General anesthesia with remimazolam for a pediatric patient with MELAS and recurrent epilepsy: a case report

Abstract

Background Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a mitochondrial disease. We report here the safe use of remimazolam in a pediatric MELAS patient. Case presentation A 10-year-old girl (118 cm, 16 kg) was scheduled for an open gastrostomy to improve nutrition and epileptic seizure control. We induced and maintained general anesthesia with remimazolam, remifentanil, fentanyl, and rocuronium. We also performed a bilateral subcostal transversus abdominis plane block before the surgery. The surgery finished uneventfully. After we discontinued remimazolam administration, the patient woke up immediately but calmly without flumazenil. Epileptic seizures did not occur during intra- and early post-operative periods. Conclusion Remimazolam enabled us to provide a pediatric MELAS patient with general anesthesia without causing delayed emergence or epileptic seizures.

Remimazolam and serious adverse events

“…While the loss of consciousness was faster after propofol versus remimazolam induction (46 versus 66 s), blood pressure was significantly lower after propofol induction. 103 Japan VATS Anaesthesia 1 100% Anaphylaxis Hong 9 Korea Arthroscopy Anaesthesia 1 0% Horikoshi 10 Japan Laparoscopy Anaesthesia 1 100% Delayed emergence Huang 11 China LMA insertion Anaesthesia NA 0% Hwang 12 Korea Teratoma resection Anaesthesia 2 0% Kawasaki 13 Japan Liver transplantation Anaesthesia 1 0% Kida 14 Japan CABG Anaesthesia 1 100% Tolerance Kim 107 Korea All kinds Anaesthesia 5 100% Anaphylactoid shock Kim 15 Korea THA Anaesthesia 1 100% Psychogenic coma Kim 16 Korea Laparotomy Anaesthesia 1 0% Kitaura 17 Japan TMVR Anaesthesia 1 0% Koh 18 Japan Spine Anaesthesia 1 100% Heart failure Lee 19 Korea RALP Anaesthesia 1 0% Liu 110 China RALP Anaesthesia 1 100% Precipitation Matsumoto 20 Japan Liver transplantation Anaesthesia 1 0% Matsuo 111 Japan Orthopaedic Anaesthesia 1 100% Precipitation Nakayama 21 Japan Minor orthopaedic Anaesthesia 2 0% Onoda 22 Japan Laparoscopy Anaesthesia 1 0% Saito 23 Japan Cardiac Anaesthesia 1 100% Hypotension Sasaki 112 Japan Dental Anaesthesia 1 100% Precipitation Sato 24 Japan Trepanation Anaesthesia 1 0% Sato 25 Japan Cardiac Anaesthesia 1 100% Hypertension Singal 102 USA Endoscopy Anaesthesia 1 100% Delayed emergence Suzuki 26 Japan ENT Anaesthesia 1 100% Delayed emergence Takemori 27 Japan RALP Anaesthesia 1 100% Delayed emergence Tsurumi 104 Japan Minor orthopaedic Anaesthesia 1 100% Anaphylaxis Uchida 28 Japan ENT Anaesthesia 1 100% Delayed emergence Uchida 29 Japan TEVAR Anaesthesia 1 100% Delayed emergence Uchida 106 Japan Skin graft; laparoscopy Anaesthesia 2 100% Anaphylaxis Yamada 30 Japan Neurosurgery Anaesthesia 3 0% Yamadori 31 Japan Laparotomy Anaesthesia 1 0% Yamamoto …”

The Role of Remimazolam in Neurosurgery and in Patients With Neurological Diseases: A Narrative Review

“…Interestingly, flumazenil reversal was used in all cases, and the authors reported positive anesthetic and surgical outcomes. Other examples include remimazolam use in patients with mitochondrial-associated myopathy, encephalopathy, and stroke-like episodes that may otherwise be exacerbated by propofol 36–38 . Case reports show no significant hypotension, metabolic derangements, or worsening neurological examination after remimazolam use in these patient cohorts.…”

Remimazolam: An Updated Review of a New Sedative and Anaesthetic

“… 60 Remimazolam could be used in a pediatric patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome in general anaesthesia without causing seizures and delayed emergence. 61 Furthermore, we searched four clinical trials assessing the use of remimazolam for sedation in pediatric patients at ClinicalTrials.gov (NCT04621305, NCT04851717, NCT04720963, and NCT05527314). 62–65…”

“… 61 Furthermore, we searched four clinical trials assessing the use of remimazolam for sedation in pediatric patients at ClinicalTrials.gov (NCT04621305, NCT04851717, NCT04720963, and NCT05527314). 62–65…”

“…60 Remimazolam could be used in a pediatric patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome in general anaesthesia without causing seizures and delayed emergence. 61 Furthermore, we searched four clinical trials assessing the use of remimazolam for sedation in pediatric patients at ClinicalTrials.gov (NCT04621305, NCT04851717, NCT04720963, and NCT05527314). [62][63][64][65] The use of remimazolam in a patient with MELAS who underwent MitraClip implantation is of particular interest, and the study results may provide new insights into sedation for patients with MELAS syndrome having heart failure.…”