From the Guidelines
The recommended dosage of midazolam for sedation in healthy adults younger than 60 years of age is 1-2 mg (or no more than 0.03 mg/kg) injected over 1-2 minutes, with additional doses of 1 mg (or 0.2-0.3 mg) administered at 2-minute intervals until adequate sedation is achieved, as supported by the most recent and highest quality study 1.
Key Considerations for Midazolam Dosage
- The initial dose for adults is 1-2 mg, with a maximum total dose of 6 mg usually not required for routine endoscopic procedures 1.
- Patients older than 60 and those with ASA physical status 3 or above require a dose reduction of 20% or more 1.
- When midazolam is used with an opioid, a synergistic interaction occurs, and a reduction in the dose of midazolam may be indicated 1.
Administration and Monitoring
- Midazolam should be administered slowly over 1-2 minutes, with continuous monitoring of vital signs essential during administration 1.
- Resuscitation equipment should be immediately available due to the risk of respiratory depression 1.
Pharmacological Profile
- Midazolam has a more rapid onset of action and shorter duration of effect compared to diazepam, with an onset of effect within 1-2 minutes and peak effect achieved within 3-4 minutes 1.
- Its duration of effect is 15-80 minutes, with clearance reduced in the elderly, obese, and those with hepatic or renal impairment 1.
From the FDA Drug Label
Patients who exhibit agitation, hypertension or tachycardia in response to noxious stimulation, but who are otherwise adequately sedated, may benefit from concurrent administration of an opioid analgesic. The initial dose of midazolam should be administered over 2 to 3 minutes For all pediatric patients, regardless of the indications for sedation/anxiolysis, it is vital to titrate midazolam and other concomitant medications slowly to the desired clinical effect. Pediatric patients less than 6 months of age: Limited information is available in non-intubated pediatric patients less than 6 months of age Pediatric patients 6 months to 5 years of age: Initial dose 0. 05 to 0.1 mg/kg. Pediatric patients 6 to 12 years of age: Initial dose 0.025 to 0.05 mg/kg; Pediatric patients 12 to 16 years of age: Should be dosed as adults Healthy Adults Below the Age of 60: Titrate slowly to the desired effect, e.g., the initiation of slurred speech. Some patients may respond to as little as 1 mg. Patients Age 60 or Older, and Debilitated or Chronically Ill Patients: Because the danger of hypoventilation, airway obstruction, or apnea is greater in elderly patients and those with chronic disease states or decreased pulmonary reserve, and because the peak effect may take longer in these patients, increments should be smaller and the rate of injection slower.
The recommended dosage and usage of midazolam for sedation vary based on age and patient status.
- For pediatric patients:
- Less than 6 months: Limited information available
- 6 months to 5 years: Initial dose 0.05 to 0.1 mg/kg
- 6 to 12 years: Initial dose 0.025 to 0.05 mg/kg
- 12 to 16 years: Dosed as adults
- For adults:
- Healthy adults below 60: Titrate slowly to desired effect, starting with 1 mg
- Patients 60 or older, debilitated, or chronically ill: Smaller increments and slower rate of injection, starting with 1 mg It is essential to titrate midazolam slowly and monitor patients closely to avoid adverse effects, especially in vulnerable populations 2 2.
From the Research
Recommended Dosage and Usage of Midazolam for Sedation
The recommended dosage and usage of midazolam for sedation vary depending on the route of administration, patient age, and medical procedure.
- For preoperative sedation, the recommended dose of midazolam is 0.07-0.1 mg/kg given by intramuscular injection one hour before surgery 3.
- For conscious sedation, 0.1-0.15 mg/kg intravenously in divided doses is usually adequate 3.
- Lower doses of midazolam are recommended for elderly or debilitated patients and patients who have severe liver disease 3.
- As a premedication, midazolam should be injected i.m. 15 min before entering an operating room in a dose of 0.04 mg.kg-1 to 0.08 mg.kg-1 according to the patient's age 4.
- For anesthesia induction, midazolam should be used together with barbiturate or propofol to take advantage of synergistic effects 4.
- During spinal or epidural anesthesia, i.v. midazolam of 0.05 mg.kg-1 has anti-anxietic and sedative effects 4.
Route of Administration
Midazolam can be administered by several routes including:
Efficacy and Safety
There is low-quality evidence that intravenous midazolam reduces anxiety when compared with placebo 5, 6. There is inconsistent evidence that oral midazolam decreases anxiety during procedures compared with placebo 5, 6. Intranasal midazolam did not reduce the risk of incomplete procedures, although anxiolysis and sedation were observed 5, 6. There is moderate-quality evidence suggesting that oral midazolam produces less effective sedation than chloral hydrate for completion of procedures for children undergoing non-invasive diagnostic procedures 5, 6. Midazolam can be safely used in the emergency department setting with careful dosing and titration to the desired clinical effects 7.