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Background and Aims Ketodex is effective in achieving sedation and has a favorable safety profile in pediatric patients undergoing MRI and invasive procedures, while producing minimal adverse effects.

Methods A 6-year-old female patient, ASA III status, weighing 21 kg, with a history of type I mucopolysaccharidosis was proposed for bilateral median nerve release with tourniquet due to carpal tunnel syndrome. Preoperative evaluation showed indicators of a potentially difficult airway (Mallampati class IV, retrognathia, limited neck extension, macroglossia). The patient was proposed for locoregional anesthesia with sedation and standard ASA+BIS monitoring. A loading dose of ketamine+dexmedetomidine (‘ketodex’) was administered, according to the hospital protocol, consisting of 1 mg/kg of ketamine and 1 µg/kg of dexmedetomidine over 10 minutes. The patient maintained SpO2>98% with 2 L/min of nasal cannula, hemodynamic stability, with BIS 70-80 on EEG. Bilateral costoclavicular blockade was performed under ultrasound guidance with 5 mL of 0.2% ropivacaine + 5 mL of 1.5% mepivacaine. Sedation was maintained with a titrated dose of ketodex according to BIS (maximum dose 1 µg/kg/h). Administration of 300 mg of paracetamol and 10 mg of ketorolac at the end.

Results The procedure was completed without complications. The patient was transferred to the post-anesthesia care unit without pain complaints, hemodynamically stable, and with SpO2 ~99% with 1 L/min of nasal cannula.

Conclusions This case underscores the importance of tailored anesthetic management in pediatric patients with comorbidities and difficult airway. Effective implementation of clinical guidance protocols and in-depth knowledge of drug pharmacology were crucial for the successful anesthetic management in this case report.