We obtained a written informed consent from the patient for the publication of this case report.
The patient was a 66-year-old man (165 cm, 62 kg) with a history of CIPD diagnosed several years ago. He was taking prescribed oral cyclosporine (75 mg per day). Because of muscle weakness in the upper and lower limbs and right and left hand grip strengths being 10 kg and 6 kg, respectively, he walked with the help of a walker and managed to have his meals using a spoon. He required some assistance with his activities of daily living.
The patient was found to have anemia in a periodic blood test, and he was diagnosed with rectal cancer following a detailed examination. Therefore, he was scheduled to undergo the laparoscopic Hartmann procedure. His respiratory function tests showed that he had restrictive ventilatory impairment (VC, 2470 ml; %VC, 66.9%; FEV1.0, 1910 ml; %FEV1.0, 77.0%). He did not have any other abnormal medical history or laboratory results.
On the morning of the surgery, the patient was administered roxatidine (75 mg) as anesthetic premedication. We induced anesthesia using propofol (80 mg), ketamine (30 mg), and remifentanil (0.3 μg/kg/min), and maintained it using propofol (4–5 mg/kg/h) and remifentanil (0.15–0.2 μg/kg/min) without the use of muscle relaxants. Tracheal intubation was uneventful with a 1% lidocaine 4 ml tracheal sprinkle. After the induction, we performed the ultrasound-guided transversus abdominis plane and rectus sheath blocks using 60 ml of 0.25% levobupivacaine. Additionally, we administered fentanyl (200 μg) and acetaminophen (1000 mg) intravenously for postoperative analgesia. The abdominal wall blocks helped in maintaining good surgical conditions without the use of muscle relaxants. The operation lasted 4 h and 25 min and the total blood loss was a little. The patient emerged from the anesthesia and was uneventfully extubated in the operating room after confirming adequate spontaneous breathing. Next, the patient was transferred to the intensive care unit and was administered a continuous intravenous infusion of fentanyl (12.5 μg/h) for postoperative analgesia. On the following day, we discontinued the continuous intravenous infusion of fentanyl and moved the patient to the general ward. The postoperative course was uneventful without any respiratory complications such as respiratory depression, aspiration pneumonia, and progression of CIPD symptoms.