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

Abstract

Purpose: We report the use of the alpha2 agonist, dexmedetomidine, with low-dose ketamine as a safe and effective treatment strategy to provide adequate comfort and sedation for a patient who fulfilled criteria of a difficult airway and required awake fibreoptic intubation (AFOI). Clinical features: A 52-yr-old male with prostate cancer presented for radical prostatectomy. He reported several failed intubations with previous surgeries and airway examination was consistent with a difficult intubation. In addition, previous fibreoptic intubations were unsuccessful. The patient reported extreme apprehension concerning his airway management. The goal of medicating patients for AFOI includes providing comfort and sedation without causing a change in ventilatory status. Dexmedetomidine has a high affinity for the alpha2 receptor and results in sedation without change in ventilatory status. In addition, dexmedetomidine is a potent anti-sialgogue which makes it desirable for cases involved with airway instrumentation. A loading dose of dexmedetomidine followed by a continuous infusion provided comfort and sedation within ten minutes. While bradycardia and hypotension have been reported with dexmedetomidine use, concurrent low-dose ketamine was employed in this case for it's cardiostimulatory properties and no bradycardia and hypotension were noted. The airway was anesthetized with selective nerve blocks and conditions for airway instrumentation were excellent. There was no change in oxygen saturation or ventilatory status during the administration of medications or airway manipulation. The patient was comfortable, sedated and tolerated the procedures well. There was no recall of the procedure. Conclusion: Dexmedetomidine and concurrent low-dose ketamine provided sedation and comfort to this patient who required AFOI.