Precipitation of remimazolam in coadministration with Plasma-Lyte 148: two case reports

Sung, Jeong Min; Kim, Kyu Nam; Jun, Young Eun

doi:10.1016/j.bjane.2022.10.003

Cited by 2 publications

(1 citation statement)

References 8 publications

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“…An incompatibility with Ringer’s lactate and Ringer’s acetate Solution has been reported by Sasaki et al in 2021 [ 9 ], leading to a complete occlusion of the used iv line during co-administration. Sung et al presented two case reports describing similar incompatibility with plasma-lyte 148 solution [ 10 ]. Decreased solubility of remimazolam in pH > 4 was assumed as one of the possible reasons for the precipitation [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

Incompatibility of the short-acting benzodiazepine remimazolam with common perioperative medication

Hofmann,

Bachmann,

Brümmer

et al. 2024

BMC Anesthesiol

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Background Remimazolam is a relatively new benzodiazepine with growing use in procedural sedation and general anaesthesia. Initiated by case reports, the physical incompatibility of remimazolam with ringer’s acetated and ringer’s lactated solution has been reported. More recently, remifentanil, fentanyl, rocuronium, vecuronium, dexmedetomidine, and midazolam, have been investigated and suggested safe for coadministration with remimazolam. Apart from case reports, incompatibility for other frequently used drugs remains unknown. Methods Sixty-five drugs and intravenous fluids were tested for possible precipitation with remimazolam in a simulated y-site administration. Equal volumes of the test drug were injected into the remimazolam solution, examined and photo documented at 1, 15, 30 and 60 min after mixture. Examination was taken by two independent investigators. pH was measured before, and 60 min after mixing the drugs. Results Seventeen (26.15%) drugs or fluids showed precipitation, 47 (72.31%) did not show any sign of interaction. Propofol could not be assessed, because of the turbidity of the substance itself. Precipitation occurred immediately and remained stable in all timestamps. The incompatible drug-remimazolam-mixtures had a median pH of 7.15 (6.67, 8.01), the non-precipitating mixtures a median pH of 4.75 (3.8, 5.6). The pH-values of both groups were significantly different (Mann-Whitney-U-test; p < .00001). There is an increasing risk for precipitation with more basic baseline pH-levels of the tested drug. No interaction was seen in baseline pH below 5. Conclusions Remimazolam (Byfavo®) is incompatible with ampicillin/ sulbactam, calcium gluconate, clindamycin, dexamethasone, dimenhydrinate, an 148mval/l electrolyte - glucose 1% solution (E148G1®), furosemide, a 4% gelatine volume expander (gelafundin®), heparin sodium, insulin, meropenem, sodium bicarbonate 8.4%, prednisolone, the crystalloid infusions jonosteril® and sterofundin®, thiopental and tranexamic acid. The results strongly affirm remimazolam’s safety requirements: A separate line for remimazolam and an approved compatible baseline infusion is mandatory and an alternative way to administer bolus medication is required.

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Section: Introductionmentioning

confidence: 99%

Incompatibility of the short-acting benzodiazepine remimazolam with common perioperative medication

Hofmann,

Bachmann,

Brümmer

et al. 2024

BMC Anesthesiol

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Remimazolam – current status, opportunities and challenges

Sneyd

2023

APS

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The short acting benzodiazepine remimazolam has been well characterised for use during procedural sedation. Onset of hypnotic effect is swifter than midazolam and recovery is faster with a period of antegrade amnesia. Haemodynamic changes associated with remimazolam sedation are modest and there is no pain on injection. General anaesthesia may be induced and maintained by infusion of remimazolam in combination with a suitable opioid. Hypotension is less frequent than when propofol is used. In addition, remimazolam may be a suitable alternative to propofol or etomidate for inducing anaesthesia in haemodynamically compromised patients prior to maintenance with a volatile agent. A small proportion of patients are slow to recover consciousness after total intravenous anaesthesia (TIVA) with remimazolam/opioid combinations. Preliminary experience suggests that flumazenil may be useful in this group however studies are required to define the appropriate dosage and timing for flumazenil administration. Future developments may include sedation and anaesthesia for infants and children as well as intensive care sedation for all age groups. These indications require demonstration in well designed clinical trials. Graphical Abstract

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Precipitation of remimazolam in coadministration with Plasma-Lyte 148: two case reports

Cited by 2 publications

References 8 publications

Incompatibility of the short-acting benzodiazepine remimazolam with common perioperative medication

Incompatibility of the short-acting benzodiazepine remimazolam with common perioperative medication

Remimazolam – current status, opportunities and challenges

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