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Vial $0.40, Tablet $1.42

Midazolam

Editor: Updated Class:

ADMINISTRATION ROUTES:

IV, IM, PO, Nasal

ALTERNATIVE NAMES:

Hypnovel

ICU INDICATIONS:

  1. Sedation
  2. Treatment of seizures

PRESENTATION AND ADMINISTRATION:

IV:

15 mg/3 mL vial and 5 mg/5 mL vial

For direct IV injection, usually diluted to a concentration of 1 mg/mL using compatible IV fluid and injected slowly.

For continuous infusion dilute 60 mg up to a total of 60 mL with compatible IV fluid

Compatible with the following IV fluids:

Normal saline, 5% dextrose, 10% dextrose , Hartmanns

Any solutions not used within 24 hours should be discarded. Store at room temperature. Do not freeze

IM:

Inject undiluted into a large muscle mass

DOSAGE:

IV:

Sedation: 1 - 5 mg bolus Infusion: 0 - 20 mg/hr

PO:

7.5 - 15 mg (usually for anaesthesia premed)

IM:

1 - 5 mg

DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:

Dose in renal impairment

GFR (ml/min) DOSE
<10 50% of normal dose
10-20 dose as in normal renal function
>20-50 dose as in normal renal function

Dose in renal replacement therapy

MODALITY DOSE
CAPD 50% of normal dose
HD 50% of normal dose
CVVHDF dose as in normal renal function

DOSAGE IN PAEDIATRICS:

For overview of analgesia & sedation for intubated and ventilated children, see Starship guidelines:

IV:

Sedation: 0. 1 - 0.5 mg/kg

Infusion (ventilated): dilute 3 mg/kg in 50 mL 5% dextrose then run infusion at 0 - 5 mL/hr (0 - 5 mcg/kg/min)

IM:

Sedation: 0.1 - 0.5 mg/kg

Intranasal:

Sedation: 0.2 mg/kg nasal

Repeated in 10 minutes if required

PO:

Sedation: 0.5 mg/kg (max 20 mg)

CLINICAL PHARMACOLOGY:

Midazolam is a benzodiazepine. The precise mechanism by which midazolam exerts its antiseizure effect is unknown, although it is believed to be related to its ability to enhance the activity of gamma aminobutyric acid (GABA), the major inhibitory neurotransmitter in the central nervous system.

CONTRAINDICATIONS:

  1. Hypersensitivity to benzodiazepines

WARNINGS:

Withdrawal Symptoms

Withdrawal symptoms of the barbiturate type have occurred after the discontinuation of benzodiazepines including midazolam

PRECAUTIONS:

General:

Hypoventilation, airway obstruction, and apnoea can lead to hypoxia and/or cardiac arrest unless effective countermeasures are taken immediately.

Laboratory Tests:

No tests in addition to routine ICU tests are indicated

Drug/Laboratory Test Interactions:

None noted

IMPORTANT DRUG INTERACTIONS IN ICU:

The CNS-depressant action of the benzodiazepine class of drugs may be potentiated by alcohol, narcotics, barbiturates, nonbarbiturate hypnotics, antianxiety agents, the phenothiazines, thioxanthene and butyrophenone classes of antipsychotic agents, monoamine oxidase inhibitors and the tricyclic antidepressants, and by other anticonvulsant drugs.

ADVERSE REACTIONS:

Neurologic:

Abnormal eye movements, aphonia, choreiform movements, coma, diplopia, dysarthria, dysdiadochokinesis, 'glassy-eyed' appearance, headache, hypotonia, nystagmus, respiratory depression, slurred speech, tremor, vertigo.

Psychiatric:

Confusion, depression, amnesia, hallucinations, hysteria, increased libido, insomnia, psychosis, suicidal attempt. The following paradoxical reactions have been observed: Excitability, irritability, aggressive behaviour, agitation, nervousness, hostility, anxiety, sleep disturbances, nightmares and vivid dreams.

Respiratory:

Apnoea, hypoventilation

Cardiovascular:

Palpitations, hypotension

Haematopoietic:

Anaemia, leukopaenia, thrombocytopaenia, eosinophilia

Hepatic:

Hepatomegaly, transient elevations of serum transaminases and alkaline phosphatase