Flumazenil (Romazicon)
Anesthesia Implications
Classification: Benzodiazepine Antagonist
Therapeutic Effects: Benzodiazepine Reversal
Contraindications
Reversal of benzodiazepines may provoke convulsions/seizures in:
Patients exhibiting signs of tricyclic antidepressants overdose
Benzodiazepine dependence
Alcohol dependence
Mixed overdose
Head injuries or altered cerebral blood flow
Benzodiazepine reversal can provoke panic attacks in those with panic disorders
Primary Considerations
Anesthesia reversal – administration of 0.3 mg at the end of surgery (in patients that did NOT receive benzodiazepines) has resulted in earlier emergence and higher BIS values. This suggest possible antagonism of inhaled anesthetics or even restorative affects of the drug itself.
Expiration – Flumazenil is only stable for 24 hours if drawn into a syringe or mixed with LR, NS, or D5W
Seizure risk – reversal of benzodiazepines can result in seizures, especially in those who use benzodiazepines to manage seizures. Those receiving Romazicon should be monitored for at least 2 hours.
Overdose/Toxicity – overdose of flumazenil is extremely rare and wouldn’t be expected in a patient that does NOT have a benzodiazepine dependence. Toxicity would most likely manifest as seizures, dysrhythmias, and hypotension
IV push dose
Adult:
Initial dose: 0.2 mg IV over 15 seconds
Followed by: 0.2 mg IV every 1 minute
If sedation reoccurs: 0.2 mg IV may be given at 20-minute intervals
MAX cumulative: 1.0 mg
Pediatric greater than or equal to 1 year old:
Initial dose: 0.01 mg/kg (MAX 0.2 mg) given over 15 seconds
Followed by: Same dose every 1 minute for up to 4 additional doses. Reassess sedation before each dose.
MAX cumulative: The LOWEST of 1 mg or 0.05 mg/kg
Method of Action
Flumazenil is a benzodiazepine antagonist. However, flumazenil also works to reverse non-benzodiazepine substances that interact with GABA/benzodiazepine receptor complex. For this reason, there are several non-FDA approved uses (eg. baclofen drug reversal, alcohol withdrawal syndrome treatment, hepatic encephalopathy, cannabis toxicity, etc.)
Shoar. Flumazenil. StatPearls. 2020 web link
Kim. Effect of flumazenil on recovery from anesthesia and the bispectral index after sevoflurane/fentanyl general anesthesia in unpremedicated patients. 2012 web link
