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Delayed emergence after general anesthesia using remimazolam for induction agent in laparoscopic cholecystectomy: a case report
1Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, 14353 Gwangmyeong-si, Republic of Korea
2Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, 06911 Seoul, Republic of Korea
3Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, 06973 Seoul, Republic of Korea
DOI: 10.22514/sv.2023.125 Vol.20,Issue 5,May 2024 pp.107-111
Submitted: 23 August 2023 Accepted: 10 October 2023
Published: 08 May 2024
*Corresponding Author(s): Min Kyoung Kim E-mail: ddolpaki86@naver.com
Remimazolam’s ultrashort-acting properties, including reduced injection discomfort, minimal impact on respiratory and cardiovascular functions and rapid metabolism, have garnered significant attention in the field of anesthesia. However, despite its widespread acclaim, we encountered an unusual case in which a patient without hepatic or renal impairment experienced unexpected delays in regaining consciousness following a single intravenous induction dose of remimazolam. The patient, a 63-year-old undergoing laparoscopic cholecystectomy for gallbladder stones, had preoperative tests revealing atrial fibrillation and a reduced ejection fraction observed in an echocardiogram. Anesthesia induction included the administration of remimazolam (0.3 mg/kg), sufentanil and rocuronium. The surgery proceeded uneventfully and was maintained with desflurane and sufentanil. However, after the surgery, the patient experienced delayed emergence from anesthesia. Opioid overdose was ruled out, and we suspected a metabolic delay associated with remimazolam. In response to this suspicion, we administered flumazenil, which promptly restored consciousness and normal breathing. Subsequent post-anesthetic observation revealed no complications, and the patient was discharged two days after surgery. This case highlights the significant delayed emergence phenomenon linked to remimazolam, even when administered as a bolus. Instances of delayed emergence following remimazolam administration underscore the complexities in anesthesia responses, emphasizing the importance of vigilant clinical monitoring and the need for ongoing research in this area.
Remimazolam; Flumazenil; Benzodiazepines; Delayed emergence; General anesthesia; Case report
Eun-Jin Ahn,Je Jin Lee,Chan Su Park,Min Kyoung Kim. Delayed emergence after general anesthesia using remimazolam for induction agent in laparoscopic cholecystectomy: a case report. Signa Vitae. 2024. 20(5);107-111.
[1] Kilpatrick GJ. Remimazolam: non-clinical and clinical profile of a new sedative/anesthetic agent. Frontiers in Pharmacology. 2021; 12: 690875.
[2] Kim KM. Remimazolam: pharmacological characteristics and clinical applications in anesthesiology. Anesthesia and Pain Medicine. 2022; 17: 1–11.
[3] Misal U, Joshi S, Shaikh M. Delayed recovery from anesthesia: a postgraduate educational review. Anesthesia: Essays and Researches. 2016; 10: 164.
[4] Lee A, Shirley M. Remimazolam: a review in procedural sedation. Drugs. 2021; 81: 1193–1201.
[5] Schüttler J, Eisenried A, Lerch M, Fechner J, Jeleazcov C, Ihmsen H. Pharmacokinetics and pharmacodynamics of remimazolam (CNS 7056) after continuous infusion in healthy male volunteers. Anesthesiology. 2020; 132: 636–651.
[6] Zhu X, Wang H, Yuan S, Li Y, Jia Y, Zhang Z, et al. Efficacy and safety of remimazolam in endoscopic sedation—a systematic review and meta-analysis. Frontiers in Medicine. 2021; 8: 655042.
[7] Nakanishi T, Sento Y, Kamimura Y, Tsuji T, Kako E, Sobue K. Remimazolam for induction of anesthesia in elderly patients with severe aortic stenosis: a prospective, observational pilot study. BMC Anesthesiology. 2021; 21: 306.
[8] Stöhr T, Colin PJ, Ossig J, Pesic M, Borkett K, Winkle P, et al. Pharmacokinetic properties of remimazolam in subjects with hepatic or renal impairment. British Journal of Anaesthesia. 2021; 127: 415–423.
[9] Singal A, Naftalovich R, Syed AR, Chaudhry FA, Discepola PJ, Rodriguez-Correa DT. Delayed emergence after remimazolam induction in end-stage liver disease. Comment on Br J Anaesth 2021; 127: 415–23. British Journal of Anaesthesia. 2022; 129: e171–e172.
[10] Takemori T, Oyama Y, Makino T, Hidaka S, Kitano T. Long-term delayed emergence after remimazolam-based general anesthesia: a case report. JA Clinical Reports. 2022; 8: 86.
[11] Uchida S, Takekawa D, Hirota K. Delayed emergence due to remimazolam extravaation. JA Clinical Reports. 2022; 8: 96.
[12] Yamamoto T, Kurabe M, Kamiya Y. Re-sleeping after reversal of remimazolam by flumazenil. Journal of Anesthesia. 2021; 35: 322–322.
[13] Cascella M, Bimonte S, Di Napoli R. Delayed emergence from anesthesia: what we know and how we act. Local and Regional Anesthesia. 2020; 13: 195–206.
[14] Ellis TA, Edberg JL, Kumar N, Applefield DJ. Delayed emergence from anesthesia: a simulation case for anesthesia learners. MedEdPORTAL. 2017; 13: 10628.
[15] Thomas E, Martin F, Pollard B. Delayed recovery of consciousness after general anaesthesia. BJA Education. 2020; 20: 173–179.
[16] Bayable SD, Amberbir WD, Fetene MB. Delayed awakening and its associated factor following general anesthesia service, 2022: a cross-sectional study. Annals of Medicine and Surgery. 2023; 85: 4321–4328.
[17] Zhang G, Pan B, Tan D, Ling Y. Risk factors of delayed recovery from general anesthesia in patients undergoing radical biliary surgery: what can we prevent. Medicine. 2021; 100: e26773.
[18] Chae D, Kim HC, Song Y, Choi YS, Han DW. Pharmacodynamic analysis of intravenous bolus remimazolam for loss of consciousness in patients undergoing general anaesthesia: a randomised, prospective, double-blind study. British Journal of Anaesthesia. 2022; 129: 49–57.
[19] Derrode N, Lebrun F, Levron JC, Chauvin M, Debaene B. Influence of peroperative opioid on postoperative pain after major abdominal surgery: sufentanil TCI versus remifentanil TCI. A randomized, controlled study. British Journal of Anaesthesia. 2003; 91: 842–849.
[20] Doi M, Morita K, Takeda J, Sakamoto A, Yamakage M, Suzuki T. Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase IIb/III trial. Journal of Anesthesia. 2020; 34: 543–553.
[21] Dai G, Pei L, Duan F, Liao M, Zhang Y, Zhu M, et al. Safety and efficacy of remimazolam compared with propofol in induction of general anesthesia. Minerva Anestesiologica. 2021; 87: 1073–1079.
[22] Oh J, Park SY, Lee SY, Song JY, Lee GY, Park JH, et al. Determination of the 95% effective dose of remimazolam to achieve loss of consciousness during anesthesia induction in different age groups. Korean Journal of Anesthesiology. 2022; 75: 510–517.
[23] Antonik LJ, Goldwater DR, Kilpatrick GJ, Tilbrook GS, Borkett KM. A placebo- and midazolam-controlled phase I single ascending-dose study evaluating the safety, pharmacokinetics, and pharmacodynamics of remimazolam (CNS 7056): part I. Safety, efficacy, and basic pharmacokinetics. Anesthesia & Analgesia. 2012; 115: 274–283.
[24] Wiltshire HR, Kilpatrick GJ, Tilbrook GS, Borkett KM. A placebo- and midazolam-controlled phase I single ascending-dose study evaluating the safety, pharmacokinetics, and pharmacodynamics of remimazolam (CNS 7056): part II. Population pharmacokinetic and pharmacodynamic modeling and simulation. Anesthesia & Analgesia. 2012; 115: 284–296.
[25] Casey Laizure S, Herring V, Hu Z, Witbrodt K, Parker RB. The role of human carboxylesterases in drug metabolism: have we overlooked their importance? Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2013; 33: 210–222.
[26] Wang D, Zou L, Jin Q, Hou J, Ge G, Yang L. Human carboxylesterases: a comprehensive review. Acta Pharmaceutica Sinica B. 2018; 8: 699–712.
[27] Liu JL. Carbamazepine treatment alters the amino acids metabolomics profile and the activity of carboxylesterase (CES). Latin American Journal of Pharmacy. 2017; 36: 1279–1283.
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