Esketamine combined with ultrasound-guided superficial cervical plexus block to complete pediatric subglottic stenosis tracheotomy-a case report and literature review

Abstract

Background

Congenital subglottic stenosis is a condition that results in airway narrowing in pediatric patients, presenting significant challenges for anesthesiologists during surgical procedures. This case report describes the successful management of a pediatric patient with congenital subglottic stenosis who underwent tracheotomy using esketamine combined with ultrasound-guided superficial cervical plexus block. The aim is to provide an alternative anesthetic approach for similar complex cases.

Case presentation

A 4-year-old child diagnosed with congenital subglottic stenosis and laryngeal obstruction (grade III) required emergency tracheotomy to alleviate the obstruction. Esketamine was selected as the sedative-analgesic agent to maintain spontaneous breathing. Ultrasound-guided bilateral superficial cervical plexus blocks were performed to enhance analgesia. The tracheotomy was successfully completed without any intraoperative movement or coughing. Postoperatively, the patient recovered well and was discharged from the hospital.

Conclusion

The combination of esketamine and ultrasound-guided superficial cervical plexus block offers a safe and effective anesthetic approach for this pediatric patient with subglottic stenosis undergoing tracheotomy. Further studies are necessary to confirm the safety and efficacy of this technique.

Background

Congenital subglottic stenosis arises from developmental anomalies, resulting in narrowing of the subglottic cavity. The severity of stenosis can lead to asphyxia in neonates and is often associated with recurrent respiratory infections or laryngitis, which may cause dyspnea and hypoxia [1]. Treatment options for congenital subglottic stenosis include various surgical interventions such as dilation, stent placement, laryngotracheal reconstruction, and tracheostomy [2]. Tracheotomy is an effective method for alleviating severe laryngeal obstructions. Preoperative management focuses on ensuring adequate oxygenation while minimizing postoperative morbidity. Anesthetic considerations involve a multidisciplinary preoperative evaluation, intraoperative management, and promoting rapid postoperative recovery. The choice of anesthesia depends on a comprehensive assessment of the patient’s condition and the specific requirements of the surgical team. Managing the shared airway between anesthesiologists and surgeons presents unique challenges. This case report details the anesthetic management of a pediatric patient with congenital subglottic stenosis undergoing tracheotomy, utilizing intravenous esketamine injection combined with a superficial cervical plexus block.

Case presentation

A 4-year-old boy weighing 20 kg was admitted to the department of Otorhinolaryngology with a chief complaint of stridor lasting for 2 years. The child exhibited prominent tracheal tug, intercostal retractions, and suprasternal retractions (three-concave sign), along with cyanosis of the lips and mouth. He experienced nocturnal respiratory distress, preventing him from lying flat, and could only fall asleep in an upright position. Electron nasopharyngoscopy revealed atrophy of the right vocal cord and granulomatous hyperplasia beneath the vocal folds. Chest radiographs and lateral laryngeal radiographs demonstrated subglottic airway stenosis. Recently, the patient’s respiratory difficulties had worsened, accompanied by laryngeal stridor, leading to a diagnosis of congenital subglottic stenosis and laryngeal obstruction (grade III). Due to severe respiratory distress and inability to sleep, the ENT surgeon decided to perform an urgent tracheotomy under general anesthesia to relieve the laryngeal obstruction.

The preoperative anesthesia consultation provided a comprehensive evaluation of the child’s physical condition. The patient was diagnosed with congenital subglottic stenosis, exhibiting pronounced laryngeal sounds during respiration and a marked triple concave sign (Fig. 1). Cardiac function was within normal limits, and all biochemical blood tests were unremarkable. The American Society of Anesthesiologists (ASA) physical status classification was II. Based on clinical symptoms and findings from electronic nasopharyngoscopy, the child’s airway was assessed as difficult to intubate. There is a risk of exacerbated airway obstruction during general anesthesia, potentially leading to failed airway management, hypoxia, and more severe consequences such as cardiac arrest and anoxic brain injury.

Fig. 1

The ‘three-concave sign’ is positive. ① superior sternal fossa; ② supraclavicular fossa; ③ Intercostal space; ④ The right vocal cord is constricted; ⑤ The airway is obstructed

In consideration of the aforementioned factors, we devised a plan to select an anesthesia method that would maintain spontaneous breathing while providing adequate sedation and analgesia. We opted for esketamine for sedation and analgesia, ensuring the preservation of the child’s spontaneous respiration. An ultrasound-guided bilateral superficial cervical plexus block was performed under sedation. Preparations included a laryngoscope, 2.5# and 3.0# tracheal tubes, oropharyngeal airway, and laryngeal mask. Upon admission to the operating room, the child was monitored for electrocardiogram, blood pressure, and oxygen saturation. Scopolamine (0.1 mg) was administered intravenously preoperatively to reduce secretions, and methylprednisolone (10 mg) was given to prevent airway edema. Once the surgical instruments were in place, the patient received 6 L/min of oxygen via mask for 3 min, followed by intravenous administration of esketamine (12.5 mg). The ultrasound-guided bilateral superficial cervical plexus block was then performed, with 3 ml of 0.3% ropivacaine injected into each side. The entire surgical procedure proceeded smoothly and remained stable throughout. Prior to incision, forceps were utilized to test the skin for adequate analgesia. The ENT surgeon then made a precise incision to expose the trachea. Following the tracheotomy, the tracheal device was successfully inserted, and the ventilator was connected in pressure control mode. At the conclusion of the procedure, an additional dose of sufentanil (0.5 µg) was administered. The operation lasted 25 min, during which there were no signs of movement or coughing, and the pulse oximeter readings remained consistently above 96%. Postoperatively, the child was transferred to the PACU where he regained consciousness within 15 min. His vital signs were monitored and found to be stable, after which he was safely returned to the ward. The patient’s airway obstruction was significantly alleviated, leading to a successful discharge from the hospital.

Discussion

Anesthesia for patients with subglottic stenosis poses significant challenges to anesthesiologists. Airway management techniques vary widely, and no standardized protocol has been established to date. Key considerations include ensuring adequate oxygenation and analgesia, minimizing complications, and meeting the surgeons’ requirements. This case report describes a pediatric patient with subglottic stenosis who underwent tracheotomy. Our experience suggests that a combination of esketamine and ultrasound-guided bilateral superficial cervical plexus block can provide effective sedation and analgesia while preserving spontaneous breathing. This approach represents a safe and reliable anesthetic strategy for tracheotomy in cases of difficult airways due to subglottic stenosis.

Airway management strategies for subglottic stenosis vary, each with its own benefits and risks. Richard M. et al. utilized a clinical database to investigate various airway management techniques for subglottic stenosis. The anesthetic techniques mentioned in this study include jet ventilation, intermittent apnea technique, small endotracheal tubes, intermittent facemask ventilation, and spontaneous ventilation. Comparative analysis revealed no significant differences in intraoperative hypoxemia rates among these techniques. The overall failure rate of airway management was 7.5%, highlighting the need for multiple backup plans and further research in managing known subglottic stenosis [3].

Several studies have reported that maintaining spontaneous ventilation during pediatric surgery is safe in cases of subglottic stenosis [4, 5]. These studies used similar anesthetic techniques to our case but differed in the specific anesthetics employed. Maintaining sufficient depth of anesthesia and oxygen saturation is crucial. There is a risk of airway compromise during surgery, and maintaining spontaneous respiration can increase the safety margin. This is particularly important when the extent of subglottic stenosis cannot be accurately assessed preoperatively [6]. The disadvantage of maintaining spontaneous breathing is the lack of adequate control over the airway, potentially leading to airway obstruction during the perioperative period. Moreover, if surgical bleeding enters the airway, it could result in asphyxia.

The rationale for using esketamine in combination with ultrasound-guided superficial cervical plexus block is based on two aspects. Firstly, esketamine provides effective sedation and analgesia while preserving spontaneous breathing. Secondly, the addition of a superficial cervical plexus nerve block significantly enhances the overall analgesic effect. Esketamine is the S-enantiomer of ketamine, characterized by superior analgesic efficacy, higher in vivo clearance, and a more favorable adverse effect profile compared to ketamine. The combination of sedation and analgesia with minimal respiratory depression renders esketamine an appropriate choice for anesthesia in this context. Previous studies have demonstrated the safety and efficacy of esketamine in pediatric patients. One study utilized intranasal esketamine, which provided effective sedation during pediatric dental surgery [7]. Another study found that 1 mg/kg of esketamine administered at induction alleviated postoperative pain and inflammatory responses following adenotonsillectomy in children [8]. A comparative analysis evaluated the safety of various esketamine doses combined with propofol in pediatric gastroenteroscopy, noting that 0.5 mg/kg of esketamine reduced the total amount of propofol required without inducing side effects such as nausea or vomiting [9]. Additionally, a study assessed the impact of 0.25 mg/kg esketamine on post-tonsillectomy agitation, revealing that this low dose decreased the incidence of emergence agitation without delaying extubation time or increasing postoperative complications [10]. In our case, esketamine 0.625 mg/kg exhibited satisfactory sedative and analgesic properties. To enhance local analgesia, we performed an ultrasound-guided bilateral superficial cervical plexus block. The superficial cervical plexus comprises the anterior rami of C3, C4, and C5 spinal nerves, innervating the skin over the occipital, retroarticular, and anterior cervical regions, as well as the shoulder and upper chest. Studies have shown that this regional block is both safe and effective for various procedures, including dialysis catheter implantation in pediatric patients [11].

There were limitations in our report. It was based on a single case, which limited the generalizability of the findings. The results may not be applicable to all pediatric patients with subglottic stenosis, especially those with different severity levels or comorbidities. The report didn’t compare the combination of esketamine and ultrasound-guided superficial cervical plexus block with other anesthetic techniques. Without comparative data, it was difficult to assess whether this approach is superior to other methods. The success of the procedure may be influenced by the specific skills and experience of the anesthesiologist and surgical team. This introduces potential bias, as the results may not be replicable in settings with less experienced personnel.

In conclusion, the combination of esketamine and ultrasound-guided bilateral superficial cervical plexus block provides a safe and effective analgesic anesthetic approach for this patient undergoing tracheotomy due to congenital subglottic stenosis. Further clinical studies are warranted to validate the efficacy and safety of this technique in optimizing airway management.