What is the recommended drip rate for a Versed (midazolam) infusion after Rapid Sequence Intubation (RSI)?

From the Guidelines

The recommended drip rate for a Versed (midazolam) infusion after Rapid Sequence Intubation (RSI) is 1-20 mg/h, with a starting dose of 0.5-1 mg/h, as needed, titrated to the desired level of sedation. This is based on the most recent and highest quality study available, which provides guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation 1.

Key Considerations

• The usual effective dose of midazolam infusion is between 1-20 mg/h, with a starting dose of 0.5-1 mg/h, as needed, titrated to the desired level of sedation.
• Midazolam is a water-soluble, short-acting benzodiazepine with a brief duration of action due to rapid redistribution, requiring continuous infusion to maintain a sustained effect.
• The advantages of midazolam include rapid onset and the ability to be administered intravenously or subcutaneously, as well as co-administered with morphine or haloperidol.
• Potential adverse effects of midazolam include paradoxical agitation, respiratory depression, withdrawal if the dose is rapidly reduced after continual infusion, and tolerance.

Clinical Application

• Regular assessment of sedation level using a validated scale such as the Richmond Agitation-Sedation Scale (RASS) or Ramsay Sedation Scale is essential for appropriate titration of the midazolam infusion.
• It is crucial to be aware that prolonged midazolam infusions can lead to accumulation of the drug and its active metabolites, potentially prolonging sedation, especially in patients with liver or kidney dysfunction.
• The infusion should be prepared by adding an appropriate amount of midazolam to a compatible IV fluid, creating a concentration that allows for precise titration based on patient response.

Monitoring and Titration

• Close monitoring of the patient's sedation level, respiratory status, and other vital signs is necessary to ensure safe and effective use of the midazolam infusion.
• Titration of the drip rate should be based on clinical assessment, taking into account the patient's response to the medication and any potential adverse effects.

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 drip rate for a Versed (midazolam) infusion after Rapid Sequence Intubation (RSI) 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, considering the patient's age, clinical status, and current medications. The goal is to use the lowest effective infusion rate to minimize the risk of accumulation and promote rapid recovery once the infusion is terminated 2.

From the Research

Recommended Drip Rate for Versed (Midazolam) Infusion after RSI

The recommended drip rate for a Versed (midazolam) infusion after Rapid Sequence Intubation (RSI) is not directly stated in the provided studies. However, the studies provide information on the dosage and infusion rates of midazolam in various clinical settings:

• In the treatment of refractory generalized convulsive status epilepticus, a continuous infusion of midazolam at 1 microg/kg/min, increased by 1 microg/kg/min every 15 min until seizure control is achieved, has been used 3.
• In children with status epilepticus, an initial bolus of 0.15 mg/kg followed by a continuous infusion at 0.1-0.15 mg/kg/hr, increased gradually up to 0.3 mg/kg/hr, has been effective 4.
• In adults with refractory generalized convulsive status epilepticus, a continuous infusion at 0.1-0.6 mg/kg/hr after a 0.2 mg/kg i.v. bolus has been used 5.

Key Considerations

When determining the drip rate for a Versed infusion after RSI, consider the following:

• The patient's clinical condition and response to the infusion
• The potential for hypotension and respiratory depression, particularly in children and neonates 6, 7
• The need for close monitoring of hemodynamic parameters and oxygen saturation

Dosage and Infusion Rates

Some studies suggest the following dosage and infusion rates:

• 0.1-0.6 mg/kg/hr after a 0.2 mg/kg i.v. bolus for refractory generalized convulsive status epilepticus 5
• 0.1-0.15 mg/kg/hr, increased gradually up to 0.3 mg/kg/hr, for children with status epilepticus 4
• 1 microg/kg/min, increased by 1 microg/kg/min every 15 min, for refractory generalized convulsive status epilepticus 3