Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia

doi:10.1016/j.jclinane.2008.03.012

Journal of Clinical Anesthesia

Volume 20, Issue 6, September 2008, Pages 455-457

https://doi.org/10.1016/j.jclinane.2008.03.012 Get rights and content

Abstract

A 6-year-old girl with Treacher Collins syndrome presented for implantation of a hearing device. The patient was developmentally delayed and had severe micrognathia. After induction of anesthesia with dexmedetomidine and ketamine, the patient tolerated the introduction of a flexible fiberoptic bronchoscope without any change in respiration, and intubation was achieved easily.

Introduction

Ventilation and intubation in children with syndromes associated with mandibular agenesis or hypoplasia, such as Pierre Robin, Treacher Collins, and Goldenhar syndromes, may be challenging for the anesthesiologist. In many of these cases, fiberoptic intubation (FOI) is the preferred means to secure the airway. Administering adequate anesthesia so that these patients will tolerate the stimulation from bronchoscopy and intubation while maintaining spontaneous ventilation is a challenge. For most pediatric patients, general anesthesia is preferable. Various regimens of anesthesia for pediatric FOI exist, including inhalational induction with sevoflurane or use of a propofol infusion. However, both agents may cause airway obstruction and central apnea in children [1], [2]. Any episode of apnea or airway obstruction in children with severe mandibular hypoplasia or agenesis may lead to hypoxia because of the potential inability to intubate or ventilate. A variety of agents have been used for sedation during FOI in children. However, to date, there are no case reports describing the use of a combination of dexmedetomidine and ketamine for this purpose. The combination has been used in adults [3]. In this report we describe the use of these two drugs for FOI in a child with Treacher Collins syndrome and severe mandibular hypoplasia.

Section snippets

Case report

A 6-year-old girl with Treacher Collins syndrome (midface hypoplasia, micrognathia, microtia, conductive hearing loss, and cleft palate) [4] presented for implantation of a Baha hearing device. This surgically implantable system for treating hearing loss works through direct bone conduction rather than sound conduction via the middle ear. Aside from developmental delay, our patient had no other significant medical problems. This procedure was the child's first anesthetic experience, and a

Discussion

Dexmedetomidine, which is a selective α²-adrenergic agonist, is an effective sedative, causing no significant respiratory depression when given in therapeutic doses [5], [6]. We elected to give glycopyrrolate because of possible bradycardia from the dexmedetomidine and the potential for increased oral secretions with ketamine. With dexmedetomidine sedation, patients are arousable with stimulation but, otherwise, remain sedated. In older cooperative pediatric patients with a well-anesthetized

Acknowledgment

We would like to thank Dr. C. Philip Larson for editing our manuscript and giving us invaluable advice in the process.

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Case reportDexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia

Abstract

Introduction

Section snippets

Case report

Discussion

Acknowledgment

Comparison of ketamine and lidocaine spray with propofol for the insertion of laryngeal mask airway in children: a double-blinded randomized trial

Anesth Analg

Apnea during induction of anesthesia with sevoflurane is related to its mode of administration

Can J Anaesth

Dexmedetomidine and low-dose ketamine provide adequate sedation for awake fibreoptic intubation

Can J Anaesth

Clinical features, treatment and genetic background of Treacher Collins syndrome

J Appl Genet

Dexmedetomidine for pediatric sedation for computed tomography imaging studies

Anesth Analg

Dexmedetomidine pharmacodynamics: part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers

Anesthesiology

Case report
Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia