Recovery from remifentanil after plasmapheresis in a paediatric patient with myasthenia gravis

A combination of total intravenous anesthesia and thoracic epidural for thymectomy in juvenile myasthenia gravis

“…Total intravenous anesthesia has been recommended for patients with MG, because it helps avoid the use of both NMBDs and volatile agents. There have been several reports of the safe use of propofol/remifentanil combinations in adult myasthenic patients (4,8), but, to date, only one report of the use of this TIVA combination in a child (9). It is often avoided because current pump technology has meant that target controlled infusion (TCI) has not been possible in children less than 16 years of age or 30 kg in weight.…”

Rapid sequence intubation without a neuromuscular blocking agent in a 14‐year‐old female patient with myasthenia gravis

“…However, one author cautioned that emergence may be delayed by slow breakdown of remifentanil in the presence of anticholinesterase agents (14), and reported a 19‐year‐old myasthenic female who received 30 μg·kg −1 of remifentanil over 2 h, and had a delay of 12 h until the return of spontaneous ventilation and the ability to follow commands. Others reported no prolongation when they used remifentanil 0.125–0.25 μg·kg −1 · min −1 for a 13‐year‐old myasthenic patient who received the infusion during a 2 h thymectomy, despite presumed reduced plasma cholinesterase levels because of eight cycles of plasmapheresis preoperatively (15). There is no report of prolonged emergence after a single bolus dose of remifentanil in a myasthenic patient.…”

Perioperative Therapeutic Plasmapheresis

“…one case report described normal emergence from a remifentanilbased anesthetic after several cycles of plasmapheresis. 42 The highly charged anticoagulant heparin is readily removed by plasmapheresis, perhaps necessitating frequent readministration if therapeutic anticoagulation is necessary. Plasmapheresis-mediated decreases in antithrombin could cause heparin resistance; therefore, careful monitoring of anticoagulation via activated clotting time or other equivalent measures is necessary.…”