Navigating the Anesthetic Challenges of Vertebral Defects, Anorectal Anomalies, Cardiac Anomalies, Tracheoesophageal Fistula (TEF)/Esophageal Atresia, Renal Anomalies, and Limb Abnormalities (VACTERL) Association: A Delicate Balancing Act.

Vertebral defects, anorectal anomalies, cardiac anomalies, tracheoesophageal fistula (TEF)/esophageal atresia, renal anomalies, and limb abnormalities (VACTERL) association is a rare congenital disorder presenting with a constellation of birth defects. The diagnosis is primarily clinical, and patients exhibit at least three of these anomalies. These patients' management involves a multidisciplinary approach tailored to the individual's condition. Anesthetic management is particularly challenging due to the diverse and complex anomalies. This article discusses the anesthetic management of a term newborn male (39 weeks, six days gestation, 3340 g) diagnosed with VACTERL association. The newborn was admitted to the neonatal intensive care unit (NICU) and scheduled for the surgical repair of TEF and derivative colostomy on the second day of life. To mitigate the risk of air leak and abdominal distension from positive pressure ventilation, a derivative colostomy was performed first under regional anesthesia preserving spontaneous ventilation. To achieve that, the patient was sedated with ketamine and dexmedetomidine, and an ultrasound-guided single-shot caudal block with ropivacaine was performed. Post-abdominal decompression, general anesthesia was induced, and intubation was managed via videolaryngoscopy. Thoracoscopic TEF repair required several pauses for ventilation and hemodynamic optimization. Dopamine was administered intraoperatively for blood pressure support. The newborn was extubated and started on enteral feeding by the seventh postoperative day, progressing well by the time of discharge. In this case, a derivative colostomy before TEF repair avoided positive pressure ventilation complications. Ultrasound-guided caudal block provided effective regional anesthesia with high success rates. Ketamine and dexmedetomidine offered balanced sedation with minimal respiratory compromise. Dopamine was used effectively to maintain adequate perfusion, monitored with invasive blood pressure and cerebral oximetry. Anesthetic management of newborns with VACTERL association undergoing simultaneous repair of TEF and anal atresia demands meticulous and tailored planning to address the specific needs and minimize associated risks. This case highlights the importance of comprehensive anesthetic management and its impact on the patient's outcome.

Ketamine and Dexmedetomidine Combination for the Management of the Pediatric Difficult Airway.

The pediatric difficult airway is a challenge for the anesthesiologist. In this article, we describe a case where ketamine and dexmedetomidine were used to approach a difficult airway in a five-month-old patient with a palatal teratoma. These two drugs have complementary effects, because of which they can be used to maintain ventilation without compromising airway reflexes and are suitable for the management of pediatric difficult airways.

Sedoanalgesia con ketodex para la intubación selectiva en la resección de un aneurisma gigante de la arteria subclavia. Reporte de caso / Sedoanalgesia with ketodex for selective intubation in the resection of a giant aneurysm of the subclavian artery associated. Case report

Resumen: El aneurisma gigante de la arteria subclavia asociado a un síndrome de vena cava superior se presenta de forma poco frecuente. La complejidad del abordaje dependerá del tamaño, forma y disposición del aneurisma, particularmente cuando el colapso de la vía aérea es potencial por un efecto compresivo de la masa mediastinal durante la aplicación del relajante neuromuscular. Presentamos el caso de un hombre de 57 años con disnea en decúbito dorsal que incrementa con el decúbito lateral izquierdo de cinco años de evolución. El estudio radiológico reporta masa mediastinal gigante compatible con aneurisma de la arteria subclavia derecha que causa compresión y desplazamiento de la vía aérea, particularmente en tráquea a nivel de la carina. El paciente es programado para resección del aneurisma y requiere de intubación selectiva para el aislamiento del pulmón derecho durante la cirugía, que fue realizada con la técnica de paciente despierto usando sedoanalgesia con ketodex. El objetivo del caso es compartir la experiencia con el uso de ketodex como una alternativa para la tolerancia de procedimientos que requieren de la cooperación del paciente, en donde el propofol y el relajante neuromuscular pueden ser un problema para la permeabilidad y el abordaje de la vía aérea.

Abstract: A giant subclavian artery aneurysm associated with superior vena cava syndrome occurs infrequently. Complexity of the approach will depend on the size, shape, and position of the aneurysm, particularly when a potential collapse of the airway is expected due to the compressive effect of the mediastinal mass after using neuromuscular relaxant for airway approach. We present a case in a 57-year-old male with shortness of breath in dorsal that increases with left lateral decubitus during five years of evolution. Radiological studies reported giant mediastinal mass compatible with an aneurysm of the right subclavian artery, which produces critical compression and airway displacement, particularly in trachea at level of the carina. The patient is scheduled for resection of the aneurysm and requires selective intubation for isolation of the right lung during surgery which was performed with the awake patient technique using sedoanalgesia with ketodex. The objective of the case is to share the experience using ketodex as an alternative for the tolerance of procedures that requires the cooperation of the patient where propofol and neuromuscular relaxant may be a problem for airway permeability and approach.

Comparison of Intraoperative Low-Dose Ketodex and Fentanyl Infusion for Postoperative Analgesia In Spine Surgery: A Prospective Randomized Double-Blind Study.

STUDY DESIGN: Prospective randomized double-blind study. PURPOSE: To assess the analgesic effects of the combination of a low-dose ketamine and dexmedetomidine (ketodex) infusion and compare it with that of fentanyl for postoperative analgesia after spine surgeries. OVERVIEW OF LITERATURE: Adequate pain management following spine surgeries is crucial. Approximately 57% of patients experience inadequate pain control in the first 24 hours following elective spine surgery, which is attributable to the extensive soft tissue and muscle damage. METHODS: The study included 60 patients graded American Society of Anesthesiologists I and II and scheduled for thoracolumbar spine surgery involving >3 vertebral levels. The patients were divided into two groups: group KD (ketodex) and group F (fentanyl). The primary objective was to compare the postoperative analgesic requirements among the groups. The secondary objectives included a comparison of the intraoperative anesthetic requirements, postoperative pain scores, hemodynamic parameters, side effects of the study drugs, and the duration of post-anesthesia care unit stay of both the groups. RESULTS: Ketodex use prolonged the mean time to first rescue analgesia (22.00±2.30 hours vs. 11.69±3.02 hours, p <0.001) and reduced the requirement of rescue analgesics in the first 24 hours postoperatively compared to fentanyl use (70.00±8.16 µg vs. 113.31±36.65 µg, p =0.03). The intraoperative requirement of desflurane was comparable between the groups (p >0.05). The postoperative pain scores were significantly lower in the group KD than in group F at most timepoints (p <0.05). Patients in group KD had a shorter post-anesthesia care unit stay than group F did (p <0.001). CONCLUSIONS: Low-dose ketodex could be a safe substitute for fentanyl infusion when employed as an anesthetic adjuvant for patients undergoing thoracolumbar spine surgeries involving >3 vertebral levels to achieve prolonged analgesia without any opioidrelated side effects.

The intranasal dexmedetomidine plus ketamine for procedural sedation in children, adaptive randomized controlled non-inferiority multicenter trial (Ketodex): a statistical analysis plan.

BACKGROUND: Procedural sedation and analgesia (PSA) is frequently required to perform closed reductions for fractures and dislocations in children. Intravenous (IV) ketamine is the most commonly used sedative agent for closed reductions. However, as children find IV insertion a distressing and painful procedure, there is need to identify a feasible alternative route of administration. There is evidence that a combination of dexmedetomidine and ketamine (ketodex), administered intranasally (IN), could provide adequate sedation for closed reductions while avoiding the need for IV insertion. However, there is uncertainty about the optimal combination dose for the two agents and whether it can provide adequate sedation for closed reductions. The Intranasal Dexmedetomidine Plus Ketamine for Procedural Sedation (Ketodex) study is a Bayesian phase II/III, non-inferiority trial in children undergoing PSA for closed reductions that aims to address both these research questions. This article presents in detail the statistical analysis plan for the Ketodex trial and was submitted before the outcomes of the trial were available for analysis. METHODS/DESIGN: The Ketodex trial is a multicenter, four-armed, randomized, double-dummy controlled, Bayesian response adaptive dose finding, non-inferiority, phase II/III trial designed to determine (i) whether IN ketodex is non-inferior to IV ketamine for adequate sedation in children undergoing a closed reduction of a fracture or dislocation in a pediatric emergency department and (ii) the combination dose for IN ketodex that provides optimal sedation. Adequate sedation will be primarily measured using the Pediatric Sedation State Scale. As secondary outcomes, the Ketodex trial will compare the length of stay in the emergency department, time to wakening, and adverse events between study arms. DISCUSSION: The Ketodex trial will provide evidence on the optimal dose for, and effectiveness of, IN ketodex as an alternative to IV ketamine providing sedation for patients undergoing a closed reduction. The data from the Ketodex trial will be analyzed from a Bayesian perspective according to this statistical analysis plan. This will reduce the risk of producing data-driven results introducing bias in our reported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04195256 . Registered on December 11, 2019.