Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2017.12.008
Brazilian Journal of Anesthesiology
Scientific Article

The use of flumazenil for benzodiazepine associated respiratory depression in postanesthesia recovery: risks and outcomes

O uso de flumazenil para depressão respiratória associada ao benzodiazepínico na recuperação pós-anestésica: riscos e resultados

Troy G. Seelhammer; Eric M. DeGraff; Travis J. Behrens; Justin C. Robinson; Kristen L. Selleck; Darrell R. Schroeder; Juraj Sprung; Toby N. Weingarten

Downloads: 0
Views: 659

Abstract

Abstract Background and objectives The primary aim was to determine risk factors for flumazenil administration during postanesthesia recovery. A secondary aim was to describe outcomes among patients who received flumazenil. Methods Patients admitted to the postanesthesia recovery room at a large, academic, tertiary care facility after surgery under general anesthesia from January 1, 2010, to April 30, 2015, were identified and matched to 2 controls each, by age, sex, and surgical procedure. Flumazenil was administered in the recovery phase immediately after general anesthesia, according to the clinical judgment of the anesthesiologist. Demographic, procedural, and outcome data were extracted from the electronic health record. Conditional logistic regression, accounting for the 1:2 matched-set case-control study designs, was used to assess characteristics associated with flumazenil use. Results The incidence of flumazenil administration in the postanesthesia care unit was 9.9 per 10,000 (95% CI, 8.4-11.6) general anesthetics. History of obstructive sleep apnea (Odds Ratio [OR] = 2.27; 95% CI 1.02-5.09), longer anesthesia (OR = 1.13; 95% CI 1.03-1.24 per 30 minutes), use of total intravenous anesthesia (OR = 6.09; 95% CI 2.60-14.25), and use of benzodiazepines (OR = 8.17; 95% CI 3.71-17.99) were associated with risk for flumazenil administration. Among patients who received midazolam, cases treated with flumazenil received a higher median (interquartile range) dose than controls: 3.5 mg (2.0-4.0 mg) vs. 2.0 mg (2.0-2.0 mg), respectively (p < 0.001). Flumazenil use was correlated with a higher rate of unanticipated noninvasive positive pressure ventilation, longer postanesthesia care unit stay, and increased rate of intensive care unit admissions. Conclusions Patients who required flumazenil postoperatively had received a higher dosage of benzodiazepines and utilized more postoperative health care resources. More conservative perioperative use of benzodiazepines may improve postoperative recovery and use of health care resources.

Keywords

Flumazenil, Benzodiazepine, Postanesthesia care unit, Postoperative complications

Resumo

Resumo Justificativa e objetivos Determinar os fatores de risco da administração de flumazenil durante a recuperação pós-anestésica e descrever os desfechos entre os pacientes que receberam flumazenil. Métodos Os pacientes admitidos em sala de recuperação pós-anestésica de um grande centro universitário em setor terciário de cuidados pós-cirurgia sob anestesia geral entre 1° de janeiro de 2010 e 30 de abril de 2015 foram identificados e pareados com dois controles cada por idade, sexo e procedimento cirúrgico. Flumazenil foi administrado na fase de recuperação imediatamente após a anestesia geral, de acordo com a avaliação clínica do anestesiologista. Os dados demográficos, dos procedimentos e dos desfechos foram extraídos do registro eletrônico de saúde. A regressão logística condicional para os desenhos do estudo de caso-controle pareado em 1:2 foi usada para avaliar as características associadas ao uso de flumazenil. Resultados A incidência da administração de flumazenil em sala de recuperação pós-anestésica foi de 9,9 por 10.000 (95% IC: 8,4-1,6) anestesias gerais. História da apneia obstrutiva do sono (razão de chances [OR] = 2,27; IC 95%: 1,02-5,09), anestesia de longa duração (OR = 1,13; IC 95%: 1,03-1,24 por 30 minutos), uso de anestesia intravenosa total (OR = 6,09; IC de 95%: 2,60-14,25) e uso de benzodiazepínicos (OR = 8,17; IC 95%: 3,71-17,99) foram associados a risco para a administração de flumazenil. Entre os pacientes que receberam midazolam, os casos tratados com flumazenil receberam uma dose mediana mais alta (intervalo interquartil) do que os controles: 3,5 mg (2,0-4,0 mg) vs. 2,0 mg (2,0-2,0 mg), respectivamente (p < 0,001). O uso de flumazenil foi correlacionado com uma taxa maior não prevista de ventilação não invasiva com pressão positiva, permanência mais longa em sala de recuperação pós-anestésica e aumento da taxa de admissões em unidade de terapia intensiva. Conclusão Os pacientes que precisaram de flumazenil no pós-operatório receberam uma dose maior de benzodiazepínicos e usaram mais recursos de cuidados da saúde no pós-operatório. O uso mais conservador de benzodiazepínicos no período perioperatório pode melhorar a recuperação e o uso de recursos de cuidados da saúde no pós-operatório.

Palavras-chave

Flumazenil, Benzodiazepínico, Sala de recuperação pós-anestésica, Complicações pós-operatórias

References

Mathus-Vliegen EM, de Jong L, Kos-Foekema HA. Significant and safe shortening of the recovery time after flumazenil-reversed midazolam sedation. Dig Dis Sci. 2014;59:1717-25.

Pregler JL, Mok MS, Steen SN. Effectiveness of flumazenil on return of cognitive functions after a general anesthetic. Acta Anaesthesiol Sin. 1994;32:153-8.

Karakosta A, Andreotti B, Chapsa C. Flumazenil expedites recovery from sevoflurane/remifentanil anaesthesia when administered to healthy unpremedicated patients. Eur J Anaesthesiol. 2010;27:955-9.

Liang P, Zhou C, Li KY. Effect of flumazenil on sevoflurane requirements for minimum alveolar anesthetic concentration-awake and recovery status. Int J Clin Exp Med. 2014;15:673-9.

Penninga EI, Graudal N, Ladekarl MB. Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication: a systematic review with meta-analyses of randomised trials. Basic Clin Pharmacol Toxicol. 2016;118:37-44.

Mora CT, Torjman M, White PF. Sedative and ventilatory effects of midazolam infusion: effect of flumazenil reversal. Can J Anaesth. 1995;42:677-84.

Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970;49:924-34.

Gali B, Whalen FX, Schroeder DR. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology. 2009;110:869-77.

Gali B, Whalen Jr. FX, Gay PC. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med. 2007;15:582-8.

Flemons WW. Clinical practice: obstructive sleep apnea. N Engl J Med. 2002;15:498-504.

Clinical Practice Guideline No. 9. 1994.

Principles of analgesic use in the treatment of acute pain and cancer pain. 1999:45.

Oderda GM, Said Q, Evans RS. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007;41:400-6.

Weingarten TN, Chong EY, Schroeder DR. Predictors and outcomes following naloxone administration during Phase I anesthesia recovery. J Anesth. 2016;30:116-22.

Grant MC, Kim J, Page AJ. The effect of intravenous midazolam on postoperative nausea and vomiting: a meta-analysis. Anesth Analg. 2016;122:656-63.

Ahn EJ, Kang H, Choi GJ. The effectiveness of midazolam for preventing postoperative nausea and vomiting: a systematic review and meta-analysis. Anesth Analg. 2016;122:664-76.

Fredman B, Lahav M, Zohar E. The effect of midazolam premedication on mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. Anesth Analg. 1999;89:1161-6.

Richardson MG, Wu CL, Hussain A. Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization. Anesth Analg. 1997;85:301-5.

Weingarten TN, Bergan TS, Narr BJ. Effects of changes in intraoperative management on recovery from anesthesia: a review of practice improvement initiative. BMC Anesthesiol. 2015;15:54.

Weingarten TN, Jacob AK, Njathi CW. Multimodal analgesic protocol and postanesthesia respiratory depression during phase I recovery after total joint arthroplasty. Reg Anesth Pain Med. 2015;40:330-6.

Errando CL, Sigl JC, Robles M. Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. Br J Anaesth. 2008;101:178-85.

5dcc2b6a0e88257a78bf58f1 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections