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Table of Contents
LETTER TO EDITOR
Year : 2012  |  Volume : 28  |  Issue : 4  |  Page : 545-546

Intubation using dexmedetomidine and ketamine in a child with Pierre Robin sequence


1 Department of Anesthesiology, Goa Medical College, Bambolim, Goa, India
2 Intensive Care Unit, NUSI Wockhardt Hospital, Panzorconi, Cuncolim, Goa, India

Date of Web Publication4-Oct-2012

Correspondence Address:
Sidhesh Bharne
F1/A2, Kurtarkar Vatika, Shantinagar, Ponda - 403401 Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.101964

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How to cite this article:
DSouza S, Barad D, Bharne S. Intubation using dexmedetomidine and ketamine in a child with Pierre Robin sequence. J Anaesthesiol Clin Pharmacol 2012;28:545-6

How to cite this URL:
DSouza S, Barad D, Bharne S. Intubation using dexmedetomidine and ketamine in a child with Pierre Robin sequence. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2019 Aug 20];28:545-6. Available from: http://www.joacp.org/text.asp?2012/28/4/545/101964

Sir,

We have presented a case of Pierre Robin sequence with repaired Fallot's tetralogy, presenting for cleft palate repair, and intubated using dexmedetomidine and ketamine in this report.

A 3 year old girl weighing 11 kg presented to the plastic surgery department for cleft palate repair. She had been diagnosed with Fallot's tetralogy and Pierre Robin sequence at birth. She had undergone a left Blalock-Taussig shunt at 3 months age, and intracardiac repair of Fallot's tetralogy at two and half year age. Both surgeries were uneventful; however, anaesthesia notes of the previous surgeries were not available. At the time of presentation, the patient did not have anycardiovascular complaints; though she had delayed milestones and was undernourished. Airway examination showed retrognathia, and grade 3 Mallampati score. Cardiovascular examination revealed a soft systolic murmur. Rest of the systemic examination was unremarkable. All biochemical investigations were within normal limits. Echocardiograhy showed no residual shunt, normal right ventricular size and function, and moderate pulmonary regurgitation. Chest radiograph showed a mild cardiomegaly with prominence of the pulmonary artery segment.

On the day of the surgery, all the necessary drugs and equipment, including pediatric difficult airway cart were kept ready. Patient was started on an infusion of lactated Ringer's solution. Infective endocarditis prophylaxis was given. She was premedicated with intravenous (IV) glycopyrrolate 0.01 mg/kg, IV ondansetron 0.1 mg/kg and IV dexmedetomidine 0.5 μg/kg slowly over 10 minutes. This was followed by IV ketamine 1 mg/kg, with continuous oxygen (O 2 ) supplementation. Patient was spontaneously breathing and was maintaining her airway; and, could be ventilated using a Jackson Reese circuit. Electrocardiogram, pulse oximetry and capnography were employed for monitoring. Laryngoscopy was then attempted using a 2 number Macintosh blade; and after external laryngeal manipulation, posterior commissure could be seen and intubation was done using a 4.5 ID uncuffed Ring, Adair, and Elwyn (RAE) tube. After confirming bilateral equal breath sounds, muscle relaxant (IV vecuronium 0.1 mg/kg) was given and anaesthesia was maintained with 60% nitrous oxide (N 2 O) in O 2 , with 1-2% sevoflurane. IV fentanyl 1 μg/kg was given for analgesia. Fentanyl and vecuronium 'top-ups' were given as needed. Intraoperative vitals were stable, and the procedure lasted for 2 hours. Neuromuscular blockade was reversed with neostigmine at the end of surgery, and the patient was extubated when fully awake with good respiratory efforts. She was then transferred to the recovery room, and made an uneventful recovery.

Pierre Robin syndrome is characterised by micrognathia, glossoptosis and cleft palate. [1] Intubation difficulties are known in these cases. [2] Different techniques have been employed in view of the difficulty in intubation. [3],[4],[5] Dexmedetomidine, a highly selective alpha 2 agonist, is being increasingly used off-label, taking advantage of its sedative-hypnotic and analgesic effects with minimal respiratory depression. [6] In our case, we combined it with ketamine which allowed our patient to be well sedated while maintaining thespontaneous ventilation. Dexmedetomidine-ketamine combination has been employed for pediatric and adult difficult airway, with good results. [7],[8] Dexmedetomidine also attenuates the cardiostimulatory effects and emergence delirium associated with ketamine. [9]

 
  References Top

1.Olasoji HO, Ambe PJ, Adesina OA. Pierre Robin syndrome: an update. Niger Postgrad Med J 2007;14:140-5.  Back to cited text no. 1
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2.Jones SE, Derrick GM. Difficult intubation in an infant with Pierre Robin syndrome and concomitant tongue tie. Paediatr Anaesth 1998;8:510-1.  Back to cited text no. 2
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3.Semjen F, Bordes M, Cros AM. Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases. Anaesthesia 2008;63:147-50.  Back to cited text no. 3
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4.Smallman B, Ball R, Tatum S. A novel technique of retrograde nasal intubation for the Pierre Robin Sequence infant with a known difficult airway. Paediatr Anaesth 2009;19:919-21.  Back to cited text no. 4
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5.Bonfils P. Difficult intubation in Pierre-Robin children, a new method: the retromolar route. Anaesthesist 1983;32:363-7.  Back to cited text no. 5
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6.Ramsay MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent. Anesthesiology 2004;101:787-90.  Back to cited text no. 6
[PUBMED]    
7.Iravani M, Wald SH. Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia. J Clin Anesth 2008;20:455-7.  Back to cited text no. 7
[PUBMED]    
8.Scher CS, Gitlin MC. Dexmedetomidine and low-dose ketamine provide adequate sedation for awake fibreoptic intubation. Can J Anaesth 2003;50:607-10.  Back to cited text no. 8
[PUBMED]    
9.Levänen J, Mäkelä ML, Scheinin H. Dexmedetomidine premedication attenuates ketamine-induced cardiostimulatory effects and postanesthetic delirium. Anesthesiology 1995;82:1117-25.  Back to cited text no. 9
    




 

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