What is the recommended dose of midazolam (Benzodiazepine) infusion for post-intubation sedation?

From the Guidelines

For post-intubation sedation, midazolam infusion should be initiated at a dose of 0.02-0.1 mg/kg/hr, with a typical range of 1-7 mg/hr for a 70 kg adult, after an initial loading dose of 0.01-0.05 mg/kg IV, and titrated to the desired level of sedation. This recommendation is based on the need to balance the benefits of sedation with the risks of over-sedation and respiratory depression, as highlighted in the study by Cole et al 1. The dose should be adjusted according to the patient's response, using a validated sedation scale such as the Richmond Agitation-Sedation Scale (RASS), and considering factors such as age, renal or hepatic impairment, and hemodynamic stability.

Key considerations for midazolam infusion include:

• Initial loading dose: 0.01-0.05 mg/kg IV
• Maintenance dose: 0.02-0.1 mg/kg/hr (1-7 mg/hr for a 70 kg adult)
• Titration: to the desired level of sedation using a validated sedation scale
• Special populations: elderly patients, those with renal or hepatic impairment, and hemodynamically unstable patients generally require lower doses
• Monitoring: continuous assessment for signs of over-sedation and regular sedation holds to assess neurological status and prevent tolerance, as midazolam accumulates with prolonged use due to its active metabolites, potentially prolonging sedative effects, as noted in the study 1.

It is also important to note that midazolam lacks analgesic effects, so concurrent pain management with opioids or other analgesics is typically necessary for intubated patients experiencing pain, and that the major side effect of midazolam is respiratory depression, which can be fatal, especially when combined with opioids, as reported in the study 1.

From the FDA Drug Label

For maintenance of sedation, the usual initial infusion rate is 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr). The infusion rate should be titrated to the desired level of sedation, taking into account the patient’s age, clinical status and current medications. In general, midazolam should be infused at the lowest rate that produces the desired level of sedation The recommended dose of midazolam infusion for post-intubation sedation is 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr) and should be titrated to the desired level of sedation. The infusion rate should be adjusted based on the patient's age, clinical status, and current medications. The lowest effective dose should be used to minimize the risk of accumulation and promote rapid recovery 2.

From the Research

Midazolam Infusion for Post-Intubation Sedation

• The recommended dose of midazolam infusion for post-intubation sedation is not explicitly stated in the provided studies, but the dose range for midazolam can be found in the study comparing dexmedetomidine vs midazolam for sedation of critically ill patients 3.
• In this study, midazolam was administered at a dose of 0.02-0.1 mg/kg per hour.
• Another study compared dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation, and midazolam was used at a dose that was not specified in the provided text, but the study can be referred to for more information 4.
• A study on the complications of sedation with midazolam in the intensive care unit mentioned that midazolam is commonly administered via titrated, continuous infusions, but did not provide a specific dose range 5.
• It is essential to note that the dose of midazolam may vary depending on the patient's condition, age, and other factors, and should be determined by a healthcare professional.

Considerations for Midazolam Use

• Midazolam has been associated with complications such as hypotension, paradoxical and psychotic reactions, tolerance, and tachyphylaxis, as well as benzodiazepine withdrawal syndrome 5.
• The use of midazolam should be carefully monitored, and the dose should be titrated to achieve the desired level of sedation while minimizing the risk of adverse effects.
• Other studies have compared midazolam to other sedatives, such as dexmedetomidine and propofol, and found that midazolam may have a more variable time course for recovery of function after the cessation of the infusion 3, 4.

Assessment and Goal Achievement

• The Richmond Agitation Sedation Scale (RASS) is a tool used to assess the level of sedation in patients, and studies have shown that achieving a target RASS score can be challenging 6.
• A study evaluating the use of RASS in mechanically ventilated patients in the emergency department found that only 18.9% of patients achieved their RASS goal in the ED 6.
• The study highlights the importance of consistent assessment and documentation of RASS measurements to ensure that patients receive appropriate sedation and achieve their target RASS score.