Ability to Reverse Deeper Levels of Unintended Sedation

Abstract

During gastrointestinal endoscopy, patients may reach a level of sedation that is deeper (i.e. deep sedation) than intended to be (i.e. moderate sedation). In such cases the ability to restore respiratory and cardiovascular function is critical. Supportive measures should be combined with administration of specific pharmacologic antagonists in cases of imminent ventilatory failure. Naloxone rapidly reverses sedation and respiratory depression due to previously administered narcotics, whereas flumazenil overturns the effects of midazolam on the central nervous system. Both agents are administered intravenously in repeated doses according to the patient’s response. Caution, however, is required, as the half-lives of these reversal agents are shorter than those of the respective agonists and re-sedation may occur. Acute withdrawal syndromes may take place in chronic users of opiates or benzodiazepine. Product monographs along with administration protocols may be demonstrated as a wall chart, to ascertain their safe and effective use in endoscopy units.

Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care

“…According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE), “sedation may be defined as a drug-induced depression in the level of consciousness” 17 . Sedation and analgesia for GIE aim to relieve the patient’s anxiety, fear and pain, minimize discomfort, improve the outcome of the examination, and diminish the patient’s recollection of the event 16 17 22 23 24 25 26 . Although their use improves tolerance and acceptance of the examination, they increase the cost and are responsible for about 50 % of all GIE complications 20 22 27 28 .…”

“…Sedation and analgesia represent a continuum ranging from minimal (anxiolysis) or moderate to deep sedation and general anesthesia 16 17 24 25 29 . Moderate sedation is recommended as it provides adequate anxiolysis, pain control, and amnesia, being safer than deep sedation 25 30 . There is a clear difference in the need for sedation related to cultural factors in different countries.…”

Quantitative pharmacological analyses of the interaction between flumazenil and midazolam in monkeys discriminating midazolam: Determination of the functional half life of flumazenil

“…Other drugs act at these binding sites with little or no positive efficacy and can competitively antagonize the behavioral effects of benzodiazepines, thereby providing an important clinical advantage. Only one drug, flumazenil, is currently approved to reverse the effects of benzodiazepines; however, its short duration of action can lead to the reemergence of effects of long-acting benzodiazepines as flumazenil is eliminated (Morse and Bamias, 2010). …”

Lorazepam-induced prolonged apnea after ECT-induced prolonged seizure

“…[45]Whether her subsequent hospital course represented a post-ictal confusional state or transient drug-induced encephalopathy is a moot point; the take-home message, however, is that patients who require medical termination of a prolonged seizure in the context of ECT may experience prolonged apnea subsequently, and clinicians should be prepared for this contingency. Parenteral flumazenil may help reverse benzodiazepine-induced sedation and respiratory depression,[6] but there is some controversy over its efficacy in the latter regard. [7] In any case, the drug is presently unavailable in India.…”