L B M M C / P H A R M A C Y S E R V I C E S

M E D I C A T I O N A D M I N I S T R A T I O N

M A N U A L

All Critical Care Areas

DOU-limited use as specified below

MIDAZOLAM (VERSED)
ROUTES OF ADMINISTRATION
Direct IV Push, Continuous IV Infusion, IM

METHODS FOR IV ADMINISTRATION AND DOSAGE

1. IV doses should be infused over 2-3 minutes.
2. Critical Care Areas:

Acute agitation in mechanically ventilated patients: 1 - 2 mg administered as slow IV

push over 2 minutes to a maximum of 2 mg every 4 hours.
ICU sedation in mechanically ventilated patients: IV push: 0.01 mg - 0.05 mg/kg (0.5-4
mg for a typical adult); may repeat in 10 - 15 minutes as needed
Continuous IV infusion in mechanically ventilated patients: initiate at 0.02 mg/kg/hour
and titrate by 0.02 mg/kg/hr every 15 30 minutes to a maximum of 0.2 mg/kg/hr.
3. DOU:
Acute agitation in mechanically ventilated patients: 1 - 2 mg administered as slow IV
push over 2 minutes to a maximum of 2 mg every 4 hours.
4. The dose of midazolam must be individualized.
When administered with an opiate agonist or other CNS depressant the dosage should
be reduced by 30% in healthy adults.
The dosage should be reduced by 50% in patients older than 60 years of age, patients
with decreased pulmonary reserve (COPD) or debilitated patients. Because the risk of
under-ventilation or apnea is greatest in geriatric patients, those patients with chronic
debilitating disease or decreased pulmonary reserve should be given dosage increments
smaller and the rate of injection should be slower due to the peak effect may occur
later.
Reduce dose in patients with hepatic dysfunction.

INDICATIONS FOR IV USE

1. Management of agitation/anxiety
2. Adjunct to opioids for pain management
3. Planned Moderate Sedation/Analgesia (i.e. sedation for procedures in patients who are not

being mechanically ventilated): Due to the increased risk of impaired/depressed ventilatory

function, midazolam can only be prescribed by physicians with privileges granted for

Moderate Sedation when used for moderate sedation/analgesia in patients who are
not intubated. For more information, refer to the policy and procedure for Moderate and
Deep Sedation (PC 228) in the Clinical Policy and Procedure Manual. The use of midazolam
as an adjunct to opioids for pain management and for the management of agitation/anxiety is
not considered to be planned moderate sedation/analgesia.

MONITORING PARAMETERS

1. CNS depression
2. Vital signs (respiratory rate, blood pressure, heart rate)

MIDAZOLAM (VERSED)

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L B M M C / P H A R M A C Y S E R V I C E S
M E D I C A T I O N A D M I N I S T R A T I O N

M A N U A L

POTENTIAL PROBLEMS WITH IV ADMINISTRATION

1. Respiratory depression
2. Hypotension, arrhythmias, PVCs, bradycardia, tachycardia
3. Hiccups and coughing (4%), laryngospasm, bronchospasm, dyspnea, hyperventilation,

wheezing, shallow respirations, airway obstruction, tachypnea

4. Nausea and/or vomiting, metallic taste, dry mouth

TREATMENT OF ADVERSE SIDE EFFECTS

1. Respiratory Depression or CNS Depression: respiratory support (oxygen, airway

support), flumazenil (Romazicon) 0.2 mg IV over 15 seconds. May repeat 0.2 mg doses
every minute until desired consciousness level is achieved or total dose of 1 mg is reached. If
resedation occurs may repeat flumazenil dosage regimen every 20 minutes.
2. Hypotension: flumazenil (Romazicon) see dosage above, vasopressors.

COMMENTS

1. Facilities for administration of oxygen and controlled respiration should be readily available

during and following IV administration of midazolam.

2. Agitation, involuntary movements, hyperactivity, and/or combativeness may be signs of

inadequate or excessive dosing, improper administration, or cerebral hypoxia, or may be

paradoxical.
3. Midazolam should not be administered parenterally to patients in shock or coma, or to patients
with acute alcohol intoxication and accompanying depression of vital signs. Caution should be
exercised if midazolam is administered IV to patients with uncompensated acute illness,
including severe fluid and electrolyte imbalances.

REFERENCES
1.
2.
3.
4.
5.

Society of Critical Care Medicine and American Society of Health-System Pharmacists: Clinical Practice Guidelines for the Sustained Use
of Sedatives and Analgesics in the Critically Ill Adult. Am J Health-Syst Pharm. 2002;59:150-78.
American Hospital Formulary Service Drug Information 2001
Drug Facts and Comparisons St Louis Mo
Drugdex Micromedex, Inc.
Romazicon Product Information, Roche, Nutley, NJ

MIDAZOLAM (VERSED)

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