The routine use of a flumazenil infusion following percutaneous endoscopic gastrostomy placement to reduce early post-procedure mortality

Objectives
:  Percutaneous  endoscopic  gastrostomy  (PEG)  insertion  offers secure enteral nutrition, but there is a significant mortality associated with the procedure. We reviewed our sedation practice and the effect of yearly protocol changes  to  establish  if  the  routine  reversal  of  midazolam  with  a  flumazenil infusion improved mortality.
Methods
: Since 2003 yearly protocol changes have been introduced, including pre-assessment  and  sedation  reversal. We  retrospectively  audited  one-week and one-month mortality and aspiration rates.
Results
: The  average  one-week  mortality  rate  was  9.2%. The  pooled  death rates  within  the  first  week  for  patients  prior  to  routine  sedation  reversal (n=522) was 10.7% and for patients who received routine reversal (n=144) was 5.4%  (p=0.087).  Within  the  first  month,  death  rates  were  26.3%  prior  to reversal and 21.4% in the sedation reversal group (p=0.30).
Conclusions
: The routine use of flumazenil infusion in appropriate patients is safe. Flumazenil infusion may have a role to play in selected patients at highest risk of aspiration. A prospective, randomised study is warranted.