Adult Dosing
Preoperative sedation/anxiolysis/amnesia
- 5 mg IM x 1
- Alt: 0.07-0.08 mg/kg IM x 1; give 30-60 mins prior to surgery
- Elderly patients: 2-3 mg IM x 1; individualize dose for high-risk or premedicated pts
Procedural sedation
<60 yrs
- 1 mg IV q2-3 mins; Max: 2.5 mg/dose; cumulative dose >5 mg rarely needed; dose, response vary with concomitant medications/clinical status of the patient
Elderly, debilitated, or chronically ill patients
- 1 mg IV q2-3 mins; Max: 1.5 mg/dose; cumulative dose >3.5 mg rarely needed; dose, response vary with concomitant medications/clinical status of the patient
Induction of general anesthesia
- 0.15-0.35 mg/kg IV; Max: 0.6 mg/kg cumulative dose
- Debilitated pts: 0.15 mg/kg IV; healthy pts: 0.2-0.25 mg/kg IV if pt has received preanesthesia; dose, response vary with concomitant medications/clinical status of the patient
Sedation of intubated and mechanically ventilated patients
- 0.02-0.1 mg/kg/hr IV
- Start: 0.01-0.05 mg/kg IV q10-15 mins until sedation achieved; titrate to desired effect; use min effective dose
Acute treatment of seizures [Non-FDA Approved]
- 0.1-0.2 mg/kg, maximum dose 4 mg/dose IV, may repeat every 5 minutes. Some will initiate an infusion, with dose of 0.1-0.4 mg/kg/hr
Status Epilepticus [Non-FDA Approved]
- 0.1-0.2 mg/kg IV slow push, may repeat dose every 5 minutes as needed [Max 4 mg/dose]
Pediatric Dosing
Procedural sedation
6 months- 5 yrs
- 0.05-0.1 mg/kg IV x 1, repeat q2-3 mins PRN; Max: 0.6 mg/kg total; cumulative dose >6 mg rarely needed; give 5 mins before procedure; use IBW in obese pts; dose, response vary with concomitant medications/clinical status of the patient
6-12 yrs
- 0.025-0.05 mg/kg IV x 1, repeat q2-3 mins PRN; Max: 0.4 mg/kg total; cumulative dose >10 mg rarely needed; give 5 mins before procedure; use IBW in obese pts; dose, response vary with concomitant medications/clinical status of the patient
>12 yrs
- 0.5-2 mg IV x 1, repeat q2-3 mins PRN; cumulative dose >10 mg rarely needed; give 5 mins before procedure; use IBW in obese pts; dose, response vary with concomitant medications/clinical status
>6 months
- 0.1-0.15 mg/kg IM x 1; Max: 0.5 mg/kg total; cumulative dose >10 mg rarely needed; give 15-30 mins before procedure; use IBW in obese pts; dose, response vary with concomitant medications/clinical status of patients
Acute treatment of seizures [Non-FDA Approved]
- Infants
2 months and children: 0.15 mg/kg followed by a continuous infusion of 1 mcg/kg/minute; titrate dose upward every 5 minutes until seizure ceases (range 1-18 mcg/kg/min with mean dose of ~2.5 mcg/kg/min typical)
Status Epilepticus [Non-FDA Approved]
- 0.1-0.2 mg/kg IV slow push, may repeat dose every 5 minutes as needed [Max 4 mg/dose]
[Outline]
Renal Dose Adjustment: (Based on CrCl)
- <10 mL/min: Decrease dose to 50%
Hepatic Dose Adjustment:
- Hepatic impairment: Dose adjustments not defined, caution advised
Narcotic or other CNS depressant premedication
- Use therapy only in hospital with ambulatory care setting with continuous respiratory and cardiac function monitoring, and under personnel skilled in airway management [US Black Box Warning]
- One dedicated person other than practitioner performing procedure should continuously monitor deeply sedated pediatric patients [US Black Box Warning]
- Initial max. adult dose should be 2.5 mg IV. Reduce dose for patients >60 yrs and debilitated patients and should be given in combination with narcotics or other CNS depressants [US Black Box Warning]
- Calculate pediatric doses on mg/kg basis. Initial dose is age, procedure, and route dependent [US Black Box Warning]
- In neonates do not give rapid IV injection as severe hypotension and seizures may occur, particularly in combination with fentanyl [US Black Box Warning]
- Do not use therapy without individualization of dosage particularly when used with other medications capable of producing central nervous system depression
- Therapy may cause hypoventilation, airway obstruction, and apnea which can lead to hypoxia and/or cardiac arrest unless effective countermeasures are taken immediately
- Increased risk of respiratory depression in patients with COPD
- Titrate slowly in adult or pediatric patients when used for sedation/anxiolysis/amnesia
- The risk of hypoventilation, airway obstruction, desaturation, or apnea is increased with Concomitant use of barbiturates, alcohol or other central nervous system depressants and may contribute to profound and/or prolonged drug effect
- Reduced initial dosage of midazolam is recommended in elderly patients
- Adult and pediatric patients with chronic renal failure and patients with congestive heart failure eliminate midazolam more slowly
- Do not administer therapy to patients in shock or coma, or in acute alcohol intoxication with depression of vital signs.
- Caution should be exercised in the use of intravenous midazolam in adult or pediatric patients with uncompensated acute illnesses, such as severe fluid or electrolyte disturbances
- It is recommended that no patient operate hazardous machinery or a motor vehicle until the effects of the drug, such as drowsiness, have subsided or until one full day after anesthesia and surgery
- The patient should be apprised of the potential hazard to the fetus if therapy is used during pregnancy
- After the discontinuation of therapy withdrawal symptoms of the barbiturate type may occur
Cautions: Use cautiously in
- Renal impairment
- Hepatic impairment
- Pulmonary impairment
- Elderly patients
- Sleep apnea
- CHF
- CNS depression
- Alcohol use
- Alcohol or drug abuse history
- Avoid abrupt withdrawal
- Hx of seizures
Pregnancy Category:D
Breastfeeding: Probably unsafe. The small amounts of midazolam excreted into breastmilk would not be expected to cause adverse effects in most breastfed infants. This information is based upon LactMed database (available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 1 April 2011). According to manufacturer data, caution should be exercised when midazolam hydrochloride is administered to a nursing woman
