Flumazenil Reversal of Remimazolam Sedation to Facilitate Emergence and Rapid Neurologic Examination in Patients Undergoing Posterior Spinal Fusion

Abstract

Background: Remimazolam is a novel, ester-metabolized benzodiazepine, which received approval by the United States Food & Drug Administration for procedural sedation in adults in 2020. Given its clinical efficacy, intraoperative use has expanded with administration as the primary agent or as an adjunct to general anesthesia in both adult and pediatric patients. Although its novel route of metabolism through tissue esterases generally results in a rapid resolution of its effects, in certain clinical scenarios, reversal may be facilitated with flumazenil.

Methods: We retrospectively reviewed our clinical experience with the use of flumazenil to reverse the effects of remimazolam and speed emergence from anesthesia to facilitate a rapid postoperative neurologic examination following posterior spinal fusion (PSF).

Results: The study cohort included 20 patients, ranging in age from 11 to 24 years. Two patients were excluded from the flumazenil-to-tracheal extubation timing analysis as they did not receive flumazenil for that clinical indication. The median flumazenil bolus dose was 0.1 mg (range 0.1–0.5 mg) with 12 patients receiving one dose, four receiving two doses, and four receiving three doses. Overall, 16 of 18 patients (88.9%) underwent tracheal extubation in less than 5 min after flumazenil administration. No clinically significant adverse events directly attributable to flumazenil were documented.

Conclusions: These preliminary findings suggest that incremental, low-dose flumazenil administration may facilitate timely emergence and tracheal extubation after remimazolam-based anesthesia in patients undergoing PSF when rapid postoperative neurologic assessment is desired.