary circulation – such as hyperventilation, systemic vasoconstrictors, or excessive oxygen tension. These changes could result in lower systemic blood flow or the potential for pulmonary congestion. On the other hand, acute changes that result in profound increases in pulmonary pressures (prolonged and severe Valsalva maneuvers) could result in right to left shunting and lower O₂ saturations. For any patient with an ASD or VSD, it is important to be sure that all lines have been de-aired and/or add air filters to the intravenous lines. A detailed exercise history from the family is important to detect any evidence of significant shunting or poor ventricular performance. Questions should be asked about any episodes of cyanosis, unexpected shortness of breath, or other signs of inadequate activity tolerance. Any patient with this history will have had multiple visits with a pediatric cardiologist and is likely seen yearly for follow-up. The most accurate assessment of residual shunt and ventricular performance would come from an echocardiogram.

Antibiotic prophylaxis is only required for those with unrepaired congenital heart disease, repaired defects with prosthetic material or device in the first 6 months after the procedure, and any lesion with a residual defect adjacent to a patch or graft.