What is the protocol for administering midazolam (Benzodiazepine) infusion in children with status epilepticus?

Midazolam Infusion Protocol for Status Epilepticus in Children

For pediatric status epilepticus, administer midazolam with an initial IV bolus of 0.15 mg/kg followed by continuous infusion starting at 0.1-0.15 mg/kg/hr, titrating up to 0.3 mg/kg/hr as needed until seizure control is achieved. 1, 2, 3

Initial Assessment and Preparation

• Ensure airway patency, adequate oxygenation, and hemodynamic stability
• Establish secure IV access (preferably two lines)
• Connect to continuous cardiorespiratory monitoring (ECG, blood pressure, oxygen saturation)
• Have resuscitation equipment immediately available
• Prepare for potential respiratory support (bag-valve-mask, intubation equipment)

Dosing Protocol

First-Line Treatment (if not already attempted)

• Benzodiazepines are first-line treatment with approximately 65% success rate 1
• If midazolam is used as first-line agent:
  • IV bolus: 0.1-0.3 mg/kg (maximum 6 mg per dose) 4
  • IM (if IV access unavailable): 0.2 mg/kg (maximum 6 mg per dose) 5

Refractory Status Epilepticus - Midazolam Infusion

1. Initial IV Bolus:

   • Administer 0.15 mg/kg IV over 2-3 minutes 2, 3
   • For hemodynamically compromised patients, titrate in smaller increments 6

2. Continuous Infusion:

   • Start at 0.1-0.15 mg/kg/hr (1-2.5 mcg/kg/min) 6, 2
   • Titrate upward in increments of 0.05-0.1 mg/kg/hr every 15 minutes as needed 2
   • Maximum recommended rate: 0.3 mg/kg/hr (5 mcg/kg/min) 5, 2
   • For intubated patients in critical care settings, may initiate at 0.06-0.12 mg/kg/hr 6

3. Monitoring During Infusion:

   • Assess seizure control continuously
   • Monitor vital signs every 5-15 minutes initially, then hourly when stable
   • Monitor oxygen saturation continuously
   • Be prepared to provide respiratory support 5, 6

4. Duration of Treatment:

   • Continue infusion for 12-24 hours after last seizure 3
   • Taper gradually by reducing rate by 25% every 4-6 hours 6

Special Considerations

Age-Specific Considerations

• Neonates (<32 weeks): Use lower infusion rates (0.03 mg/kg/hr) 6
• Neonates (>32 weeks): Start at 0.06 mg/kg/hr 6
• Children <6 months: Limited data available; use with extreme caution 6
• Children 6 months-5 years: May require higher maintenance doses 6

Precautions

• Increased risk of respiratory depression when combined with other sedatives or opioids 5, 6
• Flumazenil should be available but used cautiously as it may precipitate seizures 5
• Hypotension may occur, especially with rapid administration 6
• Drug elimination may be delayed in patients receiving erythromycin or with liver dysfunction 6

Efficacy and Safety

• Seizure cessation rates with midazolam infusion range from 85-91% 2, 3, 7
• Most seizures are controlled within 30 minutes of initiating therapy 2, 8
• Respiratory depression occurs in approximately 13% of cases, with need for assisted ventilation in 3% 7

Alternative Approaches for Refractory Cases

If seizures persist despite optimal midazolam infusion:

• Consider adding or switching to other anticonvulsants:
  • Valproate: 20-30 mg/kg IV (88% success rate) 1
  • Levetiracetam: 30-50 mg/kg IV (44-73% success rate) 1
  • Phenobarbital: 10-20 mg/kg IV (58% success rate) 1
• For super-refractory status epilepticus, consider propofol (2 mg/kg bolus, 5 mg/kg/hr infusion) 1

Discontinuation

• Once seizure-free for 12-24 hours, begin tapering by reducing infusion rate by 25% every 4-6 hours 6
• Monitor closely for seizure recurrence during and after tapering
• Consider transitioning to maintenance antiepileptic medications

This protocol provides a practical guide for administering midazolam infusion in pediatric status epilepticus, with emphasis on appropriate dosing, monitoring, and safety considerations to optimize outcomes while minimizing adverse effects.