Use of esketamine combined with dexmedetomidine for difficult tracheal intubation in an uncooperative pediatric patient with severe trismus

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.