Can I administer Versed (midazolam) to a patient in physical restraints due to agitation?

Managing Agitation in Patients with Physical Restraints: Midazolam Administration

Yes, midazolam (Versed) can be safely administered to patients who are already in physical restraints for continued agitation, and is often an appropriate intervention to reduce agitation and improve patient comfort and safety. 1

Evidence for Midazolam Use in Restrained Patients

• Midazolam has been specifically studied in physically restrained patients with continued agitation. In a randomized prospective double-blind study, patients were initially physically restrained to see if behavior improved, and if not, they were then given pharmacological intervention including midazolam 1
• Midazolam demonstrated the fastest mean time to sedation (18.3 minutes) compared to lorazepam (32.2 minutes) and haloperidol (28.3 minutes) in agitated patients who were initially physically restrained 1
• Chemical restraint with midazolam in addition to physical restraints has been shown to significantly decrease agitation scores compared to physical restraints alone 2

Dosing and Administration

• For agitated patients unable to swallow:

  • Midazolam 2.5-5 mg subcutaneously every 2-4 hours as required 1
  • If needed frequently (more than twice daily), consider a subcutaneous infusion starting with midazolam 10 mg over 24 hours 1
  • Reduce dose to 5 mg over 24 hours if eGFR is <30 mL/minute 1

• For IV administration:

  • Initial dose of 0.01 to 0.05 mg/kg (approximately 0.5 to 4 mg for a typical adult) given slowly or infused over several minutes 3
  • This dose may be repeated at 10 to 15 minute intervals until adequate sedation is achieved 3
  • Titrate to effect with multiple small doses to avoid oversedation 3

Safety Considerations

• Respiratory monitoring is essential: Midazolam can cause respiratory depression, especially when combined with other CNS depressants 3
• Immediate availability of resuscitative equipment and personnel: Ensure that equipment for airway management and personnel trained in its use are readily available 3
• Individualize dosing: Lower doses should be used in elderly patients, those with debilitating conditions, or patients with respiratory compromise 3
• Continuous monitoring: Pulse oximetry and continuous assessment of respiratory and cardiac function are required 3

Potential Adverse Effects

• Respiratory depression is the most significant risk, occurring in approximately 0.5% of emergency department patients 4
• Hypotension may occur, particularly in hemodynamically unstable patients 3
• Paradoxical reactions (increased agitation, involuntary movements) can occur in some patients 3

Clinical Decision Algorithm

1. Assess if chemical restraint is needed:

   • Determine if the patient remains agitated despite physical restraints 1, 2
   • Evaluate for reversible causes of agitation (hypoxia, pain, urinary retention, etc.) 1

2. Before administering midazolam:

   • Ensure monitoring equipment is available (pulse oximetry, blood pressure) 3
   • Have airway management equipment and resuscitative drugs readily accessible 3
   • Consider the patient's age, comorbidities, and concurrent medications 3

3. Administration approach:

   • Start with the lowest effective dose based on patient characteristics 3
   • Allow sufficient time between doses (3-5 minutes for IV) to assess effect 3
   • If inadequate response, administer additional doses in a stepwise manner 3

4. Ongoing monitoring:

   • Continuously monitor respiratory status, oxygen saturation, and vital signs 3
   • Be prepared to provide respiratory support if needed 3
   • Reassess the need for continued chemical restraint regularly 1

Special Considerations

• In patients with COPD or other respiratory conditions, use lower doses due to increased sensitivity to respiratory depression 3
• For elderly patients, reduce the initial dose by at least 20% 1, 3
• If the patient is receiving opioids or other sedatives, reduce the midazolam dose to minimize the risk of respiratory depression 3

Remember that the goal of chemical restraint is not just to control behavior but to reduce the patient's distress and improve their comfort while maintaining safety for both the patient and healthcare providers 2, 5.