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Midazolam

Classification

high alert medication

Controlled and targeted substance

Benzodiazepine

Indications

ACP: Induction and maintenance of anesthesia in intubated patients

ACP: Control of seizures

ACP: Sedation of agitated patients

Contraindications

Hypersensitivity to midazolam or other benzodiazepines
Severe pulmonary disease

Caution

Elderly patients
Decreased level of consciousness
Patients with myasthenia gravis

Adult dosages

ACP: Induction and maintenance of anesthesia

2mg IV/IO q 2-5 min prn if inadequate sedation achieved with ketamine (maximum total 15mg)
CliniCall consultation required if higher doses or additional sedation is required.

ACP: All other indications

2-5 mg IV/IO q 2-5 minutes prn

5-10 mg IM q 5 - 10 minutes
Maximum dose from all sources: 30 mg
CliniCall consultation required if higher doses or additional sedation is required.

Pediatric Considerations And Dosing

Follow weight-based dosing

ACP: Induction and maintenance of anesthesia

If inadequate sedation achieved with ketamine

0.05mg/kg IV/IO (Max 2mg) q2-5 min prn (Maximum total 15mg)

ACP: All other indications

0.2 mg/kg (max 10mg) IN q5 minutes prn
- Intranasal drug administration is recommended over intramuscular because of a more consistent absorption
- Administer half the dose in each nare
- Consult PR11: Intranasal Medication Administration for additional information on the use of mucosal atomizer devices

0.1 mg/kg (maximum 5mg) IV/IO q 2-5 minutes prn

0.1 mg/kg IM q5-10 minutes prn

Maximum from all sources: 30mg

CliniCall consultation required if higher doses or additional sedation is required.

Mechanism Of Action

Like other benzodiazepines, midazolam intensifies the activity of gamma aminobutyric acid, the major inhibitory neurotransmitter in the central nervous system. This action is believed to result in hyperpolarization of neuronal cells, which then take longer to reach threshold and depolarize.

Pharmacokinetics

Intranasal

Onset: within 10 minutes
Peak: 30 minutes

Intramuscular

Onset: 5 minutes
Peak: Adult: 30-60 minutes Pediatrics; 15-30 minutes

Intravenous

Onset: 1 to 5 minutes
Peak 3-5 minutes

Adverse Effects

Apnea or respiratory depression
Hypotension
Bradycardia
Decreased level of consciousness, confusion
Pain at injection site

Overdose

Benzodiazepine overdoses should be managed supportively, with oxygenation and ventilation supported as necessary, and fluids given to maintain an adequate blood pressure. Reversal agents are available in-hospital.

Warning And Precautions

Alcohol can potentiate the effects of benzodiazepines

Drug Interactions

Opioids and other CNS depressants such as alcohol or gabapentin can potentiate the effects of benzodiazepines

Erythromycin, diltiazem, verapamil, ketoconazole, fluconazole, and itraconazole can significantly increase the bioavailability of midazolam. Monitor closely