Remimazolam-Based Anesthesia Without Neuromuscular Blockade for Laparoscopic Surgery in a Patient With Immune-Mediated Necrotizing Myopathy: A Case Report.

BACKGROUND: Immune-mediated necrotizing myopathy causes progressive muscle weakness and may complicate anesthetic management because responses to neuromuscular blocking agents may be unpredictable and residual blockade may further compromise respiratory function. We report a case in which laparoscopic surgery was completed without neuromuscular blocking agents under remimazolam-based total intravenous anesthesia. CASE PRESENTATION: A 44-year-old woman with anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody-positive immune-mediated necrotizing myopathy and marked preexisting muscle weakness underwent laparoscopic myomectomy under total intravenous anesthesia with remimazolam and remifentanil without neuromuscular blocking agents. Low-dose rocuronium was immediately available as rescue treatment. Tracheal intubation was completed without coughing or movement. No patient movement occurred during pneumoperitoneum, and surgical exposure remained acceptable. Flumazenil was administered after responsiveness to verbal commands, airway reflexes, and adequate spontaneous ventilation had been confirmed. Tracheal extubation was uneventful, and no postoperative resedation or respiratory compromise occurred. CONCLUSION: In this patient with immune-mediated necrotizing myopathy and marked preexisting muscle weakness, laparoscopic surgery was completed without neuromuscular blocking agents under remimazolam-based total intravenous anesthesia, with low-dose rocuronium available as rescue treatment. Tracheal intubation was smooth, surgical conditions were acceptable, and postoperative respiratory recovery was uncomplicated.