What is the recommended dose of diazepam (Diazepam) for intubation?

Diazepam Dosing for Intubation

The recommended dose of diazepam for intubation is 0.2-0.4 mg/kg IV/IO as a bolus, with a maximum single dose of 20 mg regardless of patient weight. 1

Adult Dosing

• Initial dose: 5-10 mg IV administered over 1 minute 2
• Additional doses may be administered at 5-minute intervals if needed for adequate sedation 2
• For most intubation procedures, 10 mg IV is typically sufficient, though up to 20 mg may be necessary if not co-administering an opioid 2
• For rapid sequence intubation, diazepam can be given as a 5 mg IV bolus followed by additional 5 mg aliquots each minute until adequate sedation is achieved (Ramsay sedation scale 5-6) 3

Pediatric Dosing

• 0.2-0.4 mg/kg IV/IO for rapid sequence intubation 1
• Maximum single dose: 20 mg 1

Clinical Considerations

Advantages of Diazepam for Intubation

• Rapid onset of action with duration of approximately 10-15 minutes 1
• Lowers intracranial pressure without significant blood pressure reduction, making it suitable for patients with head injury, multisystem trauma, or hypotension 1
• May be more cost-effective than midazolam while providing similar sedation quality 3
• Faster time to adequate sedation compared to midazolam (132 ± 87 sec vs. 224 ± 117 sec) 3

Special Populations

• Dose reduction (20% or more) is required in:
  • Elderly patients 2, 1
  • Debilitated patients 2
  • Patients with hepatic or renal impairment 1
  • Obese patients 1

Administration Technique

• Administer IV diazepam over approximately 1-2 minutes to avoid pain at injection site 2
• When used for awake intubation, a dose of 0.1 mg/kg may be appropriate when combined with other agents like alfentanil 4

Potential Adverse Effects

• Respiratory depression, especially when combined with opioids 2, 1
• Coughing, dyspnea 2
• Brief myoclonic activity (hiccups, twitching) 1
• May exacerbate focal seizure disorders 1
• Transient adrenal suppression (not clinically significant) 1
• Potential for paradoxical excitement or agitation 2

Monitoring and Safety

• Monitor oxygen saturation and respiratory effort during administration 2, 1
• Be prepared to provide respiratory support if needed 2, 1
• Have flumazenil available for reversal of severe respiratory depression: 0.01-0.02 mg/kg IV (maximum: 0.2 mg), repeatable at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg 1
• Use caution with flumazenil in benzodiazepine-dependent patients as it may precipitate acute withdrawal 1

Combination Therapy

• When diazepam is used with an opioid (e.g., fentanyl), a synergistic interaction occurs, requiring dose reduction 2
• For awake fiberoptic intubation, combining diazepam with alfentanil can improve intubation conditions and attenuate pressor responses 4

Comparison with Midazolam

• Midazolam has a more rapid onset and shorter duration of effect compared to diazepam 2
• Midazolam is often preferred by endoscopists due to its favorable pharmacologic profile 2
• However, diazepam provides faster time to adequate sedation for intubation with similar duration of effect 3
• Diazepam is generally more cost-effective than midazolam for intubation purposes 3