Midazolam-Induced Hyperactivity
Treated with Flumazenil Volume 4 - Issue 3
Potru S1, Joseph A2 and Rajendram R3,4
1Jackson Memorial Hospital, University of Miami, USA
2Department of Anaesthesia, Changi General Hospital, Singapore
3Department of Medicine, King Abdulaziz Medical City, Saudi Arabia
4Joint Appointment Assistant Professor of Medicine, College of Medicine, King Saud bin Abdulaziz University of Health Sciences, Saudi
Arabia
Received: February 06, 2020; Published: February 18, 2020
Corresponding author: Rajkumar Rajendram AKC BSc (Hons) MBBS (Dist) MRCP (UK) EDIC FRCP Edin FRCP Lond, Department of
Medicine, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
Benzodiazepines are characteristically anxiolytic, amnestic, and sedative. However, paradoxical reactions may cause agitation
or aggression. We report a case in which a postoperative paradoxical reaction to midazolam was successfully managed with
flumazenil (a benzodiazepine-receptor antagonist). Whilst the aetiology of benzodiazepine-induced hyperactivity remains unclear,
this report demonstrates that even small amounts of flumazenil is an effective treatment. Despite the risks associated with the use
of flumazemil we recommend its use for both diagnostic and therapeutic purposes.
Benzodiazepines are characteristically anxiolytic, amnestic, and
sedative. However, paradoxical reactions may result in restlessness,
agitation, or aggression. This case report describes successful
management of a postoperative paradoxical reaction to midazolam
with the benzodiazepine-receptor antagonist flumazenil.
68-year-old Caucasian male with prostate cancer presented
for elective robot-assisted laparoscopic prostatectomy. He also
had osteoarthritis, hypertension, hypercholesterolemia, obesity,
coronary artery disease (post coronary artery bypass graft)
and obstructive sleep apnoea (not requiring CPAP). His regular
medications included aspirin, atorvastatin, finasteride, losartan,
metoprolol, mometasone furoate, nitroglycerin, terazosin, and
meloxicam. He denied previous adverse drug reactions and had not
had any previous complications with general anaesthesia.
He was premedicated with midazolam (2 mg i.v.) and, notably,
was relaxed and drowsy thereafter. The patient was induced
without incident using fentanyl 200 mcg, propofol 250 mg and
vecuronium 10 mg. Anaesthesia was maintained with isoflurane,
remifentanil infusion and intermittent boluses of morphine (total
10 mg). Dexamethasone and diphenhydramine were administered
for prophylaxis against postoperative nausea and vomiting. The
prostatectomy was extremely difficult and was aborted after two
hours. Residual neuromuscular blockade was reversed, isoflurane
was stopped and the patient was extubated uneventfully.
Prior to transfer to the post-anaesthesia care unit (PACU), the
patient became agitated and aggressive. He insisted on using the
restroom to urinate despite having a urinary catheter in situ. He
pulled at the oxygen facemask and required manual restraint to
prevent self-harm from falling out of bed. After administration of 1
mg of midazolam the agitation increased. He struggled against the
restraints and continued to try to get out of bed, despite reassurance
that he had a catheter in his bladder. His vital signs remained
stable throughout this period. Ten minutes later another 1 mg of
midazolam was given and he appeared to settle, so transfer to the
PACU was initiated. En route he became more restless and struggled
against his physical restraints; so, another 1 mg of midazolam was given. On arrival in the PACU, the patient’s vital signs were all stable
(BP 147/83 mmHg, HR 75 beats per minute, SaO2 96%, RR 14
breaths per minute, T 36.4 oC) and there was no focal neurological
deficit but physical restraint was still required. Despite a further 1
mg of midazolam the patient continued to struggle.
Ultimately, flumazenil 0.5mg was given in divided doses to
reverse the effects of midazolam. Within three minutes the patient
calmed, stopped struggling, answered all questions appropriately
and asked for removal of the restraints. He subsequently denied
having any recollection of the preceding events.
The aetiology and mechanism of benzodiazepine-induced
paradoxical hyperactivity have yet to be elucidated, although a
central cholinergic mechanism has been suggested [1]. This report
and others [1] demonstrate even small amounts of flumazenil can
be effective in treating this. Despite the risks associated with the
use of flumazemil we recommend its use for both diagnostic and
therapeutic purposes.