Difficulty Controlling Sedation Level Using Processed Electroencephalography Monitoring in a Patient With Intellectual Disability, Fontan Circulation, and a Severe Gag Reflex

Patients with cardiovascular compromise are likely to develop hypotension upon receiving even small doses of sedatives. On the other hand, patients with severe dental phobias or with intellectual disability who have a severe gag reflex often require deeper levels of anesthesia. Thus, achieving an optimal level of anesthesia can be difficult in patients with cardiovascular compromise because of the relatively narrow range of sedative dosing capable of providing sufficient sedation to prevent the gag reflex without compromising hemodynamics. We present a patient with Fontan circulation, severe intellectual disability, and a severe gag reflex who underwent dental treatment using intravenous sedation. Processed electroencephalography (EEG) via a SedLine (Masimo Corporation) monitor was used to identify anesthetic depth, and propofol infusion rates were adjusted based on changes in Patient State Index (PSI) values. However, the PSI values fluctuated greatly in response to stimuli and changes in the depth of anesthesia. In summary, the indications for using feedback control of the sedation level by way of EEG analysis and adjusting propofol infusion rates might be limited in patients with cardiovascular compromise and severe gag reflex because such monitoring may be incapable of keeping pace with rapid changes in the balance between stimulation and the level of anesthesia.