Reversal Agent Dosing for IV Sedation

Introduction to Reversal Agents

The American Society of Anesthesiologists recommends that both reversal agents be immediately available whenever benzodiazepines or opioids are used for sedation, to decrease adverse outcomes 2

Adults <20 kg should receive 0.1 mg/kg IV/IM of naloxone, while adults ≥20 kg should receive 2 mg IV/IM, with repeat doses every 2 minutes as needed for persistent respiratory depression 1
When reversing therapeutic opioid sedation, use lower doses (1-15 mcg/kg) of naloxone to avoid complete reversal of analgesia, preventing acute pain, hypertension, tachycardia, or pulmonary edema from sudden opioid reversal 1, 2
Patients should be observed for at least 2 hours after the last naloxone dose for recurrence of respiratory depression, as naloxone's duration of action (~1 hour) is shorter than most opioids 1

Before or concurrent with pharmacologic reversal, always stimulate the patient to breathe deeply, provide supplemental oxygen, and administer positive-pressure ventilation if spontaneous ventilation is inadequate, as reversal agents are adjuncts, not replacements, for airway management 2
Flumazenil is contraindicated in tricyclic antidepressant overdose and should be used with extreme caution in patients with seizure disorders treated with benzodiazepines, as it may induce seizures or arrhythmias 3
Naloxone may induce acute withdrawal in opioid-dependent patients and cause pain, hypertension, tachycardia, or pulmonary edema, and should not be used in neonates whose mothers have long-term opioid use due to the risk of seizures/acute withdrawal 1, 2

Maintain IV access throughout sedation and until the patient is no longer at risk for cardiorespiratory depression, and administer reversal agents through a freely running IV infusion into a large vein to minimize injection site pain 2
Continuous observation for at least 2 hours after the last reversal agent dose is necessary, with monitoring of vital signs, oxygen saturation, and level of consciousness 1, 2