Flumazenil Reversal of Remimazolam Sedation During Posterior Spinal Fusion in Two Adolescents

Remimazolam is a novel, ester-metabolized benzodiazepine, which received approval by the United States Food and Drug Administration (FDA) for procedural sedation in adults in 2020. Since then, its clinical uses have expanded to intraoperative use both as the primary agent or as an adjunct to general anesthesia. Although its novel route of metabolism through tissue esterases generally results in a rapid resolution of its effects when the infusion is discontinued; in certain clinical scenarios, reversal of its clinical effects may be achieved with flumazenil. We present two clinical cases outlining the use of flumazenil to reverse the effects of remimazolam, which was used as an adjunct to total intravenous anesthesia during posterior spinal fusion (PSF) in two adolescent patients. In our first case, to facilitate an intraoperative wake-up test, the clinical effects of remimazolam were reversed with flumazenil. In the second case, flumazenil reversed the residual effects of remimazolam to speed awakening and tracheal extubation at the completion of the surgical procedure. The clinical uses of remimazolam are reviewed, experience with its use as an adjunct during PSF is discussed, and the clinical role of reversal with flumazenil is presented.