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Midazolam Intravenous for Adults

Who can administer

Administration RESTRICTED - see Appendix 1

Important information

  • Flumazenil injection must be available at all times when administering midazolam by the intravenous route
  • Midazolam should only be administered by experienced physicians in a setting fully equipped for the monitoring and support of respiratory and cardiovascular function
  • Not to be used for conscious sedation in patients with severe respiratory failure or acute respiratory depression
  • Acute respiratory depression, respiratory arrest and cardiac arrest may occur especially when used for sedation in non-critical care settings
  • The need for a continuous infusion should be reassessed daily to reduce the risk of accumulation and prolonged recovery (particularly in patients with renal and hepatic impairment)
  • For Y-site compatibility see below

Available preparations

Hypnovel 10mg per 2ml ampoule

Hypnovel 10mg per 5ml ampoule

Reconstitution

Already in solution

Draw up using a 5 micron filter needle

Infusion fluids

Sodium chloride 0.9% or Glucose 5%

Methods of intravenous administration

Slow intravenous injection

  • Consider using the 10mg per 5ml strength to allow for more accurate dose measurement and titration
  • Administer required dose at a rate of 2mg per minute

Continuous intravenous infusion (critical care areas only).  Administer using an electronically controlled infusion device

  • Use 12ml of 10mg/2ml strength, and add 48ml infusion fluid to produce a 60mg in 60ml (1mg/1ml) infusion

Dose in adults

Conscious sedation for procedures

  • Adults less than 60 years: Initial dose: 2 to 2.5mg, given five to ten minutes before the beginning of the procedure. Further doses of 1mg may be given, as necessary, to a total dose of 3.5 to 7.5mg
  • Adults 60 years or more, debilitated or chronically ill: Initial dose: 0.5 to 1mg, given five to ten minutes before the beginning of the procedure. Further doses of 0.5 to1mg may be given, as necessary to a total dose of 3.5mg
  • Consider using the 10mg per 5ml strength to allow for easier dose measurement and titration

Anaesthesia

  • Used as per theatre guidelines

Sedation in intensive care units

  • In hypovolemic, vasoconstricted, or hypothermic patients, both the loading and maintenance doses should be reduced
  • Escalate in increments of 1 to 2.5mg every two minutes 
  • Infusion maintenance doses vary but are in the range of 2.1 to 14mg/hr for a 70kg patient (30 to 200 microgram/kg/hour)
  • Abrupt discontinuation after prolonged intravenous administration may lead to withdrawal symptoms 
  • Consider reducing slowly when stopping drug

Renal impairment

  • In patients with renal impairment (CrCl < 30ml/min), midazolam may be accompanied by more pronounced and prolonged sedation, including clinically relevant respiratory and cardiovascular depression
  • Such patients should be dosed carefully and dose titrated for the desired effect

Hepatic impairment

  • In patients with hepatic impairment, the clinical effects of midazolam may be prolonged
  • The required dose of midazolam may have to be reduced 

 

Adults over 60 years of age:

  • Use lower doses for all indications except ICU sedation

Monitoring

  • Monitor respiratory and cardiovascular parameters
  • Monitor blood pressure - hypotension is more common in patients also on opioids (ref 1)

Special caution should be excercised in the following patients

  • Adults over 60 years of age
  • Chronically ill or debilitated patients
  • Chronic respiratory insufficiency - respiratory arrest is more common with high doses/rapid administration
  • Chronic renal failure, impaired hepatic or cardiac function

Further information

  • The elimination half life may be prolonged up to six times in critically ill patients

Storage

Store below 25°C

References

Hypnovel 10mg/2ml SPC October 2019

Hypnovel 10mg/5ml SPC October 2019

(1) Uptodate, accessed online 19/10/2021

Therapeutic classification

Benzodiazepine