When should midazolam (Benzodiazepine) infusion be stopped in patients with status epilepticus?

When to Stop Midazolam Infusion in Status Epilepticus

Midazolam infusion should be continued for 12-24 hours after achieving seizure suppression on EEG, then gradually tapered rather than abruptly discontinued to prevent withdrawal seizures. 1, 2

Duration of Therapy

The primary endpoint for midazolam infusion is achieving complete seizure suppression confirmed by continuous EEG monitoring. 1 Once seizures are controlled:

• Continue the infusion at the effective dose for 12-24 hours after the last clinical or electrographic seizure 2
• EEG monitoring must guide the entire process, as clinical cessation of motor activity does not guarantee electrical seizure suppression 1
• Never stop abruptly—gradual tapering is essential to prevent withdrawal seizures and recurrence 2

Tapering Protocol

When ready to discontinue after the 12-24 hour seizure-free period:

• Reduce the infusion rate progressively rather than stopping suddenly 2
• If breakthrough seizures occur during tapering, return to the previous effective dose and maintain for an additional 12-24 hours before attempting to taper again 2
• One patient in the literature developed withdrawal symptoms that required progressive dose reduction for control 3

Critical Monitoring During Infusion

Continuous EEG monitoring is mandatory throughout midazolam infusion to detect:

• Ongoing electrical seizure activity without motor manifestations 1, 2
• Adequate seizure suppression to guide dose titration 1
• Breakthrough seizures during tapering 2

Vital sign monitoring is equally essential, particularly:

• Respiratory status—prepare for mechanical ventilation as midazolam causes respiratory depression, especially when combined with other sedatives 2
• Blood pressure—hypotension occurs in approximately 30% of patients (lower than pentobarbital's 77% but still significant) 1
• Oxygen saturation continuously 2

Dose Adjustments During Therapy

If seizures recur while on infusion:

• Administer a bolus dose equal to or double the hourly infusion rate 2
• If two bolus doses are needed within one hour, double the infusion rate 2
• Titrate upward by 1 mg/kg/min increments every 15 minutes up to a maximum of 5 mg/kg/min 1, 2

Common Pitfalls to Avoid

Do not stop midazolam based solely on clinical cessation of motor seizures—electrical seizure activity may persist without visible manifestations, causing ongoing brain injury 1. This is why continuous EEG is non-negotiable.

Do not abruptly discontinue the infusion—this precipitates withdrawal seizures and status epilepticus recurrence 2, 3.

Do not use neuromuscular blockers to mask seizure activity—they only eliminate motor manifestations while allowing continued electrical seizures and progressive brain damage 1.

Transition to Maintenance Therapy

Before tapering midazolam, ensure adequate levels of long-acting anticonvulsants are established:

• Load with phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital during the midazolam infusion 1
• Simultaneously treat underlying causes (hypoglycemia, hyponatremia, CNS infection, toxicity) throughout the entire treatment course 1, 2

Efficacy Context

Midazolam demonstrates 80% overall success rate in refractory status epilepticus 1, which is:

• Higher efficacy than propofol (73%) 1
• Lower efficacy than pentobarbital (92%) but with significantly less hypotension (30% vs 77%) 1
• Requires fewer mechanical ventilation days compared to barbiturates 4

The decision to stop midazolam infusion is not time-based but rather outcome-based: 12-24 hours seizure-free on EEG, followed by gradual taper with continuous monitoring for recurrence. 1, 2