What is the recommended dosage for intravenous (IV) administration of diazepam?

Intravenous Diazepam Dosage Guidelines

For adult patients, the recommended IV diazepam dosage is 5-10 mg administered slowly over at least 1 minute for each 5 mg given, with dosage individualized based on indication and severity. 1

Adult Dosing by Indication

Anxiety Disorders

• Moderate anxiety: 2-5 mg IV, may repeat in 3-4 hours if necessary 1
• Severe anxiety: 5-10 mg IV, may repeat in 3-4 hours if necessary 1

Acute Alcohol Withdrawal

• 10 mg IV initially, then 5-10 mg in 3-4 hours if necessary 1

Status Epilepticus

• 5-10 mg IV initially (preferred route)
• May repeat at 10-15 minute intervals up to maximum dose of 30 mg
• If necessary, therapy may be repeated in 2-4 hours, considering residual active metabolites 1

Muscle Spasm

• 5-10 mg IV initially, then 5-10 mg in 3-4 hours if necessary 1
• For tetanus, larger doses may be required

Preoperative Medication

• 10 mg IM (preferred route) before surgery 1

Endoscopic Procedures

• Titrate IV dosage to desired sedative response
• Generally 10 mg or less is adequate, but up to 20 mg IV may be given 1

Cardioversion

• 5-15 mg IV, within 5-10 minutes prior to procedure 1

Pediatric Dosing

Status Epilepticus

• Infants over 30 days and children under 5 years: 0.2-0.5 mg slowly every 2-5 minutes up to maximum of 5 mg (IV preferred) 2, 1
• Children 5 years or older: 1 mg every 2-5 minutes up to maximum of 10 mg (slow IV administration preferred) 1
• May repeat in 2-4 hours if necessary

Tetanus

• Infants over 30 days: 1-2 mg IV slowly, repeated every 3-4 hours as necessary 1
• Children 5 years or older: 5-10 mg repeated every 3-4 hours may be required 1

Administration Technique

Critical Safety Points

• Administer IV diazepam slowly, taking at least one minute for each 5 mg (1 mL) given 3, 1
• Do not use small veins, such as those on the dorsum of the hand or wrist 1
• Extreme care should be taken to avoid intra-arterial administration or extravasation 1
• Do not mix or dilute diazepam with other solutions or drugs in syringe or infusion container 1
• If direct IV administration is not feasible, inject slowly through infusion tubing as close as possible to vein insertion 1

Special Considerations

Respiratory Monitoring

• Facilities for respiratory assistance should be readily available 3, 1
• Risk of respiratory depression increases when combined with other sedative agents, particularly opioids 1
• Extreme caution must be used when administering to elderly, very ill patients, and those with limited pulmonary reserve due to risk of apnea and/or cardiac arrest 1

Dosage Adjustments

• Lower doses (usually 2-5 mg) and slow increase in dosage should be used for elderly or debilitated patients 1
• When diazepam is used with narcotic analgesics, reduce narcotic dosage by at least one-third 1

Contraindications

• Severe respiratory insufficiency
• Sleep apnea syndrome
• Severe hepatic impairment
• Myasthenia gravis
• Acute narrow-angle glaucoma 3

Reversal Agent

• Flumazenil is indicated for complete or partial reversal of benzodiazepine effects in overdose situations 1
• Be aware that flumazenil may precipitate seizures, particularly in long-term benzodiazepine users 1

Common Pitfalls to Avoid

1. Too rapid administration leading to respiratory depression
2. Underdosing in status epilepticus, which may lead to progression to refractory status epilepticus 4
3. Failure to have resuscitation equipment readily available
4. Mixing diazepam with other solutions (causes precipitation)
5. Using small veins for administration
6. Not accounting for prolonged effects in elderly or those with hepatic impairment

Remember that while diazepam has a rapid onset of action (2-3 minutes), its effects diminish relatively quickly compared to other benzodiazepines like lorazepam, which has a longer duration of action 5, 6. This pharmacokinetic difference may be important when selecting the appropriate benzodiazepine for specific clinical scenarios.