Successful reversal of remimazolam anesthesia in a "cannot intubate, can ventilate" situation: a case report

Abstract

Background: Compared to other intravenous anesthetics, availability of a specific antagonist flumazenil is a clear advantage of remimazolam. We report a patient who could be rapidly woken up when laryngoscopy and tracheal intubation were unexpectedly difficult.

Case presentation: A 62-year-old man was scheduled to have resection of a small gingival tumor. Preoperative airway examination was unremarkable except for an omega-shaped epiglottis. Anesthesia was induced with remifentanil/remimazolam infusion and rocuronium. A small omega-shaped edematous epiglottis precluded identification of glottis. Consciousness and spontaneous ventilation were rapidly restored after administration of flumazenil and sugammadex. Tracheostomy was done under local anesthesia while the patient breathed spontaneously.

Conclusions: Remimazolam can be a reasonable induction agent when there are concerns regarding airway management. Avoiding repeated airway manipulations is extremely important to prevent deterioration into a "cannot intubate, cannot ventilate (CICV)" emergency.

Keywords: CICV; Difficult laryngoscopy; Epiglottis; Flumazenil; Remimazolam.

Fig. 1

A computed tomography done 2 weeks before surgery. An omega-shaped epiglottis shown in a CT scan

Fig. 2

Fiberoptic examination finding at the outpatient clinic. An omega-shaped epiglottis was detected by fiberoptic examination, but the vocal cords were not visible