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midazolam
generic
Black Box Warnings .
Appropriate Use
use only in hospital/ambulatory care setting w/ continuous resp./cardiac fxn monitoring, resuscitative drugs, appropriate ventilation/intubation equipment, and personnel trained/skilled in airway management; continuously monitor deeply sedated pediatric pts via 1 dedicated person other than practitioner performing procedure
Respiratory Depression/Arrest Risk
syrup assoc. w/ resp. depression, airway obstruction, desaturation, hypoxia, apnea, and arrest, especially w/ sedation use in noncritical care settings and most often in combo w/ other CNS depressants
Individualize IV Dosage
max initial dose 2.5 mg IV in adult pts; use lower dose for pts >60 yo, debilitated pts, and in combo w/ narcotics or other CNS depressants; admin. 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 w/ fentanyl
Risks from Concomitant Opioid Use
concomitant benzodiazepine use w/ opioids may result in profound sedation, resp. depression, coma, and death; reserve concomitant use for pts w/ inadequate alternative tx options; limit to minimum required dosage and duration; monitor pts for s/sx of resp. 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 w/ concomitant medications/clinical status
- [IV route, elderly, debilitated, or chronically ill pts]
- Dose: 1 mg IV q2-3min; Max: 1.5 mg/dose; Info: cumulative dose >3.5 mg rarely needed; dose, response vary w/ concomitant medications/clinical status
- [intranasal route (off-label)]
- Dose: 0.1 mg/kg/dose intranasally x1; Start: 15min before procedure; Info: use injectable form w/ 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 pts; individualize dose for high-risk or premedicated pts
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 pts; 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 dz 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 dz 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 w/ 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 w/ 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: SOL: 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 IBW in obese pts; dose, response vary w/ 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 IBW in obese pts; dose, response vary w/ 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 IBW in obese pts; dose, response vary w/ 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 IBW in obese pts; dose, response vary w/ 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 IBW in obese pts; dose, response vary w/ 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 w/ 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 w/ 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 IBW in obese pts; 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 w/ 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 w/ 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