This was an 11-year-old patient (35 kg weight) scheduled for bilateral knee tenotomy for knee flexion correction that prevented him from resting in supine position.
He had been diagnosed with DMD at 3 years of age by means of a genetic study, and due to the progression of the disease he needed a wheelchair from eight.
Preoperatively, there was an increase in transaminase levels 131 mU.ml-1, ALT 187 mU.ml-1) and CPK 4226 IU/l.
The rest of the biochemical control, blood count and coagulation were within normal limits.
The chest X-ray showed an increase in the base bronchovascular network.
It was not possible to perform a respiratory functional study due to lack of cooperation of the patient, but the last one available (8 years old) showed a severe restrictive disorder.
The electrocardiogram (ECG) showed deep Q waves in the left precordial leads, with no changes in repolarization.
The patient was premedicated with 7 mg of oral midazolam.
Anesthesia was induced by slow bolus administration of propofol (2 mg.kg-1) and remifentanil 0.5 μg.kg-1.
Endotracheal intubation was performed with a 6.5 Fr. Fr. phlexometallic tube with endotracheal cuff after neuromuscular blockade with mivacurium (0.2 mg.kg-1).
Anesthesia was maintained with propofol (10-4 mg.kg-1) to achieve a bispectral index (BIS) of 40-60, remifentanil (0.25 μg.kg-1.min-1) and mechanically maintained with oxygen (0.6 mg).
With the patient in lateral decubitus, before placing the patient in prone position for surgery, epidural anesthesia at L4-L5 level was performed with an 18G Tuohy needle through a catheter (20G).
Two ml of 0.25% bupivacaine with vasoconstrictor were administered as a test dose and 12 ml of 0.2% ropivacaine.
The surgery was uneventful and the patient could be extubated at the end of surgery with good ventilatory mechanics.
Muscle blockade recovery with mivacurium, monitored with a neurostimulator, was not prolonged and muscle blockade reversal was not necessary.
The patient was admitted to the hospital in charge of traumatology and followed up by the Pain Unit of our hospital.
As post-surgical analgesia, 7 ml.h-1 of 0.18% ropivacaine with 1 μg.ml-1 fentanyl were administered through the lumbar epidural catheter. After 8 hours, the patient had adequate analgesia (from 0 to 10 orom visual analogue scale).
No other adverse events were recorded.
Epidural analgesia was effective (VAS < 2) with the new LA concentration.
The epidural catheter was removed on the fifth postoperative day.
