Propofol sedation for infants with idiopathic clubfoot undergoing percutaneous tendoachilles tenotomy.

OBJECTIVES: To determine whether percutaneous tenotomy of the Achilles tendon in infants with idiopathic clubfeet can be safely performed under propofol sedation. BACKGROUND: Many orthopaedic surgeons prefer to do a tenotomy under general anesthesia. At our institution, we have been using 2 different methods of induction and maintenance of anesthesia: one method using combined propofol and sevoflurane and various types of airway management, and the other using only propofol with facemask. METHODS: We reviewed the medical records of all patients less than 1 year of age with idiopathic clubfoot who underwent a percutaneous tendoachilles tenotomy under anesthesia. Collected data included: chronological age, earlier apneic events, medical risk factors, time from operating room entry to surgery, and surgical-related and anesthesia-related complications. RESULTS: The study group comprised 114 patients who underwent 162 tenotomies. Sixty-five patients were in group 1 (sevoflurane/propofol) and 49 patients were in group 2 (propofol). The 2 groups did not differ with respect to sex, bilaterality, chronological age, number of preterm infants, ASA class, or associated risk factors. The average time from operating room entry to surgery was approximately 5 minutes longer with group 1, which included 14 cases taking longer than 20 minutes. However, there were no differences between the 2 groups with respect to postoperative complications. CONCLUSIONS: Percutaneous tendoachilles tenotomy in infants with idiopathic clubfeet may be safely performed under anesthesia. Propofol sedation was safe and effective without the need for airway instrumentation for this short procedure. LEVEL OF EVIDENCE: Level IV (retrospective).

Unique clinical situations in pediatric patients where ketamine may be the anesthetic agent of choice.

Ketamine has been recognized as an anesthetic agent of choice in areas with limited resources, particularly in emergency situations. Unlike other commonly used induction agents, it preserves respiratory drive and maintains predominant sympathetic tone. However, ketamine's application in other clinical settings has been limited by its psychomimmetic properties, which other anesthetics do not posses. Despite these drawbacks, ketamine has become a favorable drug for the sedation of children undergoing various procedures. Here we propose 3 clinical paradigms where ketamine may be the agent of choice for the pediatric patient requiring sedation or anesthesia, including (1) the child with a difficult airway, (2) the child with a reactive airway disease, and (3) the uncooperative child requiring intravenous access.

Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia.

A 6-year-old girl with Treacher Collins syndrome presented for implantation of a hearing device. The patient was developmentally delayed and had severe micrognathia. After induction of anesthesia with dexmedetomidine and ketamine, the patient tolerated the introduction of a flexible fiberoptic bronchoscope without any change in respiration, and intubation was achieved easily.