Unconventional Use of Continuous Ketofol with Therapeutic Hypermagnesemia for Spasm-Free Conscious Sedation in Refractory Tetanus: First Reported Case

Background: Prolonged neuromuscular blockade in severe tetanus remains a major clinical challenge, often complicating ventilator weaning and exposing patients to secondary complications. We report, to our knowledge, the first PubMed-indexed use of continuous ketamine-propofol (ketofol) in tetanus and its sequential use after sustained therapeutic hypermagnesemia. A 48-year-old man with refractory generalized tetanus and dysautonomia required continuous cisatracurium for 18 days despite repeated weaning attempts. Therapeutic hypermagnesemia (serum magnesium 2-4 mmol/L) was established from day 15, followed by ketofol on day 18. Within 24 hours, cisatracurium was discontinued and spasm-free conscious sedation with hemodynamic stability was achieved. Ketofol was continued for five days, with progression to CPAP, T-piece trials, and decannulation on day 26. By facilitating earlier withdrawal of paralysis, this sequential strategy may reduce exposure to ICU-acquired weakness and pulmonary complications associated with prolonged ventilation, although causality cannot be established from a single case.

Keywords: Generalized tetanus; dysautonomia; therapeutic hypermagnesemia; ketamine-propofol; ketofol; cisatracurium; tracheostomy.