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Anesthetic management with remimazolam for a pediatric patient with Duchenne muscular dystrophy
Yuta Horikoshi1, Norifumi Kuratani1,2, Ken Tateno1
1Department of Anesthesiology, Saitama Medical University Hospital, Saitama, Japan.
Insights
This study reports the first use of remimazolam for general anesthesia in a pediatric patient with Duchenne muscular dystrophy (DMD). The anesthetic was found to be safe and well-tolerated, with no adverse events noted during the perioperative period.
Area of Science:
- Anesthesiology
- Pediatric Medicine
- Genetics
Background:
- Duchenne muscular dystrophy (DMD) poses significant risks during general anesthesia due to cardiac and respiratory compromise.
- Improved treatments have increased surgical candidacy for DMD patients, necessitating safe anesthetic options.
- Remimazolam offers potential advantages over propofol due to its circulatory stability and available antagonist.
Observation:
- A 4-year-old boy with newly diagnosed DMD, asymptomatic except for elevated creatine phosphokinase, was scheduled for hernia repair.
- Anesthesia was induced and maintained using remimazolam, fentanyl, remifentanil, and rocuronium.
- Post-operatively, sugammadex was administered for neuromuscular blockade reversal.
Findings:
- Remimazolam administration was successfully managed throughout the procedure.
- The patient experienced a 20-minute recovery time after remimazolam discontinuation.
- The pediatric DMD patient was discharged on postoperative Day 2 without complications.
Implications:
- Remimazolam appears to be a safe anesthetic agent for pediatric patients with Duchenne muscular dystrophy.
- This case provides crucial data for the anesthetic management of DMD patients undergoing surgery.
- Further research is warranted to explore remimazolam's role in this specific patient population.
Rationale:
With Duchenne muscular dystrophy (DMD) being the most common and most severe type of muscular dystrophy, DMD patients are at risk for complications from general anesthesia due to impaired cardiac and respiratory functions as the pathological condition progresses. In recent years, advances in multidisciplinary treatment have improved the prognosis of DMD patients, and the number of patients requiring surgery has increased. Remimazolam is a benzodiazepine derivative similar to midazolam. Its circulatory stability and the fact that it has an antagonist make it superior to propofol.There are no reports of pediatric patients with DMD undergoing total intravenous anesthesia with remimazolam.
Patient Concerns:
A 4-year boy was scheduled for single-incision laparoscopic percutaneous extraperitoneal closure for inguinal hernia under general anesthesia, but the surgery was postponed because his serum creatine phosphokinase level was extremely high.
Diagnosis:
He was diagnosed with DMD. According to the results of the genetic test, exon deletion of the DMD gene was detected using multiplex ligation-dependent probe amplification, although he had no symptoms of DMD except for elevated serum levels of creatine phosphokinase, etc.
Intervention:
He was admitted for the same surgical purpose. Anesthesia was induced with 3 mg of intravenously administered remimazolam. He lost the ability to respond to verbal commands. After the intravenous administration of 100 μg of fentanyl, a continuous infusion of remifentanil (1.0 μg/kg/min) and remimazolam (15 mg/h) was started, and the endotracheal tube was inserted smoothly after the administration of 10 mg of rocuronium with which the muscle twitches disappeared in train-of-four monitoring. At the end of the surgery, 15 mg of flurbiprofen was administered intravenously. After surgery, we injected 40 mg of sugammadex to confirm a train-of-four count of 100%.
Outcomes:
Although the dose of remimazolam was reduced to 5 mg/h 30 minutes before the end of the surgery, it took 20 minutes after the discontinuation of remimazolam for the patient to open his eyes upon verbal command. On postoperative Day 2, he was discharged from the hospital without any complications.
Lessons:
Remimazolam was shown to be safe to use for general anesthesia in a pediatric patient with DMD.
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