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Use of Flumazenil in the Treatment of Drug Overdose

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Use of Flumazenil in the Treatment of Drug Overdose Critical Care Medicine Issue: Volume 24(2), February 1996, pp 199-206 Copyright: © Williams & Wilkins 1996. All Rights Reserved. Publication Type: [Clinical Investigation] ISSN: 0090-3493 Accession: 00003246-199602000-00004 [Clinical Investigation] Use of flumazenil in the treatment of drug overdose: A double-blind and open clinical study in 110 patients Weinbroum, Avi MD; Rudick, Valeri MD; Sorkine, Patrick MD; Nevo, Ygal MD; Halpern, Pinchas MD; Geller, Eran MD; Niv, David MD Author Information From the Departments of Anesthesiology and Critical Care Medicine (Drs. Weinbroum, Rudick, Sorkine, Nevo, and Niv), and Emergency Room (Dr. Halpern), Tel-Aviv- Elias Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel, and the Surgical Intensive Care Unit (Dr. Geller), Palo Alto Veterans Administration Medical Center and the Stanford University School of Medicine, Palo Alto, CA. This study was supported, in part, by institutional departmental funds. Address requests for reprints to: Avi Weinbroum, MD, Department of Anesthesiology and Critical Care Medicine, Tel-Aviv-Elias Sourasky Medical Center, 6 Weizman Street, Tel-Aviv 64239, Israel. Abstract Objectives: To assess the efficacy, usefulness, safety, and dosages of flumazenil required when flumazenil is used in the diagnosis of benzodiazepine-induced coma (vs. other drug-induced coma), and to reverse or prevent the recurrence of unconsciousness. Design: A two-phase study: a controlled, randomized, doubleblind study followed by a prospective, open study. Setting: An 800-bed, teaching, university-affiliated hospital. Patients: Unconscious patients (n equals 110) suspected of benzodiazepine overdose, graded 2 to 4 on the Matthew and Lawson coma scale, were treated with flumazenil, the specific benzodiazepine receptor antagonist. The first 31 patients were studied in a double-blind fashion, while the rest of the patients were given flumazenil according to an open protocol. Interventions: All patients received supplemental oxygen; endotracheal intubation was performed, and synchronized intermittent mandatory ventilation was initiated whenever it was deemed necessary. A peripheral intravenous cannula was inserted, as were indwelling arterial and urinary bladder catheters. Blood pressure, electrocardiogram, respiratory rate, end-tidal CO2, and core temperature were continuously monitored. The first 31 double-blind patients received either intravenous flumazenil (to a maximum of 1 mg) or saline, while the rest of the patients were given flumazenil until either regaining consciousness or a maximum of 2.5 mg was injected. Patients remaining unconscious among double-blind patients or those patients relapsing into coma after the first dose were later treated in the open phase of the study. Treatment continued by boluses or infusion as long as efficacious. Measurements and Main Results: Fourteen of 17 double-blind, flumazenil-treated patients woke after a mean of 0.8 plus minus 0.3 (SD) mg vs. one of 14 placebo patients (p less than .001). Seventy-five percent of the aggregated controlled and uncontrolled patients awoke from coma scores of 3.1 plus minus 0.6 to 0.4 plus minus 0.5 (p less than .01) after the injection of 0.7 plus minus 0.3 mg of flumazenil. These patients had high benzodiazepine serum blood concentrations. Twenty-five percent of the patients did not regain consciousness. These patients had very high serum concentrations of nonbenzodiazepine drugs. Sixty percent of the responders who had primarily ingested benzodiazepines remained awake for 72 plus minus 37 mins after flumazenil administration; 40% relapsed into coma after 18 plus minus 7 mins and various central nervous system depressant drugs were detected in their blood in addition to benzodiazepines. Seventy-one percent of the patients had ingested tricyclic antidepressants. Seventy-eight percent of the responders were continually and efficaciously treated for less than equals 8 days. Fourteen (25%) of the intubated patients were extubated safely while 12 patients, who had shown increased respiratory insufficiency, resumed satisfactory respiration after flumazenil injection. Five cases of transient increase in blood pressure and heart rate were encountered. There were 27 mildly unpleasant ``waking'' episodes, such as anxiety, restlessness, and aggression, but no patient had benzodiazepine withdrawal signs, convulsions, or dysrhythmia, most noticeably absent in tricyclic antidepressant- intoxicated patients. Conclusions: Flumazenil is a valid diagnostic tool for distinguishing pure benzodiazepine from mixed-drug intoxication or nondrug-induced coma. Flumazenil is effective in preventing recurrence of benzodiazepine-induced coma. Respiratory insufficiency is reversed after its administration. Flumazenil is safe when administered cautiously, even in patients with coma caused by a mixed overdose of benzodiazepine plus tricyclic antidepressants. (Crit Care Med 1996; 24:199-206) KEY WORDS: coma; overdose; intoxication, drug; benzodiazepines; barbiturates; flumazenil; tricyclic antidepressive agents Since their discovery in the early 1960s, the use of benzodiazepines has seen an enormous expansion world- wide [1-3]. Their anxiolytic, sedative, hypnotic, and anticonvulsant properties have led to frequent and sometimes inappropriate use. In the early 1980s, benzodiazepines were reported to be implicated in 40% to 60% of all suicide attempts [4-7], while the use of the potent benzodiazepine, flunitrazepam, has recently been reported to be popular among youths around the globe. Pure benzodiazepine overdoses are usually not fatal [8-10]. However, the newer, short-acting, but potent derivatives (e.g., flunitrazepam, triazolam) may greatly increase the frequency of complications [11-13], especially when benzodiazepines are combined with other central nervous system- depressant drugs [13-15], or when aged or debilitated patients are involved [16,17]. Flumazenil (Anexate Registered Trademark in Europe, Romazicon Registered Trademark in the United States, Hoffmann-La Roche, Basel, Switzerland), a specific competitive central benzodiazepine receptor antagonist, has been increasingly used during the last decade in the treatment of benzodiazepine overdoses [15,18,19]. In the present study, we prospectively evaluated the clinical efficacy of flumazenil, both as a diagnostic and as a therapeutic tool in drug-intoxicated patients. MATERIALS AND METHODS Patients and Grouping. The study group was comprised of 110 consecutive comatose patients, who were admitted to the emergency room or to the intensive care unit (ICU) between January 1, 1987 and January 1, 1992. Patients suspected of having ingested an overdose of drugs, based on history, physical examination, or information obtained from accompanying persons, were enrolled into the study. Patients less than 18 yrs of age, pregnant women, and individuals who had suspected brain trauma were excluded from the study. The study was approved by the Institutional Human Studies Committee and written informed consent was obtained from the next of kin. The study was conducted in two phases. The initial phase (31 patients) was performed in a randomized, controlled, double-blind fashion. The remaining 79 consecutive patients were studied in an open-design protocol. The change to the open study was prompted by the efficacy of flumazenil in reversing coma due to benzodiazepine overdose in the first double-blind phase, making it unethical in the authors' view to withhold or delay the administration of the drug from such patients. On arrival to the emergency room or ICU, patients received supplemental oxygen by mask if they were breathing spontaneously. Endotracheal intubation was performed whenever deemed necessary, and synchronized intermittent mandatory ventilation was initiated as required. Each patient was connected to an electrocardiogram monitor. A peripheral intravenous cannula was inserted, through which a solution of 5% dextrose in 0.45% sodium chloride was infused. Indwelling arterial and urinary bladder catheters were also introduced in all patients. A central venous catheter was inserted and vasoactive drugs (e.g., dopamine, ephedrine) were administered whenever blood pressure was below normal despite adequate fluid load, or when urine output was less than 0.5 mL/kg/min. Blood pressure, heart rate, respiratory rate, and end-tidal CO2, as well as core temperature, were continuously recorded on paper (Cardiocap Registered Trademark, Datex Corporation, Helsinki, Finland). Whenever it was available, the patients were monitored by a two-channel, computerized, online spectral analysis electroencephalogram, displaying left and right hemispheric electrical activity (Cerebro Trac 2500 Trademark, SRD, Shorashim, Israel). Depth of coma was graded according to the Matthew and Lawson scale [20]: 0 equals patient fully conscious; 1 equals patient drowsy but reawakens to verbal commands; 2 equals asleep, awakens to skin stimulation; 3 equals asleep, reactive to mild painful stimulation; and 4 equals patient comatose, does not react to maximal painful stimulation. Patients with a coma grade of 0 to 1 were not admitted into the study. Hemodynamic and respiratory variables were measured upon the individual's entry into the trial and at 5, 10, 15, 30, 45, 60, and 90 mins later, as well as hourly after the start of the study for as long as treatment continued. All patients underwent gastric lavage with tap water through a nasogastric tube, which was introduced only when
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