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
ACP: Ketamine emergence reaction
Contraindications
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 AND ketamine emergence reaction due to Procedural Sedation
- 2 mg IV/IO q 2-5 min prn (maximum total 15mg) if inadequate sedation achieved with ketamine alone OR if ketamine emergence reaction
- 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
OR
Pediatric Considerations And Dosing
Follow weight-based dosing
ACP: Induction and maintenance of anesthesia AND ketamine emergence reaction due to Procedural Sedation
- 0.05mg/kg IV/IO (Max 2mg) q2-5 min prn (Maximum total 15mg) if inadequate sedation achieved with ketamine alone OR if ketamine emergence reaction
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
OR
- 0.1 mg/kg (maximum 5mg) IV/IO q 2-5 minutes prn
OR
- 0.1 mg/kg IM q5-10 minutes prn
Maximum from all sources: 30mg
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