Midazolam Infusion Dosage and Administration Protocol
For sedative-naïve adult patients requiring midazolam infusion, begin with a 2 mg intravenous bolus dose followed by a continuous infusion of 1 mg/h, with doses adjusted based on patient size, age, and organ dysfunction. 1
Adult Dosing Protocol
Initial Bolus Dose
- For sedative-naïve patients: 2 mg IV bolus administered over 2-3 minutes 1
- For patients with renal/hepatic impairment or elderly: Consider reducing initial bolus to 1-1.5 mg 2
- Allow 3-5 minutes to evaluate sedative effect before additional dosing 2
Continuous Infusion Setup
- Dilute midazolam 5 mg/mL to a concentration of 0.5 mg/mL with 0.9% sodium chloride or 5% dextrose in water 2
- Initial infusion rate: 1 mg/h (0.02 mg/kg/h for a typical adult) 1
- Maintenance range: 0.02-0.10 mg/kg/h (1-7 mg/h for a typical adult) 2
Titration Protocol
- If patient becomes symptomatic during infusion, administer a bolus dose equal to or double the hourly infusion rate 1
- Order IV bolus doses every 5 minutes as needed 1
- If patient requires two bolus doses within an hour, double the infusion rate 1
- Adjust infusion rate by 25-50% to maintain desired sedation level 2
- Decrease rate by 10-25% every few hours to find minimum effective dose 2
Pediatric Dosing Protocol
Initial Bolus Dose
- For sedation/anxiolysis: 0.05-0.10 mg/kg IV over 2-3 minutes (maximum: 5 mg) 1
- For seizures: 0.15-0.20 mg/kg IV loading dose 1
Continuous Infusion
- For children with intubated trachea: Start at 0.06-0.12 mg/kg/h (1-2 μg/kg/min) 2
- For refractory status epilepticus: Start at 1 μg/kg/min, increase by increments of 1 μg/kg/min (maximum: 5 μg/kg/min) every 15 minutes until seizures stop 1, 3
- Recent evidence suggests a therapeutic window of 2.0-5.0 μg/kg/min (0.12-0.30 mg/kg/h) may achieve earlier seizure cessation 3
Neonatal Dosing
- For intubated neonates <32 weeks: 0.03 mg/kg/h (0.5 μg/kg/min) 2
- For intubated neonates >32 weeks: 0.06 mg/kg/h (1 μg/kg/min) 2
- Do not use loading doses in neonates 2
Monitoring Requirements
- Continuous monitoring of vital signs and oxygen saturation 2
- Assess sedation level at regular intervals using standardized sedation scales 4
- Be prepared to provide respiratory support regardless of administration route 1
- Have flumazenil available to reverse life-threatening respiratory depression 1
- Monitor for hypotension, especially in hemodynamically compromised patients 2
Special Considerations
- For elderly patients (>60 years) or those with organ dysfunction: Use lower doses (reduce by 25-50%) 2
- When combined with opioids: Increased risk of respiratory depression; consider reducing midazolam dose by 25-30% 2
- For withdrawal of life-sustaining measures: Titrate to symptoms with no specified dose limit 1
- Non-benzodiazepine alternatives (propofol, dexmedetomidine) may be preferred for ICU sedation due to lower risk of delirium 1
Common Pitfalls to Avoid
- Oversedation: Assess sedation level frequently and adjust dose accordingly 2, 4
- Respiratory depression: Particularly when combined with other sedatives or opioids 1
- Paradoxical agitation: May occur especially in younger children 1
- Prolonged emergence: Due to accumulation with extended infusions, especially in renal/hepatic impairment 4
- Delirium: Benzodiazepine use is a strong risk factor for ICU delirium 1
By following this protocol and adjusting doses based on individual patient response, midazolam infusions can be safely and effectively administered while minimizing adverse effects and optimizing patient outcomes.