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midazolam
generic
Black Box Warnings .
Appropriate Use
use only in hospital/ambulatory care setting with continuous respiratory/cardiac function monitoring, resuscitative drugs, appropriate ventilation/intubation equipment, and personnel trained/skilled in airway management; continuously monitor deeply sedated pediatric patients via 1 dedicated person other than practitioner performing procedure
Respiratory Depression/Arrest Risk
syrup associated with respiratory depression, airway obstruction, desaturation, hypoxia, apnea, and arrest, especially with sedation use in noncritical care settings and most often in combo with other CNS depressants
Individualize IV Dosage
max initial dose 2.5 mg IV in adult patients; use lower dose for patients >60 yo, debilitated patients, and in combo with narcotics or other CNS depressants; administer over >2min and allow >2min to fully evaluate sedative effect; calculate pediatric doses on mg/kg basis, initial dose is age, procedure, and route dependent; do not give rapid IV injection in neonates as severe hypotension and seizures reported, particularly in combo with fentanyl
Risks from Concomitant Opioid Use
concomitant benzodiazepine use with opioids may result in profound sedation, respiratory depression, coma, and death; reserve concomitant use for patients with inadequate alternative tx options; limit to minimum required dosage and duration; monitor patients for signs/symptoms of respiratory depression and sedation
Adult Dosing .
Dosage forms: INJ
sedation, procedural
- [IV route, <60 yo]
- Dose: 1 mg IV q2-3min; Max: 2.5 mg/dose; Info: cumulative dose >5 mg rarely needed; dose, response vary with concomitant medications/clinical status
- [IV route, elderly, debilitated, or chronically ill patients]
- Dose: 1 mg IV q2-3min; Max: 1.5 mg/dose; Info: cumulative dose >3.5 mg rarely needed; dose, response vary with concomitant medications/clinical status
- [intranasal route (off-label)]
- Dose: 0.1 mg/kg/dose intranasally x1; Start: 15min before procedure; Info: use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
sedation, preop
- [5 mg IM x1]
- Start: 30-60min before surgery; Alt: 0.07-0.08 mg/kg/dose IM x1; Info: give 2-3 mg IM x1 in elderly patients; individualize dose for high-risk or premedicated patients
general anesthesia induction
- [<55 yo]
- Dose: 0.3-0.35 mg/kg/dose IV x1; Info: may give incremental doses of 25% of initial dose prn to achieve complete induction, up to 0.6 mg/kg total dose in resistant patients; consider decr. dose to 0.25 mg/kg/dose IV x1 if premedicated or to 0.15 mg/kg/dose IV x1 if severe systemic disease or debilitated
- [55 yo and older]
- Dose: 0.3 mg/kg/dose IV x1; Info: consider decr. dose to 0.2 mg/kg/dose IV x1 if premedicated or 0.15 mg/kg/dose IV x1 if severe systemic disease or debilitated
general anesthesia maintenance
- [25% of induction dose IV prn]
- Info: not used alone, a component of balanced anesthesia
sedation, mechanical ventilation
- [0.02-0.1 mg/kg/h IV]
- Start: 0.01-0.05 mg/kg/dose IV q10-15min until sedation achieved; Info: titrate to effect; taper dose gradually to D/C if long-term use
seizures, acute repetitive (off-label)
- [intranasal route]
- Dose: 5 mg intranasally x1; Max: 2 doses/single episode; 1 episode q3 days up to 5 episodes/mo; Info: may repeat dose x1 after 10min x1; use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
- [buccal route]
- Dose: 10 mg buccally x1; Info: use injectable 5 mg/mL; apply to buccal cavity using oral syringe
status epilepticus (off-label)
- [IM route]
- Dose: 10 mg IM x1
- [intranasal route]
- Dose: 5 mg intranasally x1; Max: 2 doses/single episode; 1 episode q3 days up to 5 episodes/mo; Info: may repeat dose x1 after 10min x1; use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
- [buccal route]
- Dose: 10 mg buccally x1; Info: use injectable 5 mg/mL; apply to buccal cavity using oral syringe
status epilepticus, refractory (off-label)
- [0.05-2 mg/kg/h IV]
- Start: 0.2 mg/kg/dose IV x1; Info: may repeat 0.1-0.2 mg/kg/dose x1, then incr. by 0.05-0.1 mg/kg/h q3-4h prn
rapid sequence intubation (off-label)
- [0.1-0.3 mg/kg/dose IV x1]
- Start: 3min after premedications; Info: see Rapid Sequence Intubation (RSI), Adult table
renal dosing
- [adjust dose amount]
- CrCl <10: decr. usual dose by 50%
- HD/PD: not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Peds Dosing .
- Dosage forms: SOLUTION: 2 mg per mL; INJ: various
sedation, procedural
- [IV route, 6 mo-5 yo]
- Dose: 0.05-0.1 mg/kg/dose IV x1, repeat q2-3min prn; Start: 5min before procedure; Max: 0.6 mg/kg total; Info: cumulative dose >6 mg rarely needed; use ideal body wt in obese patients; dose, response vary with concomitant medications/clinical status
- [IV route, 6-12 yo]
- Dose: 0.025-0.05 mg/kg/dose IV x1, repeat q2-3min prn; Start: 5min before procedure; Max: 0.4 mg/kg total; Info: cumulative dose >10 mg rarely needed; use ideal body wt in obese patients; dose, response vary with concomitant medications/clinical status
- [IV route, >12 yo]
- Dose: 0.5-2 mg IV x1, repeat q2-3min prn; Start: 5min before procedure; Info: cumulative dose >10 mg rarely needed; use ideal body wt in obese patients; dose, response vary with concomitant medications/clinical status
- [PO route, 6 mo and older]
- Dose: 0.25-0.5 mg/kg/dose PO x1; Start: 20-30min before procedure; Max: 20 mg; Info: children <6 yo may require up to 1 mg/kg/dose; use ideal body wt in obese patients; dose, response vary with concomitant medications/clinical status
- [intramuscular route, 6 mo and older]
- Dose: 0.1-0.15 mg/kg/dose IM x1; Start: 15-30min before procedure; Max: 0.5 mg/kg total; Info: cumulative dose >10 mg rarely needed; use ideal body wt in obese patients; dose, response vary with concomitant medications/clinical status
- [intranasal route, 1-5 mo (off-label)]
- Dose: 0.2 mg/kg/dose intranasally x1; Start: 15-30min before procedure; Info: use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
- [intranasal route, 6 mo and older (off-label)]
- Dose: 0.2-0.3 mg/kg/dose intranasally x1; Start: 15-30min before procedure; Max: 10 mg/dose; Info: use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
sedation, mechanical ventilation
- [<32 wk gestation, <1 mo]
- Dose: 0.5 mcg/kg/min IV; Info: titrate to effect; taper dose gradually to D/C if long-term use
- [>32 wk gestation, <1 mo]
- Dose: 1 mcg/kg/min IV; Info: titrate to effect; taper dose gradually to D/C if long-term use
- [1 mo-12 yo]
- Dose: 1-2 mcg/kg/min IV; Start: 0.05-0.2 mg/kg/dose IV x1; Alt: 0.05-0.15 mg/kg/dose IV q1-2h prn; Info: use ideal body wt in obese patients; titrate to effect; taper dose gradually to D/C if long-term use
seizures, acute repetitive (off-label)
- [intranasal route, 1 mo and older]
- Dose: 0.2 mg/kg/dose intranasally x1; Max: 5 mg/dose; 2 doses/single episode; 1 episode q3 days up to 5 episodes/mo; Info: may repeat dose x1 after 10min; use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
- [buccal route, 1 mo and older]
- Dose: 0.2 mg/kg/dose buccally x1; Max: 10 mg/dose; Info: use injectable 5 mg/mL; apply to buccal cavity using oral syringe
status epilepticus (off-label)
- [IM route, 1 mo and older]
- Dose: 0.2 mg/kg/dose IM x1; Max: 10 mg/dose
- [intranasal route, 1 mo and older]
- Dose: 0.2 mg/kg/dose intranasally x1; Max: 5 mg/dose; 2 doses/single episode; 1 episode q3 days up to 5 episodes/mo; Info: may repeat dose x1 after 10min; use injectable form with mucosal atomization device; divide dose and give as 1 spray in each nostril
- [buccal route, 1 mo and older]
- Dose: 0.2 mg/kg/dose buccally x1; Max: 10 mg/dose; Info: use injectable 5 mg/mL; apply to buccal cavity using oral syringe
status epilepticus, refractory (off-label)
- [2 mo and older]
- Dose: 0.05-2 mg/kg/h IV; Start: 0.2 mg/kg/dose IV x1; Info: may repeat 0.1-0.2 mg/kg/dose x1, then incr. by 0.05-0.1 mg/kg/h q3-4h prn
renal dosing
- [adjust dose amount]
- CrCl 10-29: decr. usual dose by 25%; CrCl <10: decr. usual dose by 50%
- HD/PD: not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised