Use of Esketamine Combined with Dexmedetomidine for Difficult Tracheal Intubation in an Uncooperative Pediatric Patient with Severe Trismus: A Case Report

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.