WARNING - ANECDOTAL EVIDENCE ALERT!
Several years ago, whilst doing anaesthetics in a DGH south of Yorkshire
(missionary work), an A&E SHO zonked a patient with midazolam for a
dislocated shoulder then reversed him after relocation with flumazanil as
she had been told that this was routine practice. As he was elderly and it
was late evening, he was admitted for observation. He was placed on a
nightingale orthopaedic ward in the 'bed of doom' at the end (usually
reserved for ultra-fit or imminently croaking) and when his next lot of obs
were due, was found deceased from a respiratory arrest. It was decided that
he had re-sedated after the flumazanil had worn off with midazolam still on
board.
The main problem is when people use midazolam who are not familiar with it.
The patient does not have to be 'asleep' for it to be effective. I never use
flumazanil because the time that the patient snoozes after release of their
painful stimulus is usually quite short so long as they have not been
completely flattened beforehand. You can achieve adequate relaxation (with
protection of airway reflexes) and more than adequate amnesia whilst you
relocate their joint at the same time that they profess their undying love
to you and promise you a crate of ale for your troubles (damn that
amnesia!).
Having said that, I rarely use midazolam for shoulders, as that is usually
evidence of failure at correctly trying to relocate them (in those with no
associated fracture). But don't get me started on that one......!
Andy
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of rmcglone
Sent: 15 October 2001 18:38
To: [log in to unmask]
Subject: Re: Flumazenil, Sedation and Fits
The "reference" for not using it routinely is cost. However, I do use it if
clinically indicated or if we are short of nursing staff to recover the
patient. I've never had a problem with patients re-sedating after a bolus of
midazolam reversed by flumazenil.
Ray McGlone
A&E Lancaster
----- Original Message -----
From: <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, October 15, 2001 2:43 PM
Subject: Flumazenil, Sedation and Fits
> Recently while reducing bilateral shoulder 'erecta' dislocations (don't
ask)
> under a bit of Midazolam and opiate I was challenged by a colleague as why
I
> was not wanting to use Flumazenil to simply reverse the Midaz as soon as
the
> procedure was over.
> I gave the standard 'Fit Risk' answer but was then asked to prove it....
> So trying to be the good evidence based practitioner i went to Medline and
searched
> around the subject. To my surprise their are papers that not only document
Flumazenil
> causing fits, usually in relation to mixed ODs, but several advocating its
USE
> as an ANTI-epileptic ( Oral flumazenil in the treatment of epilepsy.
Annals
> of Pharmacotherapy.29(5):530-1,1995May Reisner-Keller LA et al)
> So does anyone have a reference/evidence for why we don't use it for
simply
> waking uncomplicated sedated patients up?
> Cheers
> Peter A Cutting
>
>
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