Perioperative Management of a Patient With Fontan Circulation Presenting for Laparoscopic Cholecystectomy: A Case...

We present the perioperative management of a 22-year-old female patient with congenital heart disease and Fontan circulation presenting for laparoscopic cholecystectomy. Careful preoperative review of recent cardiac testing and assessment of the patient's physical status allowed for an individualized anesthetic approach. Perioperative management began in the preoperative holding area with preload optimization. Intraoperative management focused on supporting flow through the Fontan circulation through positioning adjustments, ventilatory management, and vasopressor support. Collaboration with the surgical team to minimize insufflation pressures and head-up positioning promoted adequate venous return. Minimizing peak airway pressures and maintaining a mild respiratory alkalosis mitigated the pulmonary vasoconstricting effects of hypercapnia. Additionally, vasopressin was administered via intermittent boluses and continuous infusion to maintain adequate systemic vascular resistance while minimizing pulmonary vasoconstrictive effects. The perioperative course was uncomplicated, and the patient was discharged home after overnight observation. This case adds to existing literature on anesthetic management of adults with Fontan circulation presenting for noncardiac surgery and presents a unique combination of vasopressor choice and minimally invasive monitoring when compared to prior case reports. The case also highlights the importance of interdisciplinary collaboration and individualized anesthetic management for this patient population.