# General Anesthesia Management Using Remimazolam and Dexmedetomidine in a Patient Undergoing Palatal Fistula Closure With a Tongue Flap

## TL;DR

This paper describes a successful anesthetic strategy using remimazolam and dexmedetomidine for a patient undergoing a complex oral surgery, ensuring safe recovery and airway management.

## Contribution

The novel contribution is the use of remimazolam and dexmedetomidine combination for anesthetic management in palatal fistula closure with a tongue flap.

## Key findings

- The combination of remimazolam and dexmedetomidine enabled smooth emergence and extubation without respiratory complications.
- Flumazenil effectively reversed remimazolam-induced sedation, allowing controlled recovery of cognitive function.
- Dexmedetomidine helped maintain mild sedation and respiratory stability during the procedure.

## Abstract

Palatal fistula closure with a tongue flap presents unique challenges in anesthetic management, particularly due to postoperative limitations in mouth opening, which complicate airway management. This report describes the anesthetic management of an 18-year-old male undergoing palatal fistula closure with a tongue flap. Anesthesia was induced and maintained with remimazolam and remifentanil, followed by the administration of dexmedetomidine toward the end of the surgery. After thorough oral suctioning, sugammadex was administered to reverse neuromuscular blockade, and flumazenil was used to counteract remimazolam-induced sedation. The patient regained consciousness smoothly, exhibiting a Ramsay Sedation Score of 2 and adequate spontaneous breathing. Mild postoperative bleeding was observed but was effectively managed with temporary re-sedation using sevoflurane. Extubation was successfully performed with a tube exchanger, and no postoperative respiratory complications ensued. Remimazolam, with its rapid metabolism and the availability of a specific antagonist (flumazenil), enabled controlled and timely recovery of cognitive function, minimizing the risk of postoperative agitation. Additionally, dexmedetomidine contributed to maintaining mild sedation and ensuring respiratory stability during emergence. This combination of remimazolam and dexmedetomidine offers an effective anesthetic strategy for safe emergence and extubation in patients undergoing palatal fistula closure with a tongue flap. It may also apply to other cases requiring cautious extubation and difficult airway management.