Midazolam
Versed
Short-acting benzodiazepine
GABA-A potentiation at benzodiazepine receptor.
Indications
- •Premedication (anxiolysis, amnesia)
- •Procedural sedation
- •Status epilepticus
- •ICU sedation
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| Premed adult IV | 1–2 mg IV | — |
| Premed peds PO | — | 0.5 mg/kg PO (max 20 mg) |
| Status epilepticus | 5–10 mg IV/IM/buccal/intranasal | — |
| ICU infusion | 0.02–0.1 mg/kg/hr | — |
Pharmacokinetics
Onset 1–3 min IV. Duration 30–60 min. Hepatic CYP3A4 (interactions with macrolides, azoles).
Hemodynamic effects
Mild ↓BP at induction doses; minimal otherwise.
Respiratory effects
Synergistic respiratory depression with opioids.
Side effects
- !Paradoxical agitation (peds, elderly)
- !Prolonged sedation in elderly + hepatic dysfunction
- !Tolerance with chronic use
Contraindications
- ×Acute angle-closure glaucoma (relative)
- ×Severe respiratory depression without monitoring
Reversal / antidote
Flumazenil 0.2 mg IV q1 min (max 1 mg) — caution in benzo-dependent (seizure risk).
Clinical pearls
- ★PO peds dose tastes bitter — consider mixed in cherry syrup.
- ★Avoid in elderly when alternatives exist; one of strongest delirium triggers.
- ★Intranasal midaz works for combative pediatric induction.
Education only — confirm against current package inserts and institutional protocols. Doses assume normal organ function unless otherwise noted.