| DRUG | SUPPLIED | DOSE | COMMENTS |
|---|---|---|---|
| MIDAZOLAM (Paeds) Mechanism of action: Benzodiazepine; Hypnotic Ref: 44 ,53, 464 Last update: 2023-12-09 |
injection: 1 mg/mL, 5 mg/mL oral liquid: 3 mg/mL Standard concentrations for continuous infusion: PICU: 1 mg/mL in D5W (25 mL PLS) and 5 mg/mL (50 mL PLS) 6 West (neurology): 1 mg/mL in D5W (25 mL PLS) |
Procedural sedation: Intravenous: 0.1 mg/kg IV over 2-3 min. May repeat dose at 5 min intervals. Maximum 8 mg/dose Oral: 0.5-1 mg/kg/dose PO 15-30 min prior to procedure. Maximum: 20 mg/dose Intranasal*: 0.3-0.5 mg/kg/dose intranasal 10 min prior to procedure. Maximum 10 mg/dose (5 mg per nostril) Sedation in Mechanical Ventilation: Loading dose (if required): 0.05-0.2 mg/kg IV over at least 3 min.30-360 mcg/kg/hr IV continuous infusion Lower dose by 25% when used with opioids. Refractory Status Epilepticus: Loading dose: 0.1 mg/kg (max 10 mg) IV over 2-3 minutes followed by continuous IV infusion of 120 mcg/kg/hr. Increase by 120 mcg/kg/hr every 5 min until seizures are controlled (usual maximum 900 mcg/kg/hr) Acute Seizure Treatment: Buccal*: 0.2-0.3 mg/kg/dose (maximum 10 mg/dose). May repeat in 5 minutes Intranasal*: 0.2-0.3 mg/kg/dose (maximum 10 mg/dose; 5 mg per nostril)**. May repeat in 5 minutes Intramuscular: 0.1 mg/kg/dose (maximum 10 mg/dose). May repeat in 5 minutes. |
Caution: IV midazolam is a benzodiazepine that has potent respiratory depression and mild hypotensive effects. The parenteral route should be used only when facilities are available to monitor and support cardio-respiratory functions. Risk of respiratory depression increases when used in combination with opioids/sedatives. *Use 5 mg/mL injectable form for intranasal and buccal use due to volume. **For children receiving intranasal midazolam in schools, dose must be rounded to nearest 2.5 mg (0.5 mL). Refer to BC Ministry of Education and Child Care Seizure Action Plan. Disinhibitory reactions (which may manifest as agitation or increased anxiety) occur unpredictably in about 20% of children with midazolam. Careful titration using the lowest effective dose may help to avoid these reactions. Flumazenil may be used to treat respiratory depression and severe paradoxical reactions. Oral doses of > greater than 20 mg may result in excessive sedation, even in large children. Tachyphylaxis may develop following 48-72 hours of continued treatment resulting in higher dosage requirements . After prolonged infusions, midazolam may accumulate in peripheral tissues and result in a prolonged half life up to 50 hours. Intranasal route can be irritating. Refer to Guidelines for the Administration of intranasal midazolam. Refer to Nursing Guideline: Intranasal Drug Delivery via Atomizer. Refer to Procedural Sedation and Analgesia Standards and Guidelines. Refer to BCCH benzodiazepine seizure rescue and test dose guidelines. Guidelines on PHSA SHOP Standard Prescription: midazolam__mg IV x 1 dose (___ mg/kg/dose) (May repeat dose at__min intervals) midazolam__mg PO__ minutes prior to procedure midazolam__mcg/kg/hour continuous IV infusion |