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Fiberoptic Intubation with Dexmedetomidine in Two Children with Spinal Cord Impingements

Jooste, Edmund H., MBChB; Ohkawa, Susumu, MD; Sun, Lena S., MD

doi: 10.1213/01.ANE.0000173765.94392.80
Letters to the Editor: Letters & Announcements

Department of Anesthesiology; Pediatric Anesthesiology Division; College of Physicians and Surgeons; Columbia University; New York, NY;

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To the Editor:

We successfully used a combination of midazolam and dexmedetomidine during awake endotracheal intubation for pediatric patients with spinal cord impingement. The first case was a 10-yr-old girl with a history of Klippel-Feil syndrome and progressive leg weakness. The second case was a 10-yr-old girl with a history of Chiari malformation and progressive leg weakness. Both patients’ range of neck motion was severely limited. Magnetic resonance imaging and clinical symptoms were consistent with spinal cord impingement, and both patients were scheduled for occipital decompression. Because we considered a neurological examination after intubation to be critical, we discussed awake intubation with the patients and their families. They consented to the use of the procedure. Glycopyrrolate (5 μg/kg) and incremental IV doses of midazolam (0.1 mg/kg total) were given. Dexmedetomidine IV (1 μg/kg) was given over 10 min and followed by infusion (0.7 μg · kg−1 · h−1). During the initial dose, 1% lidocaine (2 mg/kg) was administered through a nebulizer. After the initial dose, the patients’ Ramsay scores were 4 (brisk response to loud auditory stimulus or glabellar tap). Further 1% lidocaine sprays through the mouth were required for them to accept oral airways. The airways had to be slit anteriorly for the removal of scopes. The scopes were advanced through the oral airways and the vocal cords were visualized. Additional 1% lidocaine was sprayed through the scope side ports. The grand total of lidocaine was limited to 5 mg/kg. Tubes were advanced over the scopes. The patients were intubated without desaturation, neck movement, or coughing. After intubation, neurological examination was confirmed to be at baseline before the induction of general anesthesia. The patients did not have any memory of intubation after the procedure. Propofol, fentanyl, or remifentanil are usually associated with significant respiratory depression. Butyrophenone derivatives, including droperidol or haloperidol, may cause significant Q-T interval prolongation. Dexmedetomidine may prove to be a reasonable alternative to these medications during awake intubation in pediatric population. Glycopyrrolate-premedication may decrease the incidence of bradycardia or hypotension. An α-2 antagonist atipamezole is being tested for human use. Availability of specific reversal drugs in the future may increase the safety margin of this medication.

Edmund H. Jooste, MBChB

Susumu Ohkawa, MD

Lena S. Sun, MD

Department of Anesthesiology

Pediatric Anesthesiology Division

College of Physicians and Surgeons

Columbia University

New York, NY

© 2005 International Anesthesia Research Society