Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website https://www.jocmr.org

Case Report

Volume 15, Number 3, March 2023, pages 174-180

Remimazolam as a Primary Agent for Brief Invasive and Noninvasive Procedures: A Case Series

Tables

Table 1. Summary of Patient Demographics and Preoperative Comorbid Conditions
 
Patient number and procedureDemographic data (age, gender, weight)Patient comorbid conditions
EGD: esophagogastroduodenoscopy; d-TGA: dextro-transposition of the great arteries; TEE: transesophageal echocardiogram; CT: computed tomography; AICD: automatic implantable cardioverter-defibrillator; BTT: Blalock-Thomas-Taussig.
1. EGD27, male, 62 kgCongenital heart disease including d-TGA status post Fontan procedure, hepatic cirrhosis, paroxysmal atrial flutter, amiodarone-induced hyperthyroidism, listed heart transplant candidate for failing Fontan physiology
2. Placement of pericardial drain14, female, 87.5 kgRecurrent idiopathic pericardial effusion, obesity
3. Cardioversion, TEE28, male, 117.8 kgTricuspid atresia status post Fontan procedure, atrial flutter, permanent pacemaker, obesity
4. CT imaging19, female, 47.3 kgOral-facial-digital syndrome, Dandy-Walker syndrome, cleft palate, partial epilepsy, global developmental delay, chronic lung disease, hydrocephalus with ventriculoperitoneal shunt, obstructive sleep apnea, bilateral sensorineural hearing loss, end-stage renal disease on hemodialysis, obesity
5. AICD placement27, male, 60 kgBecker’s muscular dystrophy, dilated cardiomyopathy, obstructive sleep apnea
6. Halo removal16, male, 64.1 kgPolytrauma secondary to motor vehicle accident with C2 fracture, left vertebral artery injury, traumatic brain injury, lumbar spine transverse process fractures, pelvic fracture
7. Cardioversion51, male, 71 kgTetralogy of Fallot status post BTT shunt and repair, atrial flutter, severe pulmonary regurgitation and tricuspid regurgitation status post valve replacement, intra-atrial re-entrant tachycardia, complete heart block with dual chamber pacemaker/AICD

 

Table 2. Summary of Remimazolam Dosing, Procedure Times, and Outcomes
 
Patient number and procedureRemimazolam dosing (bolus and infusion)Anesthesia duration (minutes in OR)Procedure duration (min)Outcomes
EGD: esophagogastroduodenoscopy; LMA: laryngeal mask airway; SpO2: peripheral oxygen saturation; PACU: post anesthesia care unit; BIS: bispectral index; BP: blood pressure; TEE: transesophageal echocardiogram; RR: respiratory rate; CT: computed tomography; AICD: automatic implantable cardioverter-defibrillator; BiPAP: bilevel positive airway pressure; CTICU: cardiothoracic intensive care unit; NC: nasal cannula; OR: operating room.
1. EGDBolus dose: 2.5 mg41 min4 minAdjunct medications: fentanyl 100 µg, etomidate 10 mg for LMA placement
Infusion: 10 µg/kg/min; titrated up to 30 µg/kg/minPreoperative SpO2 85% on room air
Period of apnea associated with oxygen desaturation down to SpO2 70%; resolved with supplemental oxygen via mask and subsequent LMA placement
Time from PACU arrival to ready for discharge: 20 min
2. Placement of pericardial drainBolus dose: 5 mg78 min29 minAdjunct medication: fentanyl 100 µg
Infusion: 30 µg/kg/min; titrated down to 10 - 15 µg/kg/min using the BISNative airway maintained with NC
Oxygen desaturation to 89%; resolved with increased O2 via NC
Lowest BP 72/55 mm Hg; resolved with decrease in remimazolam infusion rate
Time from PACU arrival to ready for discharge: 74 min
3. Cardioversion, TEEBolus dose: 5 mg52 min31 minAdjunct medication: fentanyl 100 µg
Infusion: 10 µg/kg/min; titrated up to 20 µg/kg/min. Brief pause of infusion and then restarted at 10 µg/kg/minRemimazolam infusion rate adjusted and paused based on the BIS number
Native airway maintained with NC
Preoperative SpO2 84-91% on room air
Oxygen desaturation down to 76%; resolved with supplemental O2 flow via NC
Time from PACU arrival to ready for discharge: 38 min
4. CT imagingTotal of 4 bolus doses of 2.5 mg throughout the procedure. No infusion.37 min47 minNo adjunct medications
Native airway maintained with NC
Intraoperative hypotension, lowest BP 79/44 at the end of the case; resolved without intervention
Periods of bradypnea RR 5 - 6 and one period of apnea. All episodes resolved without intervention or with temporary increase in O2 flow via NC.
Time from PACU arrival to ready for discharge: 11 min
5. AICD placementInitial bolus: 3 mg133 min107 minAdjunct medication: fentanyl 100 µg, dexmedetomidine 16 µg
Infusion started at 20 µg/kg/minPatient on BiPAP preoperatively, continued throughout the case
Second bolus 3 mgMilrinone 0.25 µg/kg/min preoperatively, continued throughout the case
Infusion decreased to 15 µg/kg/min, increased back to 20 µg/kg/min, decreased to 10 µg/kg/minPreoperative BP range 77/45 - 87/52 mm Hg
Two episodes of intraoperative hypotension. The first coincided with remimazolam infusion increase to 20 µg/kg/min and dexmedetomidine 8 µg bolus dose and resolved with surgical stimulation. The second episode of hypotension resolved without intervention.
Time from PACU arrival to planned discharge back to CTICU: 19 min
6. Halo removalInitial bolus: 5 mg followed by 3 subsequent boluses of 2.5 mg38 min21 minNitrous oxide for placement of intravenous cannula
Adjunct medication: fentanyl 50 µg
Native airway maintained with NC
No intraoperative adverse effects
Time from PACU arrival to ready for discharge: 21 min
7. CardioversionBolus 3.5 mg50 mins19 minAdjunct medication: fentanyl 100 µg
Infusion: 20 µg/kg/min, titrated down to 15 µg/kg/min then to 10 µg/kg/minNative airway maintained with NC
Six intermittent periods of apnea/bradypnea. All episodes resolved with decrease in remimazolam infusion rate and supplemental O2 via NC.
Time from PACU arrival to ready for discharge: 4 min