Ketamine-Based Modified Rapid Sequence Induction and Torso-Ramped Airway Alignment in a Child with Giant Hydrocephalus, Obstructive Ileus, and Sepsis: An Observational Case Study

Abstract

Background. Giant hydrocephalus predicts a difficult airway and limited intracranial compliance. With obstructive ileus, sepsis and malnutrition, induction must protect cerebral perfusion, support the circulation and guard against aspiration.

Objective. To describe the anesthetic management, hemodynamic course and early outcome of one child with these conditions who underwent emergency laparotomy.

Methods. A 5-year-old boy (15 kg) had untreated communicating hydrocephalus (head circumference 81 cm), cerebral palsy, a four-day low small-bowel obstruction, sepsis physiology and dehydration. After resuscitation and nasogastric decompression, a modified rapid sequence induction used fentanyl 15 mcg, ketamine 7.5 mg (0.5 mg/kg) and rocuronium 8 mg (≈0.53 mg/kg), with gentle mask ventilation, torso ramping and a cuffed tube. Ventilation targeted an end-tidal carbon dioxide of 30–35 mmHg. Six epochs (T0–T5) were recorded. Shunting was deferred.

Results. Ramping allowed first-attempt cuffed intubation (Cormack-Lehane grade I). Mean arterial pressure rose from 60.0 to 65.0 mmHg after resuscitation and stayed at 65.3–70.7 mmHg without vasopressors. End-tidal carbon dioxide was 32–34 mmHg and lactate fell from 4.2 to 1.3 mmol/L. An adhesive band obstructing the terminal ileum was divided during a 2.5-hour laparotomy (blood loss 20 mL). The child went to intensive care intubated and sedated (Glasgow Coma Scale E2V(ett)M1) with no clinical sign of raised intracranial pressure. Follow-up beyond handover was not recorded.

Conclusion. In this child, a ketamine-based modified rapid sequence induction, torso ramping, normocapnic ventilation and deferral of the shunt were followed by hemodynamic stability and uncomplicated intubation. One case cannot show causation; intracranial pressure was not measured.