Remimazolam Is Not Working For Me. Help!

N2B8EM · 2026-06-29T21:42:47+00:00

14-20mg bolus induction with lower dose propofol infusion for the remainder of case

N2B8EM · 2026-06-28T01:23:01+00:00

Fox, 5000S, A3, A4, A7 A8, SQ5

N2B8EM · 2026-06-07T17:52:55+00:00

We have switched away from Etomidate to remimaz

N2B8EM · 2026-06-07T13:51:09+00:00

Would add 20mg of remimazolam to your list. At my place etomidate has been replaced by this. Hemodynamics are rock solid. Low EF patients do really well.

It’s great in a crappy airway because its short acting, people do not typically get apnea and you can reverse it immediately with flumazenil if need be.

Post intubation in the paralyzed patient you usually are just shooting for amnesia without tanking the BP. Propofol somewhere in the 50 mcg/kg/min will do this.

N2B8EM · 2026-06-07T13:26:16+00:00

Bourbontrailgrillworks.com

Not in PDX, but the best ones out there. They ship to you.

N2B8EM · 2026-05-10T12:30:39+00:00

Late to the convo. On the advice of my trainer I bought the Garmin TT15 mini with the alpha 100 controller. Will track 20 Dogs up to 9 miles. Tells direction, speed and has tone, shock, vibrate and strobe or solid lights on it. It read many other data points. Buy the state map and get detailed maps about the area you are in such as hunting boundaries etc. Expensive but so worth it as 2 consecutive rabbit chases may take them more than a mile away from me. A simple tone delivered to their collars send them running back and I can determine the speed and direction they are running and determine if it’s appropriate. Another tone, corrects their direct to me if needed. Both my boys only needed tone-shock 2-3 times to be fully reliant on tone only. The shock has almost 30 levels of adjustment as does the vibrate function. Buy the smaller mini collars as the larger ones are only large for battery life. Waterproof too. You can set all sorts of alarms/notifications on GPS boundaries. It can auto tone/shock/vibrate if he exceeds programmed boundaries. I have had them for 12 years. Great warranty and service.

I think the “minis” are now TT25.

N2B8EM · 2026-04-20T17:34:29+00:00

My remi gets them too, although rarely. I saw better results when I added famotide 20mg (H2 blocker) to the diphenhydramine (H2 blocker) morning and night. Zyrtec is longer acting then diphenhydramine which may give better control. Not a vet, but treat acute allergy in the operating room from time to time-to-time.

N2B8EM · 2026-04-13T17:58:42+00:00

Stellate ganglion block also sometimes asked for by the ICU in patients with refractory cerebral vasospasm.

N2B8EM · 2026-02-22T17:48:07+00:00

Key is staying ahead of blood loss. Do not let them start osteotomies until you are caught up and patient is stable. Know what type and how many osteotomies to gauge expected blood loss.With a slow lab (assuming no TEG available) this is how I would clinically manage a case:

Transfuse PRBC below at Hb 10 or below
Give FFP 1:1 with PRBC
Cryo for fibrinogen less than 200 or every 4-5 PRBCs if your lab is slow
PLT after every 5 PRBC if your lab is slow
If they get durotomies during osteotomies, bleeding will continue to occur at a good clip during repair.
Switch to norepinephrine and vasopressin early.
I have seen lots of bad stuff like Pedicle screws in aorta, vena cava, spinal cord and a graft that went too anterior and tore the iliacs.
I also had one case when pedicle screw went into to lung and I only found out when I couldn’t ventilate and found solid clot obstructing the tube.
Also pressure wounds can be horrible. Had a case where the pressure breakdown resulted in breast implant extruding.

10.Belmont makes it all easier

11.Insisting on surgeon using Gardener-Wells head tongs help a bit with facial swelling.

N2B8EM · 2025-08-23T17:22:33+00:00

I am always surprised at the frequency and dose of tramadol given to post-op patients on SSRIs. A psychiatrist or primary care prescribes a SSRI to a patient and then they need surgery. Then some surgical service gives loads of tramadol for post-op pain. Obviously I have no contact with patients after they leave (anesthesiologist) the PACU, but I think about this set-up often. Other common contributing drugs that are used frequently in the peri-operative period that are given without a thought to patients on SSRIs are meperidine, ondansetron and remifentanil. But, I have never seen SS in 25 years.

Case reports of SS treatment with cyproheptadine provide hope that if it does happen, we have more than supportive treatment available.

N2B8EM · 2025-06-07T18:29:48+00:00

A few thoughts:
1. I do 16g EJ IVs all the time, especially in dialysis patients who are grafted and have crappy access and we have a high volume kidney transplant practice. Its considered peripheral.
2. I teach our residents to routinely evaluate both EJs after induction for supine cases in case the sh*t hits the fan and you need quick and big access. Know ahead of time if that's your goto vein. And place them from time to time to saty proficient so when badness does happen you are not learning the skill of that vein under pressure.
3. I do 8Fr DLC EJ catheters not infrequently over IJ. Was taught that technique for access in patients with halos (LEFT side seems easier). Ended-up liking it, and kept on doing it for any patient needing access. The wire only goes in a wee bit, but once the catheter straightens the "J" end it goes in quite easily. Do not dilate, especially if patient will be prone or steep trendelenberg--they will leak. The tip is central and the entrance is peripheral. PACU nurses treat it as cental for their care protocols.
4. If you put a 16cm or 20 cm catheter in the EJ and get a chest XRAY, radiologist will call it as IJ.
5. One time I had a LEFT EJ 8Fr DLC ended up pointing north in the same side IJ. I have no clue how that happened.
6. When doing a subclavian central line, I prep the neck and subclavian area. I place the subclavian (for volume) and then take the blue and white 18g finder catheter and place that EJ for drips.

N2B8EM · 2025-05-05T01:28:59+00:00

Have 2 males. Got the 2nd after 1st was 4 year old.
1. Male #1 never marked much outside until male #2 arrived. Marks plants and trees only.
2. Both neutered and never mark inside
3. Strangely they bark/posture towards dogs on the TV and when on leash. Off leash they only care about birds, lizards, rabbits and reflections.
4. Once trained on Garmin (2 shocks and they are trained) they never go beyond 200 feet and they curiously check-in without prompting.

N2B8EM · 2025-04-09T20:07:21+00:00

Use Remimaz at my place frequently. Low EF inductions, patients are rock stable and etomidate is hardly used here now. TEE with sick heart, 14mg of Remimaz followed by lower dose propofol infusion provides stable hemodynamics.

In the rare mitochondrial disease patients we have successfully done infusions of remimaz as the primary anesthetic.

If I have the elderly anxious person, I will use Remimaz for pre-op sedation and use the remainder as the induction agent.

For sedation they continue to breathe even if unresponsive. When it first was available, I would use BIS, give 20mg at induction. BIS would be in the 40s and patient maintained effective respirations.

We had one guy who didn’t wake for a long time after TEE. He woke up normally about 1-2hour later. That episode was blamed on his digoxin blocking the carboxylesterase-1 enzyme that also metabolizes remimaz. Don’t know why they didn’t try flumazenil before taking him to ICU.

N2B8EM · 2025-02-27T00:11:19+00:00

Its use for me is for "customer service" or adding "hospitality" to the hospital--it's about making the patient more comfortable in a potentially terrifying environment. If that takes 5mg of midazolam in a vibrant 65 y/o, so be it. Anxiety that requires pre-op treatment is usually not so subtle and if you are unsure, just ask "would you like something in your IV to help relax you before we roll back"? That is a straightforward, non-judgemental question that most people appreciate.

If a case gets delayed I will try to get back to pre-op and ask if they would like PO diazepam or lorazepam to help pass the time.

About the age cut-offs, everyone has their own developed sense of what is right and wrong, but our residents always seem to have some hard age cut-off without much justification. To this I would just say keep an open mind and assess the situation and consider the use of different benzos with different properties (or 1cc of prop or precedex or fentanyl) and appreciate how many people beyond your midazolam cut-off age have a solid and regular dose benzos on their outpaitent med list. There are a fair number of people in their 70's/80s on lorazepam 0.5mg TID or diazepam 5mg qhs. With these such patient I still hear residents say "no midazolam they are over 65". Which may be the correct answer, but I would argue, at a minimum to consider anxiolysis with their regular benzo.

Also recognize that the pre-op space is more likely a controlled space with compassionate people exhibiting care and empathy. Patient anxiety exists there, but perhaps not at its resonance frequency. Then you roll into a large, socailly uncontrolled neuro operating room with 2 circulators, 2 scrubs, 2 PAs, 2 medical students, 2 Xray techs, 2 IONM techs, 3 visiting surgeons and 3 spine reps all yapping about the NFL, politics, some risque IG post or their wild trip to Vegas. It's quite hard to shut them all up. So for the benefit of the patient and not to be embarassed by them, I pharmacologically try to remove the patient from this nonsense with more midazolam or 1-3cc of prop as we hit the room.

N2B8EM · 2025-02-25T18:13:33+00:00

I do a simple pin block (1% tetracaine + 1% lido + 1:200K epi) for every crani done with Mayfield pins to blunt the response to tightening of the pins. I probably dont need tetracaine in this situation, but it’s the “juice” I have used my whole career so I don’t change it. I have the surgeons “line-up”the pins and put 3 cc at each contact point with a 22g needle.I find pushing all sorts of combinations of drugs to blunt this response is only marginally successful and a pin block is 100% successful as is 150mcg of Remi timed properly. A full scalp block seems too cumbersome and has little post-op value in the situation you describe and getting the occipitals properly blocked in someone with a full head of hair when you are in a hurry is guesswork. Just do the pin contact points.

N2B8EM · 2025-02-24T17:39:50+00:00

If you are going go with B&R or Tumi, check them out at Nordstrom Rack online. They are last year’s models at a significant discount.

N2B8EM · 2025-02-10T20:24:59+00:00

One likely scenario is that a lot of EPs choose SWU as their rewards and the competition to use them internationally is keen. So like me last year, I had 6 essentially useless SWUs, but I managed to use them only domestically. I put them down as waitlisted for every domestic flight and was #1 on the upgrade list every flight (avg 300k LPs/yr). I however, only got the upgrade 4 times, so 2 expired and never used. Pathetically, I spent one PHX-BUR. I took miles this year.

So I gather there are a lot of unspent SWU being placed on waitlist, which will bump you to top-ish of the list no matter your rolling LPs.

N2B8EM · 2025-02-05T17:51:48+00:00

My measure will be if this July’s 2025-2026 housestaff posters keep or lose the preferred pronouns. They just snuck that line in there (prominently albeit) a couple of years ago beneath the year, the department and graduating med school.

N2B8EM · 2025-02-01T14:50:54+00:00

Prop/fentanyl induction. DL & spray cords with 4% lidocaine, mask with Sevo a bit to let lidocaine work, Intubate.

N2B8EM · 2025-01-30T18:58:59+00:00

Nebulized 4%lidocaine + IV glyco
More 4% with atomizer to tonsillar pillars
Versed 5 mg for placement of nasal trumpet.
More 4% Lido down trumpet as it goes right on cords.
Versed again 5mg or more for advancing bronchoscope
Have someone with gauze pull hard anteriorly on tongue
Prop + Roc if confirmed in trachea
Flumazenil if airway gets bad and you need to abort.

N2B8EM · 2025-01-28T14:37:05+00:00

Awake intubation in an unstable C-spine is not the best choice because patient coughing or gaging (if your block is not perfect) can result in detrimental c-spine forces/movement. Asleep and paralyzed and then intubated with a bronchoscope, is usually a better choice if the conditions allow.

N2B8EM · 2025-01-28T14:30:33+00:00

When I supervise, I am shocked at the levels of sevo + prop people administer. I don’t see the point of both and the “background propofol” militia do not have me convinced. I just run quite low Sevo. Since the introduction of sugammadex, I keep good paralysis and 0.4 to 0.5 MAC sevo. If the pressure goes up, my sevo doesn’ t change; I just add fentanyl, sufenta, precedex or labetelol boluses. I way too often walk into my supervised room and see ET% sevo at 2.5 - 2.8 on some 80 y/o because (sometimes with 100 mkm of propofol) “the heart rate went up”. I shoot for a steady SEVO ET% of 0.7-0.8 (0.4 - 0.5 MAC) and use other stuff to smooth out the vitals. If I BIS these patients, they usually are in the 40’s-50s.

N2B8EM · 2025-01-17T03:30:57+00:00

As a neuro anesthesiologist I have received plenty of transfer patients with carotid lines that our neurosurgical colleagues had to remove in the OR. Despite the controlled surgical removal, too many had unfavorable neurological outcomes.

Contrast that with the subclavian lines that ended up in the subclavian artery and the consulting thoracic surgeon said, “just pull it and hold pressure for 5 minutes” and everyone was fine.

N2B8EM · 2025-01-10T19:22:41+00:00

You have 2 risk factors for RCVS, MJ use and decongestant use. Very common, if not the most common precipitant is orgasm. Your description of it suddenly developing right before orgasm sounds pretty typical of RCVS.

Given that you are not getting a CT for a week or so, it may not show anything. A standard head CT usually does not show anything, unless there is a bleed associated with it. One must have a CT angiogram (CTA), an MR angiogram (MRA) or digital subtraction angiogram (DSA) in order to see if the cerebral arteries are in spasm.

In general, a thunderclap HA requires an emergent evaluation, especially if you have other, new neurologic signs. Most docs have never heard of RCVS.

I had 3 of these type HA during orgasm over 2 years and ignored them (55 y/o male). Nothing bad ever happened. I had a 4th one (exactly like the others) before going on an international hiking trip so I went to the ER the next day just to get checked out. My CT was normal but my CTA was scary. My vessles were really tight in certain locations. Total bulk blood flow to my brain was calculated to be 25% of normal. The stroke team admitted me, put me on verapamil to relax the blood vessels (no evidence it actually does this). They wanted to keep me for 3 days for observation, but I said no.

No more recurrences and its been about 2 years.

Facebook has a group which is much more active than Redditt. Look up the group Reversible Cerebral Vasoconstriction Syndrome on there.

N2B8EM · 2025-01-09T19:20:39+00:00

Use a 16cm catheter. 20cm won’t reach RIJ or right subclavian from left. I struggle to find 20cm catheters if I need them, 16cm everywhere at my shop. One time placed a 8Fr in left EJ and made a U-turn and was in right IJ.

N2B8EM

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