Pharm
Midazolam
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Midazolam
, Versed
See Also
Benzodiazepine
Procedural Sedation and Analgesia
(
PSAA
)
Rapid Sequence Intubation
Indications
Procedural Sedation and Analgesia
(
PSAA
)
Other agents are preferred in most cases (unpredictable)
Rapid Sequence Intubation
(induction agent)
Other induction agents are preferred due to the large and unpredictable Midazolam doses required for induction
Rarely given at adequate doses (a typical adult dose for RSI is an astounding 8-10 mg)
Consider where
IV Access
unavailable or other intubation agents contraindicated
Could be considered in
Status Epilepticus
(although
Thiopental
might be preferred)
Class
Parenteral short acting
Benzodiazepine
Mechanism
Sedative
,
Anxiolytic
, and amnestic effects
Antagonist:
Flumazenil
Dosing
Procedural Sedation
Indications for Midazolam
Other sedation agents are preferred in most cases
Intranasal Versed in children may allow for imaging,
Intravenous Access
,
Laceration Repair
Intravenous
Age 6 months to 5 years
Initial: 0.05 to 0.1 mg/kg IV
Titrate: Up to 1 mg increments IV every 3 min to max of 0.6 mg/kg
Age 6 to 12 years
Initial: 0.025 to 0.05 mg/kg IV
Titrate: Up to 1 mg increments IV every 3 min to max of 0.4 mg/kg
Adults (and over age 12 years)
Initial: 0.02 mg/kg IV
Titrate: 1 mg increments IV every 3 min (typically up to 5 mg)
Intramuscular
Child: 0.1 to 0.15 mg/kg (up to 10 mg)
Adult: 0.07 mg/kg (up to 10 mg)
Other Dosing
Oral: 0.5 mg/kg/dose
Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
Rectal 0.25 to 0.5 mg/kg/dose per
Rectum
Commonly used in combination with
Fentanyl
When combined with
Opioid
s (e.g.
Fentanyl
), use lower Midazolam dose
Risk of
Deep Sedation
with cardiopulmonary depression
Safety
Contraindicated in pregnancy (Category D)
Wait at least 4 hours for
Breast Feeding
Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
Unreliable sedation for painful procedures
Best delivered in incremental doses (e.g. 1 mg increments)
Exercise
extra caution in elderly, debilitated, children, hepatic insufficiency,
Dementia
Reversal:
Flumazenil
0.01 mg/kg up to 2 mg over 15 seconds
Do not use if on longterm
Benzodiazepine
s
Pharmacokinetics
Gene
ral
Duration: 1-4 hours
Half life: 2.5 hours
Oral
Onset: 20 to 30 minutes
Peak: 40 minutes
Intramuscular
Onset: 5 to 7 minutes (up to 10-20 minutes)
Peak: 10 to 15 minutes
Duration: 60-120 minutes
Intravenous
Onset: 2-3 minutes
Peak: 5 to 10 minutes
Duration: 45-60 minutes
Precautions
Monitor closely with respiratory depression
Have Ambubag and Oxygen available when administered
Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
Best delivered in incremental doses (e.g. 1 mg increments)
Risk of
Hypotension
Use with caution if risks for respiratory depression
Elderly, debilitated patients or children
Concurrent
Narcotic
use
Existing CNS depression
Chronic lung disease
Neuromuscular disorder
Apnea history
Risk of
Agitation
Elderly
Liver
disease
References
Miner (2012) APLS Lecture, HCMC, Minneapolis
Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
University Minnesota Childrens - Pediatric Emergency Drug Card
Becker (2012) Anesth Prog 59:28-42 [PubMed]
Brown (2005) Am Fam Physician 71:85-90 [PubMed]
Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
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