Recommended Dosage of Diazepam for Sedation Prior to Intubation
The recommended dose of diazepam for sedation prior to intubation is 0.2-0.4 mg/kg intravenously (IV) with a maximum dose of 20 mg. 1
Dosing Guidelines
- Diazepam should be administered as an IV/IO (intraosseous) bolus at 0.2-0.4 mg/kg for rapid sequence intubation (RSI) 1
- The maximum recommended single dose is 20 mg, regardless of patient weight 1
- Diazepam has a quicker onset of sedation compared to midazolam (132 ± 87 sec vs. 224 ± 117 sec) 2
- For urgent intubations, diazepam can be given as a 5 mg intravenous bolus followed by aliquots of 5 mg each minute until adequate sedation is achieved 2
Clinical Considerations
- Diazepam will lower intracranial pressure (ICP) and typically does not significantly lower blood pressure, making it a desirable agent for patients with head injury, multisystem trauma, or hypotension 1
- Onset of action is rapid with duration of approximately 10-15 minutes 1
- Diazepam is approximately 2-4 times less potent than midazolam, requiring higher doses to achieve equivalent sedation 3
- Diazepam is significantly more cost-effective than midazolam while providing similar efficacy for intubation 2
Potential Adverse Effects
- May cause brief myoclonic activity (hiccups, cough, twitching) 1
- May exacerbate focal seizure disorders 1
- Causes transient adrenal suppression that is not clinically significant 1
- There is an increased risk of respiratory depression when combined with other sedative agents, particularly opioids 4
- Elderly patients, those with obesity, or patients with hepatic or renal impairment may require dose reduction (20% or more) due to reduced clearance 4
Monitoring and Safety Precautions
- Monitor oxygen saturation and respiratory effort during administration 5
- Be prepared to provide respiratory support if needed 5
- Have flumazenil available for reversal of benzodiazepine effects if severe respiratory depression occurs 1
- Flumazenil dosing for benzodiazepine reversal: 0.01-0.02 mg/kg IV (maximum: 0.2 mg); can repeat at 1-minute intervals to a maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower 1
Special Considerations
- Use with caution in benzodiazepine-dependent patients, as flumazenil may precipitate acute withdrawal if needed 4
- When diazepam fails to provide adequate sedation, rescue with additional benzodiazepines is successful in only about 36% of cases 6
- Diazepam appears safe and effective as a component of goal-directed sedation therapy in critically ill patients 7