- Sedation during mechanical ventilation
- Prior to procedure or before induction of anesthesia
- Treatment of refractory neonatal seizures
- Adjunct in palliative care
- IV direct: over 5 minutes
- IV continuous infusion
- PO
- Sublingual (SL)/ buccal (see Palliative Care Symptom Management Protocol below)
- Intranasal (IN)
- Administer injection solution intranasally using Mucosal Atomization Device (MAD). Larger volumes should be divided between both nostrils.
-
Ensure to account for the deadspace volume in the MAD (approx 0.06 mL for the MAD300 model). Either draw up extra medication for this volume, OR draw back on the syringe after administration of dose and then empty the air into the nostril so no drug remains in the MAD.
- Sedation:
- IV direct: 50-150 mcg/kg/dose Q2-4H PRN
- IV continuous infusion : 10-60 mcg/kg/hour
- PO: 0.25 to 0.5 mg/kg/dose Q4H PRN
-
Intranasal: 0.1 - 0.2 mg/kg/dose
- Seizures, refractory:
- GA > 34 weeks AND postmenstrual age < 44 weeks
- 150 mcg/kg IV bolus followed by 120 mcg/kg/hr IV infusion
- Increase as needed by 120 mcg/kg/hr every 10 minutes
- Bolus 150 mcg/kg with each increase in infusion rate
- Maximum infusion rate: 1080 mcg/kg/hr
- * Note: 1 mg = 1000 mcg
- GA > 34 weeks AND postmenstrual age < 44 weeks
-
Intranasal: 0.1 - 0.2 mg/kg/dose
- Palliative Care Symptom Management Protocol
| Birthweight |
Midazolam Buccal or Sublingual dose
|
Midazolam Intranasal dose
|
|
< 500 g- < 1000 g |
0.1 mg SL/buccal q5min prn. Titrate to effect by administering the same dose q5 minutes PRN. |
0.15 mg IN q5min prn |
|
> 1000 g - < 3000 g |
0.25 mg SL/buccal q5min prn. Titrate to effect by administering the same dose q5 minutes PRN. |
0.3 mg IN q5min prn |
|
> 3000 g - < 4000 g |
0.5 mg SL/buccal q5min prn. Titrate to effect by administering the same dose q5 minutes PRN. |
0.6 mg IN q5min prn Administer 0.3 mL per nostril |
| > 4000 g |
0.5 mg SL/buccal q5min prn. Titrate to effect by administering the same dose q5 minutes PRN. |
0.6 mg IN q5min prn Administer 0.3 mL per nostril |
- CVS: hypotension
- Respiratory: respiratory depression, apnea (especially with rapid administration or if used in conjunction with narcotics)
- Other: withdrawal after abrupt discontinuation of prolonged therapy
- HR, BP
- RR and oxygen saturation
CHEO:
IV direct:
- Use midazolam 0.2 mg/mL (200 mcg/mL) - 3 mL prefilled syringe prepared by pharmacy
- If patient receiving midazolam by continous infusion, use appropriate setting on pump to administer bolus
IV continuous infusion:
- Use 0.2 mg/mL (200 mcg/mL) 20 mL prefilled syringe prepared by pharmacy
Intranasal:
- If midazolam 1 mg/mL not readily available:
- Withdraw 2 mL (10 mg) of midazolam 5 mg/mL and add to 8 mL of D5W.
Final concentration: 1 mg/mL
- Withdraw 2 mL (10 mg) of midazolam 5 mg/mL and add to 8 mL of D5W.
PO/SL/Buccal
- Available as a 2.5 mg/mL oral syrup
-
For SL/buccal use, midazolam injection 1 mg/mL is advisable.
-
If midazolam 1 mg/mL not readily available:
-
Withdraw 2 mL (10 mg) of midazolam 5 mg/mL and add to 8 mL of D5W.
Final concentration: 1 mg/mL
-
-
** Midazolam 1 mg/mL (1000 mcg/mL) prefilled syringe can also be dispensed by pharmacy or obtained from the PICU medication cabinet if required urgently.
TOH:
IV direct:
- Midazolam 5 mg/mL
- Take 0.4 mL (2000 mcg) and add to 9.6 mL 0.9% NaCl
- Final concentration: 200 mcg/mL
IV continuous infusion:
- Midazolam 5 mg/mL
- Take 0.2 mL (1000 mcg) and add to 19.8 mL D5W
- Final concentration: 50 mcg/mL
- Midazolam 5 mg/mL
- Take 0.8 mL (4000 mcg) and add to 19.2 mL D5W
- Final concentration: 200 mcg/mL
- Midazolam 5 mg/mL
- Take 2 mL (10 mg) and add to 8 mL D5W
- Final concentration: 1 mg/mL or 1000 mcg/mL
Intranasal/SL/Buccal:
- Use undiluted midazolam 1 mg/mL injection solution
- Solutions Compatible: D5W, 0.9% NaCl
- Y-site Compatible: calcium gluconate, dopamine, epinephrine, erythromycin, fentanyl, gentamicin, heparin, KCl, ketamine, metronidazole, morphine, piperacillin, ranitidine, SMOF, tobramycin, vancomycin
Incompatible: dobutamine, phenytoin, phenobarbital, TPN
-Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook 22nd Edition. Hudson: Lexi-Comp Inc.; 2015.
-American Society of Health-System Pharmacists (ASHP). Handbook on Injectable Drugs 19th Edition. Bethesda: ASHP 2017
- Castro,Conde JR, Hemandez Borges AA, Domenech Martinez E et al. Midazolam in Neonatal Seizures With No Response to Phenobarbital. Neurology, 2005, 64(5):876-9
- Therapeutic Intranasal Drug Delivery. Intranasal Sedation from the web http://www.intranasal.net/sedation/Sedation_overview.htm
- Milesi C, Baleine J, Mura T, Benito-Castro F, Ferragu F, Thieriez G, Thevenot P, Combes C, Carbajal R, Cambonie G. (2018). Nasal midazolam vs ketamine for neonatal intubation in the delivery room:P a randomized trial. Arch Dis Child: Fetal and Neonatal Edition 103, 221-226