Jul 2026· Croatian journal of anaesthesiology and intensive medicine· Vol 2, pp. 60-64· 0 citations· 12 references
TL;DR
This multimodal sedation approach may offer a safe and effective alternative when preserving spontaneous respiration is critical in uncooperative pediatric patients with severely restricted mouth opening.
Abstract
Managing difficult airways in pediatric patients with severe trismus and poor cooperation is challenging because conventional sedatives may suppress spontaneous respiration. We report a case of a 15-year-old girl (weight 50 kg) with recurrent rhabdomyosarcoma causing severe trismus (0-finger mouth opening) and facial deformity. After premedication with atropine and methylprednisolone, sedation was achieved with a slow infusion of dexmedetomidine (20 μg over 10 minutes) followed by intravenous esketamine (20 mg, 0.4 mg/kg). This regimen preserved spontaneous breathing with oxygen saturation maintained at 99–100% throughout the procedure. Topical anesthesia of the nasopharynx was performed using 2% lidocaine spray (total dose 100 mg, approximately 2 mg/kg) via spray-as-you-go technique. Fiberoptic nasotracheal intubation was then successfully accomplished without coughing, body movement, or hemodynamic instability. No adverse events such as emergence reactions or hallucinations occurred. This multimodal sedation approach may offer a safe and effective alternative when preserving spontaneous respiration is critical in uncooperative pediatric patients with severely restricted mouth opening.
Rationale: The anesthetic management of intertrochanteric fractures in patients with dual contraindications to neuraxial and general anesthesia is highly challenging. We illustrate a unique salvage multimodal strategy combining a comprehensive ultrasound-guided regional blockade with esketamine-based sedation to manage such complex cases. Patient concerns: A 55-year-old female (147 cm, 45 kg) was admitted following a slip-and-fall accident resulting in severe right hip pain and limited mobility. Due to her complex medical history, the patient and her family expressed significant anxiety regarding the risks of conventional anesthesia. Diagnoses: Imaging confirmed a comminuted right intertrochanteric fracture. The patient’s clinical profile was complicated by congenital spinal dysraphism (spina bifida) with a local meningocele and a history of 2 recent episodes of spontaneous pneumothorax. Interventions: The patient underwent surgical fixation under a primary ultrasound-guided supra-inguinal fascia iliaca compartment block (40 mL of 0.4% ropivacaine) supplemented by a lateral femoral cutaneous nerve block. Intraoperative management utilized a multimodal approach combining esketamine-mediated systemic analgesia and remimazolam-based sedation while strictly preserving spontaneous ventilation. Outcomes: The 70-minute procedure was successful without conversion to general anesthesia or positive-pressure ventilation. Hemodynamics remained stable throughout the surgery (systolic blood pressure: 128–151 mm Hg; heart rate: 61–78 bpm). The patient awakened fully within 3 to 4 minutes postoperatively, reported no intraoperative discomfort, and achieved excellent pain control (VAS 1/10) with an unremarkable one-month recovery. Lessons: For high-risk surgical candidates where both neuraxial and general anesthesia are relatively contraindicated, a multimodal approach centered on comprehensive nerve blocks combined with remimazolam and esketamine sedation represents a safe and effective salvage strategy. This technique minimizes physiological stress and avoids the specific risks of conventional anesthesia in complex clinical scenarios.
Intranasal DEX at a dose of 1.5 mcg/kg is safe and effective premedication for paediatric patients, which results in successful sedation with tolerated changes in vitals, which was well tolerated.
Mona Sharma, Swagat Gongal, B. Yadav et al.· Journal of Nepal Health Rese...· 0 citations
Severe adult idiopathic scoliosis with a Cobb angle >80° is a complex condition that presents significant anesthetic challenges due to restrictive ventilatory impairment, potential hemodynamic instability, and the risk of massive blood loss during spinal surgery. A 20-year-old woman with an American Society of Anesthesiologists (ASA) Physical Status Classification II was diagnosed with Lenke type 3 idiopathic scoliosis (Cobb angle: 83°) and scheduled for spinal stabilization surgery. Preoperative evaluation revealed a Mallampati class II airway, preserved cardiac function (ejection fraction [EF] 62%), and restrictive pulmonary impairment with low cardiopulmonary risk. General anesthesia was administered using a combination of dexmedetomidine (0.3 mcg/kg/hour), fentanyl (3 mcg/kg), propofol (2 mg/kg), rocuronium (1 mg/kg), and desflurane (6–7 vol%). Intraoperative hemodynamic parameters remained stable. Postoperatively, the patient was successfully extubated in the operating room and transferred to the inpatient ward after 24 hours of intensive care unit (ICU) monitoring, with adequate pain control and no neurological complications. The dexmedetomidine-based anesthesia regimen provided hemodynamic stability, reduced the requirement for additional anesthetic agents, and supported early extubation without respiratory depression. A comprehensive anesthetic approach and blood conservation strategy contributed to optimal clinical outcomes. Comprehensive anesthesia management in severe scoliosis may improve physiological stability, reduce complications, and facilitate recovery.
Unknown authors· Jurnal Sehat Indonesia (JUSI...· 0 citations
In this selected population of older patients undergoing ERCP, the remimazolam-esketamine regimen was associated with fewer composite SRAEs than propofol-fentanyl while achieving a similar anesthetic regimen success rate.
Yong-Bo Yu, Jiyuan Wang, Qian-Qian Zhang et al.· Drug Design, Development and...· 0 citations
STUDY OBJECTIVES
Adolescents with severe agitation may require repeated administration of sedatives. We describe dexmedetomidine infusion as a novel bridge therapy for selected agitated adolescents awaiting psychiatric treatment and disposition.
METHODS
We retrospectively studied adolescents (12 to 17 years) treated with dexmedetomidine infusion for severe agitation at our emergency department (ED) over a 16-month period. We abstracted demographics, sedatives administered, psychiatric therapy, type and frequency of adverse events, and ED disposition. Our primary outcome was the need for additional sedation despite dexmedetomidine.
RESULTS
The median age of our 20 qualifying patients was 15 years. The median duration of dexmedetomidine infusion was 21 hours, with a median maximum dose of 1.6 mcg/kg per hour. During the infusion, 9 patients (45%, 95% confidence interval 26% to 66%) required additional sedation. One patient experienced desaturation responding to head repositioning and supplemental oxygen. Five patients were transferred to the pediatric ICU owing to the need of multiple sedatives.
CONCLUSION
Our preliminary results support the feasibility of dexmedetomidine infusion as bridge sedation for selected severely agitated adolescents awaiting psychiatric care and disposition.
Giorgio Cozzi, Alessandro Zago, Alberto Di Mascio et al.· Annals of Emergency Medicine· 0 citations
BACKGROUND
Adequate sedation during spinal anesthesia requires careful titration to avoid hemodynamic instability and respiratory complications. We hypothesized that intrathecal fentanyl, used as an adjunct to neuraxial anesthesia, would reduce dexmedetomidine requirements for conscious sedation. This study evaluated the effects of intrathecal fentanyl on the total dose of dexmedetomidine during spinal anesthesia.
METHODS
Sixty-four patients undergoing knee or ankle arthroscopy under spinal anesthesia were randomly assigned to two groups. The fentanyl group received 0.5% bupivacaine 10 mg with fentanyl 20 μg, whereas the control group received bupivacaine 10 mg with saline. After confirmation of sensory block, dexmedetomidine was infused at 1 μg/kg over 10 minutes and maintained at 0.1-1 μg/kg/hour to maintain a bispectral index (BIS) of 70 to 80. The primary outcome was the total dose of dexmedetomidine. Secondary outcomes included BIS values, Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores, mean blood pressure, and heart rate at predefined time points.
RESULTS
The total dose of dexmedetomidine did not differ significantly between the groups. The MOAA/S scores were significantly affected by group, time, and group-by-time interactions (p=0.003, p<0.001, and p=0.007, respectively). The BIS values were influenced by group (p=0.026) and time (p<0.001), but not by group-by-time interactions (p=0.413). Exploratory analyses suggested deeper sedation in the fentanyl group during the early phase of dexmedetomidine infusion. Hemodynamic variables were comparable between the groups.
CONCLUSION
Intrathecal fentanyl did not significantly reduce dexmedetomidine requirements during spinal anesthesia, although it was associated with deeper sedation at several time points.
K. B. Park, J. Yeom, Juhee Min et al.· Journal of Yeungnam Medical...· 0 citations
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