Off-Label Uses of Midazolam (Versed)
Midazolam has numerous off-label applications beyond its FDA-approved indications, including treatment of seizures, delirium management in cancer patients, and as part of targeted temperature management protocols after cardiac arrest. 1
Seizure Management
- Effective for acute seizure control and refractory status epilepticus when administered via multiple routes 1
- Intramuscular dosing (0.2 mg/kg, maximum 6 mg per dose) can be repeated every 10-15 minutes for seizure control when IV access is unavailable 1
- For refractory status epilepticus not controlled by standard therapies, can be administered as IV loading dose (0.15-0.20 mg/kg) followed by continuous infusion (1-5 mg/kg per minute) 1
- Nasal administration is effective for acute seizure management, particularly in outpatient settings 2, 3
Procedural Applications
- Sedation/anxiolysis for emergency department procedures at 0.05-0.10 mg/kg IV (maximum single dose: 5 mg) 1, 4
- Oral administration at 0.25-0.50 mg/kg (maximum 20 mg) for pre-procedure sedation, with children under 6 potentially requiring up to 1 mg/kg 1
- Adjunct for endotracheal intubation at 0.2 mg/kg IV, allowing 2-3 minutes for effect before administering muscle relaxant 1
Critical Care Applications
- Management of delirium in cancer patients at 2.5 mg subcutaneous or IV every hour as needed (up to 5 mg maximum) 1
- Lower doses (0.5-1 mg) recommended for older or frail patients, those with COPD, or when co-administered with antipsychotics 1
- Used in targeted temperature management protocols after cardiac arrest, though propofol is often preferred for initial sedation due to midazolam's association with longer delirium 1
Pediatric Applications
- Treatment of laryngotracheobronchitis (croup) at 1-2 mg/kg IV/IM (must use acetate salt for IM route) 1
- Management of increased intracranial pressure in conjunction with other measures such as hyperventilation, head elevation, and cerebrospinal fluid drainage 1
Cardiovascular Applications
- Treatment of infundibular spasm (hypercyanotic spell with tetralogy of Fallot) at 0.1 mg/kg IV or IM, repeating as necessary 1
- Management of myocardial dysfunction and increased systemic/pulmonary vascular resistance (e.g., after cardiac surgery, normotensive septic shock) with loading dose of 50-75 mg/kg over 10-60 minutes, followed by infusion of 0.50-0.75 mg/kg per minute 1
Important Considerations and Precautions
- Respiratory depression is a significant risk, particularly when combined with opioids or in elderly patients 5, 6
- Reduced clearance in elderly, obese patients, and those with hepatic or renal impairment necessitates dose adjustments 5, 7
- Paradoxical agitation may occur, especially in younger children 1
- When used for delirium management, should be started on an as-needed basis before considering scheduled dosing 1
- Flumazenil may be administered to reverse life-threatening respiratory depression, though this will also reverse anticonvulsant effects and may precipitate seizures 1, 6