What is the recommended starting dose for a midazolam (Versed) drip after Rapid Sequence Intubation (RSI)?

Recommended Starting Dose for Midazolam (Versed) Drip After Rapid Sequence Intubation (RSI)

For adult patients after RSI, the recommended starting dose for a midazolam continuous infusion is 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr), with an initial loading dose of 0.01 to 0.05 mg/kg if needed to rapidly initiate sedation. 1

Initial Dosing Strategy

• For most adult patients, begin with an infusion rate of 0.02-0.10 mg/kg/hr after RSI, titrating to the desired level of sedation 1
• If immediate sedation is needed after RSI, consider a loading dose of 0.01-0.05 mg/kg (approximately 0.5-4 mg for a typical adult) given slowly or infused over several minutes before starting the continuous infusion 1
• Lower doses should be used in patients with residual effects from anesthetic drugs used during RSI, or in those concurrently receiving other sedatives or opioids 1

Patient-Specific Considerations

• For elderly patients (age 60 or older), debilitated patients, or those with chronic illness:

  • Reduce the initial infusion rate by at least 50% (approximately 0.01-0.05 mg/kg/hr) 1
  • Use smaller increments when titrating and allow longer intervals between dose adjustments 1
  • These patients are at higher risk for hypoventilation, airway obstruction, and apnea 1

• For patients with hepatic or renal impairment:

  • Midazolam clearance is reduced, requiring lower initial doses and careful titration 2
  • Monitor more frequently for signs of oversedation 1

Titration and Monitoring

• Assess sedation level at regular intervals (every 1-2 hours) 2
• Adjust the midazolam infusion rate up or down by 25-50% of the initial rate to maintain the desired level of sedation 1
• Target the lowest infusion rate that achieves adequate patient-ventilator synchrony 3
• Monitor oxygen saturation continuously, as respiratory depression is the major side effect of midazolam 2

Common Pitfalls and Caveats

• Studies have shown that ED patients often receive inadequate post-intubation anxiolysis and analgesia after RSI - ensure appropriate dosing is initiated promptly 4
• There is an increased incidence of apnea when midazolam is combined with other sedative agents, particularly opioids 2
• Be prepared to provide respiratory support regardless of the route of administration 2
• Flumazenil may be administered to reverse life-threatening respiratory depression caused by midazolam, but it will also reverse the sedative effects 2
• Longer-term midazolam infusions may lead to prolonged weaning times compared to propofol 3

Combination Therapy

• When midazolam is used with an opioid, a synergistic interaction occurs, requiring a reduction in the midazolam dose 2
• Ensure adequate analgesia is provided alongside anxiolysis - many patients receive inadequate analgesia after RSI 4
• Consider adding fentanyl 25-100 μg IV followed by an appropriate infusion if analgesia is needed 2