Parenteral Manual

Midazolam

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
VERSED®
Classification: 
Benzodiazepine, sedative, anticonvulsant
Original Date: 
August 2005
Revised Date: 
June 2020
Indications: 
  • Status epilepticus refractory to standard therapy
  • Conscous sedation prior to short procedures
  • Continous sedation of intubated or mechanically ventilated patients in an intensive care setting
  • Anxiolytic
  • Preoperative sedation
Reconstitution and Stability: 
  • Store vials at room temperature. Protect vials from light
  • When diluted to 0.5 mg/mL or less, solution is stable for 24 hours in D5W or NS
  • When diluted to 1 mg/mL in NS, solution is stable for 28 days at room temperature
  • Diluted solutions do not require protection from light
Compatibility: 

- Solutions Compatible: D5W, 0.9% NaCl, D5NS, ringer's lactate

- Additives/Above Cassette Compatible: atropine, diphenhydramine, hydromorphone, meperidine, morphine, scopolamine, fentanyl, glycopyrrolate, hydroxyzine, promethazine

- Y-site Compatible: amikacin, atracurium, calcium gluconate, cefazolin, ciprofloxacin, dopamine, epinephrine, erythromycin, fentanyl, fluconazole, gentamicin, haloperidol, heparin, metronidazole, morphine, pancuronium, piperacillin, KCl, ranitidine, SMOF Lipid 20%, vancomycin, vecuronium

- Incompatible: imipenem-cilastatin sodium, sodium bicarbonate, albumin, ampicillin, ceftazidime, cefuroxime, dimenhydrinate, dexamethasone, foscarnet, furosemide, hydrocortisone, methotrexate, pentobarbital, prochlorperazine, perphenazine, thiopental, TPN

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC & SC Infusion NO  -except for Palliative Care Service
IM

YES, deep into large muscle 
Usual dilution: 5 mg/mL

IV Direct

YES
Usual dilution: 1-5 mg/mL
Infusion time: 2-5 minutes
Infusion rate: do not exceed 1 mg/minute

IV Intermittent Infusion YES
IV Continuous Infusion

YES
Standard concentrations in ER/OR/PICU: 200 mcg/mL, 1000 mcg/mL

Click here to access SDC Drug Infusion Sheet

Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

Pediatric:
- Pre-operative sedation or conscious sedation for procedures:

  • 0.1-0.15 mg/kg IM 30-60 minutes before surgery   (Maximum: 10 mg total dose)
  • 6 months-5 years: 0.05-0.1 mg/kg IV   (Maximum: 6 mg total dose)
  • 6-12 years: 0.025-0.05 mg/kg IV   (Maximum: 10 mg total dose)

- Conscious sedation during mechanical ventilation:

  • 0.05-0.2 mg/kg IV over 2-3 minutes followed by a 60-120 mcg/kg/hour infusion
  • Range: 25-500 mcg/kg/hour
  • IV intermittent infusion: 0.05-0.2 mg/kg Q1-2H PRN

- Status epilepticus refractory to standard therapy:

  • Loading dose: 0.15 mg/kg IV x 1 followed by;
  • Continuous infusion: 50 mcg/kg/hour; titrate to effect Q 5 minutes (range 50 -1000 mcg/kg/hour)

-Seizure: 0.15 mg/kg/dose IV/IM, Max 10 mg

Adults:
- Pre-operative sedation or conscious sedation for procedures:

  • 0.07-0.08 mg/kg IM 30-60 minutes before surgery
  • 1-2.5 mg IV over at least 2 minutes
  • Wait 2 minutes or more and if needed dosage may be further titrated to a total dose of 5 mg
  • Maintenance doses may be administered in increments of 25% of the initial dose

- Conscious sedation during mechanical ventilation:

  • Loading dose: 0.01-0.05 mg/kg IV, may repeat Q 10-15 minutes until adequate sedation followed by a 20-100 mcg/kg/hour IV infusion
Potential hazards of parenteral administration: 
  • Respiratory depression/arrest, apnea, hypotension, tachypnea, cough
  • Nausea, vomiting and retching occur in a small number of patients
  • Headache, drowsiness, excessive sedation, dizziness, retrograde amnesia
  • Paradoxical reactions possible (i.e. restlessness, agitation)
Notes: 
  • Respiratory status must be monitored continuously during parenteral midazolam
  • Recommended monitoring of patients receiving midazolam for conscious sedation: monitor heart rate and respirations every 15 minutes for one hour following procedure, every 30 minutes for the next 2 hours, then every 60 minutes until the patient has recovered
  • Concomitant use of other CNS depressants can increase the risk of serious respiratory adverse events, dose adjustment may be necessary
  • IV route should be used  where continuous monitoring of respiratory rate and cardiac function is possible and where facilities for assisted ventilation are readily available
  • Use with caution in patients with CHF, pulmonary disease and renal or hepatic impairment
  • Midazolam is 3-4 times as potent as diazepam
  • Flumazenil used to counteract the extrapyramidal reactions in children

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