Midazolam
VERSED
What it isShort-acting GABA-A positive allosteric modulator; procedural sedation and emergency seizure treatment.
Why this oneWater solubility permits intravenous, intramuscular, intranasal, and buccal delivery when no IV line is available.
What limits itRespiratory depression demands airway monitoring, especially with opioids; CYP3A4 inhibitors and prolonged infusion cause accumulation.
FDA-approved for
- procedural sedation (1985)
- seizure clusters (nasal) (2019)
Off-label
- status epilepticus (intranasal or IM)
FDA label
Read the full label on DailyMed ↗
BOXED WARNING IV midazolam can cause respiratory depression/arrest — use only where continuous respiratory/cardiac monitoring and resuscitation are available; concomitant opioids may cause profound sedation, respiratory depression, coma, death; individualize dose
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Preop sedation/anxiolysis/amnesia (IM) | Adult <60 yr | 0.07–0.08 mg/kg IM (~5 mg) up to 1 h preop | ||
| Preop sedation (IM) | Adult ≥60 yr/debilitated | 2–3 mg (0.02–0.05 mg/kg) IM; 1 mg may suffice | ||
| Procedural sedation/anxiolysis/amnesia (IV) | Adult <60 yr | 1–2.5 mg IV over ≥2 min | usually ≤5 mg total | |
| Procedural sedation (IV) | Adult ≥60 yr/debilitated/chronically ill | ≤1.5 mg IV over ≥2 min; further titration ≤1 mg over 2 min | usually ≤3.5 mg total | |
| Induction of anesthesia (IV), unpremedicated | Adult <55 yr | 0.3–0.35 mg/kg IV over 20–30 s | up to 0.6 mg/kg in resistant cases | |
| Induction of anesthesia (IV), unpremedicated | Adult >55 yr / debilitated | >55 yr: 0.3 mg/kg; severe systemic disease/debilitated: 0.2–0.25 mg/kg (as little as 0.15 mg/kg) | ||
| Induction of anesthesia (IV), premedicated | Adult | 0.15–0.35 mg/kg IV (<55 yr usually 0.25 mg/kg; ASA I/II >55 yr: 0.2 mg/kg; severe systemic disease: 0.15 mg/kg) | ||
| Continuous IV infusion, sedation (critical care) | Adult | Loading (if needed) 0.01–0.05 mg/kg (~0.5–4 mg) slowly, may repeat q10–15min; then 0.02–0.10 mg/kg/hr (1–7 mg/hr) | titrate to lowest effective rate; adjust by 25–50% of initial rate; decrease rate 10–25% every few hours | |
| Preop/procedural sedation (IM) | Pediatric (non-neonatal) | 0.1–0.15 mg/kg IM; up to 0.5 mg/kg for more anxious patients | total usually ≤10 mg | |
| Procedural sedation (IV, intermittent) | Pediatric <6 mo | Limited data; titrate with small increments to effect, monitor closely (dosing recommendations unclear) | ||
| Procedural sedation (IV, intermittent) | Pediatric 6 mo–5 yr | 0.05–0.1 mg/kg IV over 2–3 min | total up to 0.6 mg/kg may be needed, usually ≤6 mg | |
| Procedural sedation (IV, intermittent) | Pediatric 6–12 yr | 0.025–0.05 mg/kg IV over 2–3 min | total up to 0.4 mg/kg may be needed, usually ≤10 mg | |
| Procedural sedation (IV, intermittent) | Pediatric 12–16 yr | Dose as adults | total usually ≤10 mg | |
| Continuous IV infusion, sedation (critical care, intubated) | Pediatric (non-neonatal) | Load 0.05–0.2 mg/kg IV over ≥2–3 min (intubated patients), then 0.06–0.12 mg/kg/hr (1–2 mcg/kg/min) | adjust rate (generally by 25%) or give supplemental doses to maintain effect | |
| Continuous IV infusion, sedation (critical care, intubated) | Neonate | <32 wk gestation: 0.03 mg/kg/hr (0.5 mcg/kg/min); >32 wk: 0.06 mg/kg/hr (1 mcg/kg/min). Do NOT use IV loading doses; run infusion faster for first several hours instead | reassess rate frequently (esp. after 24 h) to use lowest effective dose |
Titration Allow ≥2 min (peak CNS effect 3–5 min) between IV doses to fully evaluate sedative effect before re-dosing
Renal Undefined
Hepatic Undefined
Titrate slowly; contains benzyl alcohol
Instructions
- Give IM deep into a large muscle, or IV slowly over ≥2 min; avoid intra-arterial injection/extravasation
- Do not give by rapid injection in neonates (severe hypotension, seizures reported)
- Reduce dose ~30% with narcotic premedication (≥50% in elderly)
- Maintenance increments ~25% of the dose used to first reach sedative endpoint
- Pediatric doses on mg/kg basis; in obese pediatric patients calculate dose on ideal body weight
- For continuous infusion, use 5 mg/mL formulation diluted to 0.5 mg/mL in 0.9% NaCl or D5W
Contraindications
- Acute narrow-angle glaucoma
- Intrathecal or epidural administration (contains benzyl alcohol preservative)
- Premature infants (formulation contains benzyl alcohol)
Cautions
- Respiratory depression/airway obstruction/apnea, esp. with rapid injection or upper-airway procedures
- Profound sedation/respiratory depression with concomitant opioids or CNS depressants
- Paradoxical reactions (agitation, involuntary movements, combativeness)
- Neonatal hypotension/seizures with rapid IV injection (esp. with fentanyl)
- Potential pediatric neurotoxicity with prolonged/repeated anesthesia
Adverse reactions
- ↓Tidal volume / respiratory rate decrease
- Apnea
- BP/pulse variations
- Hiccoughs
- Nausea/vomiting
- Injection-site pain/tenderness
- Headache, drowsiness, oversedation
- Peds: desaturation, apnea, hypotension, paradoxical reactions
Pregnancy Historically Category D; anesthetic/sedation drugs (NMDA-block/GABA-potentiating) for >3 h during peak brain development increase neuronal apoptosis in animal offspring
Lactation Undefined
⚠ BOXED WARNINGS
- Risk from concomitant use with opioids
- Abuse, misuse and addiction
- Dependence and withdrawal reactions
Cost, est. cash$20–$1,500/dose or month
Generic entry2000
Classes and tags
Clinical profile
Legacy pregnancy categoryD
Defining liabilityProfound respiratory depression and apnea can occur, especially with opioids or rapid parenteral dosing.
Mechanism of action: Midazolam ballicule
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Memory aids: mascots and interaction avatars
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