midazolam

Disclaimer to the Online Edition

This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

midazolam

Indication

  • Treatment of refractory seizures after other therapies such as PHENobarbital, levETIRAcetam or phenytoin have failed
  • Sedation

Dosage Guidelines

Seizures: 0.15 mg/kg IV direct followed by 2 micrograms/kg/minute IV continuous infusion. If seizures continue, give 0.15 mg/kg bolus and increase infusion rate by 2 microgram/kg/min q5 minutes as needed to a maximum of 24 microgram/kg/min.

If no seizures for 48 hours, taper by 1 microgram/kg/min q15 minutes. If seizure recurs during taper, give 0.15 mg/kg IV direct and resume prior infusion rate for 48 hours

Sedation:

  • Loading dose: 0.05-0.1 mg/kg/dose IV direct over 5 minutes
  • Maintenace dose: 0.16-1 microgram/kg/min IV via continuous infusion
  • Procedural sedation: 0.05-0.1 mg/kg/dose IV direct/IM or 0.1-0.2 mg/kg/dose intranasal (administer approximately half total volume in each nostril)

Administration

  • IM
  • IV direct over 5 minutes
  • Intranasal
  • IV continuous infusion
  • For patients 2 kg or less:
    • Use midazolam 0.2 mg/mL
    • To make 50 mL of midazolam [0.2 mg/mL] [10 mg/50mL]:
    • Add 10 mL (10 mg) of midazolam [1 mg/mL] to 40 mL of solution
  • For patients over 2 kg to 4 kg:
    • Use midazolam 0.6 mg/mL
    • To make 50 mL of midazolam [0.6 mg/mL] [30 mg/50mL]:
    • Add 30 mL (30 mg) of midazolam [1 mg/mL] to 20 mL of solution
  • For patients over 4 kg to 10 kg:
    • Use midazolam 1 mg/mL
    • To make 50 mL of midazolam [1 mg/mL] [50 mg/50mL]:
    • 50 mL (50 mg) of midazolam [1 mg/mL] (straight drug)

Adverse Effects

  • Hypotension, bradycardia, respiratory depression, oxygen desaturation, apnea
  • Rhythmic myoclonic jerk

Comments

  • Use with caution in preterm infants
  • Doses should be tapered gradually with prolonged use.  Benzodiazepine withdrawal may occur with abrupt discontinuation.

  • Monitor blood pressure, ECG

    Remember that midazolam provides sedation, NOT analgesia.

Supplied As

  • 1 mg/mL (2 mL and 5 mL vials)
  • Supplied by Pharmacy as standard concentrations:
    • 2 kg or less: 0.2 mg/mL, supplied as 10 mg in 50 mL solution
    • Over 2 kg to 4 kg: 0.6 mg/mL, supplied as 30 mg in 50 mL solution
    • Over 4 kg to 10 kg: 1 mg/mL, supplied as 50 mg/mL (straight drug)
  • At LHSC, standard concentration reference charts are available on the NICU Intranet site

References

LexiComp Sick Kids and LexiComp Pediatric and Neonatal