NM-254
Monitored Anesthesia Care with Combined-Spinal-Epidural, Dexmedetomidine Infusion, and Ketamine Bolus for Right Above the Knee Amputation in a Pediatric Patient with Bronchiolitis Obliterans and a Difficult Airway
Lehn S, Moore L, Condrey J
Medical University of South Carolina, Charleston, SC, USA
Very few case reports exist regarding the use of regional anesthesia as the primary anesthetic in a pediatric patient, especially patients with the diagnosis of bronchiolitis obliterans and difficult airway. The majority of case reports in the literature involving CSEs in pediatric patients utilized propofol infusions for supplemental sedation. Utilizing propofol as opposed to dexmedetomidine or ketamine becomes important when preservation of spontaneous respirations and airway reflexes is of supreme importance. An anesthetic plan for a patient with both of these diagnoses would undoubtedly involve administering anesthetics that preserve spontaneous respirations and airway reflexes. This case describes the successful use of a CSE with supplemental sedation from dexmedetomidine and ketamine on one such particular patient.
The patient is a 15-year-old AA male with PMHx significant for osteosarcoma of his R distal femur s/p chemotherapy and limb salvage surgery who developed sAML secondary to his chemotherapy. BMT then resulted in severe chronic GVHD. The GVHD affected multiple organ systems but most notably resulted in decreased mouth opening and bronchiolitis obliterans requiring nighttime BiPAP. The patient then developed mechanical failure of his limb salvage implant and a severe leg length inequality that required an AKA.
Pre-operative midazolam was not ordered since our goal was to avoid factors that could compromise the airway. Once in the operating room the patient was given a bolus of ketamine and started on a dexmedetomidine infusion. The patient was placed in a sitting position and was allowed to listen to music through his own earbuds. A certified childlife specialist (CCLS) was present to provide patient reassurance. The CSE was placed midline at L3-4 with LOR at 3 cm (17g Tuohy needle). 2 mg of 0.5% hypobaric bupivacaine was administered intrathecally through 25G Whitacre needle. Catheter was left at 7 cm and a bilateral T8 level was achieved. The surgery lasted roughly one and a half hours with the patient in a modified beach chair position. The patient’s own BiPAP was used with his home settings both to augment respirations and to provide an unspoken sense of comfort to the patient. For post-operative pain control the epidural was started at 5 ml/hr of ropivacaine 0.2% with 10 mcg/ml of dilaudid. Post-operative course was uneventful and the epidural was removed on POD 2 and the patient was discharged home on POD 5.
The anesthetic was carried out successfully due to a couple key reasons. The first reason being that the patient was both cooperative and calm. The use of the CCLS, patient’s earbuds, and home BiPAP machine all helped reduce the stress surrounding the placement of the CSE and the surgical procedure. A second reason for the success is due to the use of anesthetics that preserved spontaneous respirations and airway reflexes. Dexmedetomidine and ketamine provided those characteristics so these drugs were ideal in this situation. In regards to the patient’s spinal a hypobaric solution was used in order to achieve maximal lumbar coverage and avoid a saddle block that may have developed if an iso- or hyperbaric solution was used since the patient was in a modified beach chair position.
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