(1384) Flumazenil: The Kiss of Life?

Introduction: Delirium is prevalent in the ICU and has been identified as an independent predictor of mortality. ICU patients face multiple precipitating risk factors for delirium, including benzodiazepine therapy. A novel approach involves identifying persistent hypoactive delirium and utilizing flumazenil, a competitive antagonist for the benzodiazepine binding site, for reversal.

Description: A 35-year-old man with a history of HIV-AIDS, with a viral load of 166 copies/mL and CD4 count of 10 cells/mm3, and recurrent opportunistic infections noncompliant with anti-retroviral therapy presented after a cardiac arrest at home with eventual return of spontaneous circulation (ROSC) after forty minutes of CPR. In the ICU, he was initially managed with fentanyl, midazolam, and dexmedetomidine infusion. His ICU course was complicated by episodes of ventricular tachycardia, aspiration pneumonia treated with antibiotics, and oliguric acute kidney injury requiring dialysis. CT brain showed no intracranial abnormalities, and his hemodynamic status improved as his sedatives were gradually weaned and stopped within 48 hours. However, he remained unresponsive with no neurological reflexes. An MRI brain revealed no abnormalities, and lumbar puncture ruled out infections with negative cultures and viral PCR. Empirical treatment with ceftriaxone, vancomycin, and acyclovir for possible meningitis was initiated. Continuous electroencephalogram monitoring indicated diffuse cerebral slowing suggestive of encephalopathy, but no epileptiform activity was observed. After 8 days without sedation, there was no neurological improvement. Subsequently, the patient was started on Flumazenil 0.5mg bolus, followed by 0.2mg hourly, which resulted in significant improvement in his sensorium. After 48 hours, he was successfully extubated.

Discussion: In this case, despite being off all sedatives for 8 days and ruling out other potential causes of encephalopathy, the patient remained unresponsive. Benzodiazepine overdose was excluded as 8 days were sufficient for the short acting drug to be metabolized. The use of Flumazenil in managing hypoactive delirium associated with benzodiazepine exposure has recently gained recognition, but further studies are needed to establish the optimal dosage and administration approach.