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Benzodiazepine Pregnancy: Avoid prolonged use — neonatal withdrawal and respiratory depression; single doses for procedures acceptable

Midazolam (IV/IM)

Brand names: Midazolam (generic), Buccolam (buccal), Epistatus (buccal)

Adult dose

Dose: Premedication: 2–2.5 mg IV (titrated), up to 5 mg. Sedation: 1–2.5 mg IV over 2 min, repeat as needed (max 7.5 mg). ICU sedation infusion: 0.03–0.2 mg/kg/h. Status epilepticus: 10 mg buccal/IM.
Route: IV, IM, or buccal
Frequency: Titrated bolus or continuous infusion
Max: 7.5 mg IV for conscious sedation; ICU infusion titrated
Water-soluble (no propylene glycol unlike diazepam IV). Short half-life vs diazepam. Active metabolite alpha-hydroxy-midazolam accumulates in renal failure. Reversal: flumazenil.

Paediatric dose

Dose: 0.1 mg/kg
Route: IV, IM, buccal, or intranasal
Frequency: Single or titrated doses
Max: 10 mg buccal for SE; 6 mg per dose for sedation
Concentration: 5 mg/mL or 1 mg/mL mg/ml
Status epilepticus (Buccolam): <3 months: 0.3 mg/kg buccal; 3–6 months: 2.5 mg; 6–12 months: 2.5 mg; 1–5 years: 5 mg; 5–10 years: 7.5 mg; 10–18 years: 10 mg

Dose adjustments

Renal

Caution with prolonged ICU infusion — active metabolite accumulates; reduce infusion rate

Hepatic

Significantly reduced clearance in hepatic impairment — use with caution; consider dose reduction

Paediatric weight-based calculator

Status epilepticus (Buccolam): <3 months: 0.3 mg/kg buccal; 3–6 months: 2.5 mg; 6–12 months: 2.5 mg; 1–5 years: 5 mg; 5–10 years: 7.5 mg; 10–18 years: 10 mg

Clinical pearls

  • Faster onset (1–5 min IV) and shorter duration than diazepam — preferred for procedural sedation
  • RASS target in ICU — aim for light sedation (RASS -1 to -2) to reduce ventilator days (MENDS, SLEAP trials)
  • Paradoxical agitation: more common in elderly and children — increase dose or switch agent
  • Buccal midazolam for community SE (Buccolam): available for home use by carers of patients with prolonged/cluster seizures

Contraindications

  • Severe respiratory depression without ventilatory support
  • Severe hepatic impairment
  • Acute narrow-angle glaucoma
  • Myasthenia gravis

Side effects

  • Respiratory depression
  • Hypotension (especially with opioids or in elderly)
  • Paradoxical agitation (especially in elderly/children)
  • Anterograde amnesia (useful perioperatively)
  • Sedation
  • Dependence with prolonged use

Interactions

  • Opioids — respiratory depression synergy (very common anaesthetic combination)
  • Propofol — additive sedation
  • Alcohol — avoid (additive CNS depression)
  • Erythromycin/clarithromycin — increase midazolam levels (CYP3A4 inhibition)

Monitoring

  • Respiratory rate and SpO2
  • Blood pressure
  • Sedation depth (RASS score in ICU)
  • Flumazenil availability for reversal

Reference: BNFc; BNF; BNF for Children; RASS/SAT protocols; MENDS Trial (Pandharipande et al, JAMA 2007). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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