What is the recommended dosage and administration guidelines for Versed (midazolam)?

Midazolam (Versed) Dosage and Administration Guidelines

For adult patients requiring sedation, the recommended initial dose of midazolam is 1-2 mg IV administered over 2 minutes, with titration in small increments to the desired effect, not exceeding 5 mg total dose in healthy adults under 60 years. 1

Adult Dosing Guidelines

Intravenous Administration

• Initial dose for healthy adults under 60 years: 1-2 mg (0.03 mg/kg) IV administered over 2 minutes 1
• Wait 2 or more minutes to evaluate sedative effect before administering additional doses 1
• Titrate in small increments (1 mg) until desired effect (e.g., slurred speech) 1
• Total dose rarely exceeds 5 mg in healthy adults 1
• For patients receiving opioids or other CNS depressants, reduce midazolam dose by approximately 30% 1

Special Populations

• Adults 60 years or older: Initial dose 1-1.5 mg IV over 2 minutes; total dose rarely exceeds 3.5 mg 1
• Debilitated or chronically ill patients: Reduce dose by 50% compared to healthy adults 1
• Patients with hepatic or renal impairment: Reduce dose due to decreased clearance 2

Intramuscular Administration

• Preoperative sedation: 0.07-0.08 mg/kg IM (approximately 5 mg) administered up to 1 hour before procedure 1
• Inject deep into large muscle mass 1
• Onset within 15 minutes, peak effect at 30-60 minutes 1

Continuous Infusion

• For critical care sedation: Initial IV loading dose of 0.05-0.2 mg/kg administered over 2-3 minutes 1
• Maintenance infusion: 0.06-0.12 mg/kg/hr (1-2 mcg/kg/min) 1
• Adjust rate by 25% of initial rate as needed based on clinical response 1

Pediatric Dosing

• 6 months to 5 years: Initial dose 0.05-0.1 mg/kg IV; total dose up to 0.6 mg/kg (not exceeding 6 mg) 1, 3
• 6-12 years: Initial dose 0.025-0.05 mg/kg IV; total dose up to 0.4 mg/kg (not exceeding 10 mg) 1, 3
• 12-16 years: Dose as adults 1
• For seizures: 0.05-0.1 mg/kg IV/IM (maximum 4 mg per dose), may repeat every 10-15 minutes if needed 2

Administration Precautions

• Always titrate slowly, administering over at least 2 minutes 1
• Allow 2 or more minutes between doses to fully evaluate sedative effect 1
• Ensure immediate availability of resuscitative equipment and personnel trained in airway management 1
• Monitor oxygen saturation continuously during administration 2
• Reduce dose when used with other CNS depressants, especially opioids 1

Potential Adverse Effects

• Respiratory depression and apnea, especially when combined with opioids 4, 5
• Hypotension, particularly in elderly, critically ill patients, or with rapid administration 1
• Paradoxical reactions including agitation, anxiety, and insomnia 6
• Hiccups, cough, nausea, and vomiting 4

Reversal Agent

• Flumazenil can reverse midazolam-induced sedation in emergency situations 7
• Typical flumazenil dose: 0.2-0.4 mg IV every 2-3 minutes until desired response 6

Clinical Pearls

• Midazolam is approximately 2-4 times more potent than diazepam 4, 8
• Half-life is approximately 1 hour in healthy adults but may be prolonged in renal or hepatic dysfunction 4
• Water-soluble in commercial formulation but becomes lipid-soluble at physiological pH, allowing rapid CNS penetration 3
• Metabolized by cytochrome P450 enzyme system; drug interactions possible with inhibitors like cimetidine 4

Remember that careful titration to clinical effect and close monitoring are essential for safe administration of midazolam in all patient populations.