Prolonged infusion of flumazenil for the reversal of sedation from chlordiazepoxide: a case report

Abstract

A continuous infusion of flumazenil may be needed to mitigate prolonged sedation from benzodiazepines. Some benzodiazepines have extended durations of action. We describe a cirrhotic patient who was on an infusion of flumazenil for 37 days due to prolonged sedation from chlordiazepoxide. An 80-year-old man with alcohol use disorder and cirrhosis presented to the emergency department for abdominal distention and was admitted for management of ascites. On hospital day (HD) 2, he developed alcohol withdrawal, for which he received 350 mg of chlordiazepoxide over 48 h. Without receiving further sedatives, the patient remained deeply sedated. A bolus dose of flumazenil on HD 18 improved his mental status, allowing him to follow commands. A flumazenil infusion was started on HD 18. Serum chlordiazepoxide and nordiazepam concentrations were 230 ng/mL and 265 ng/mL, respectively, on hospital day 21, despite no additional doses since HD 4. The infusion was stopped 37 days after initiation (HD 55) and the patient was discharged on HD 76 to subacute rehabilitation. Patients with cirrhosis may develop prolonged sedation from chlordiazepoxide. This patient had detectable metabolites of chlordiazepoxide weeks after his last dose, which was associated with prolonged sedation managed with flumazenil infusion.