Delayed emergence after general anesthesia using remimazolam for induction agent in laparoscopic cholecystectomy: a case report

Abstract

Remimazolam’s ultrashort-acting properties, including reduced injection discomfort, minimal impact on respiratory and cardiovascular functions and rapid metabolism, have garnered significant attention in the field of anesthesia. However, despite its widespread acclaim, we encountered an unusual case in which a patient without hepatic or renal impairment experienced unexpected delays in regaining consciousness following a single intravenous induction dose of remimazolam. The patient, a 63-year-old undergoing laparoscopic cholecystectomy for gallbladder stones, had preoperative tests revealing atrial fibrillation and a reduced ejection fraction observed in an echocardiogram. Anesthesia induction included the administration of remimazolam (0.3 mg/kg), sufentanil and rocuronium. The surgery proceeded uneventfully and was maintained with desflurane and sufentanil. However, after the surgery, the patient experienced delayed emergence from anesthesia. Opioid overdose was ruled out, and we suspected a metabolic delay associated with remimazolam. In response to this suspicion, we administered flumazenil, which promptly restored consciousness and normal breathing. Subsequent post-anesthetic observation revealed no complications, and the patient was discharged two days after surgery. This case highlights the significant delayed emergence phenomenon linked to remimazolam, even when administered as a bolus. Instances of delayed emergence following remimazolam administration underscore the complexities in anesthesia responses, emphasizing the importance of vigilant clinical monitoring and the need for ongoing research in this area.