What is the recommended dosing for Midazolam (Versed)?

Midazolam (Versed) Dosing Recommendations

Midazolam dosing varies significantly by indication and patient population, with procedural sedation requiring 0.05-0.1 mg/kg IV (maximum 5 mg initially) in adults under 60, while ICU sedation typically uses 2.5-5 mg/hr continuous infusion after a loading dose. 1, 2

Procedural Sedation/Anxiolysis

Adults Under 60 Years

• Initial dose: 0.05-0.1 mg/kg IV given over 2-3 minutes 3, 2
• Maximum single dose: 5 mg 3
• Peak effect occurs at 3-5 minutes 3
• Titrate by repeating doses every 3-5 minutes to avoid oversedation 3
• Total doses >5 mg rarely necessary 2
• Reduce dose by 30% if narcotic premedication or other CNS depressants used 2

Adults 60+ Years, Debilitated, or Chronically Ill

• Start with no more than 1.5 mg over at least 2 minutes 2
• Some patients respond to as little as 1 mg 2
• Wait additional 2+ minutes between doses to fully evaluate sedative effect 2
• Total doses >3.5 mg not usually necessary 2
• Reduce dose by at least 50% if concomitant CNS depressants used 2

Pediatric Sedation

• Ages 6 months-5 years: 0.05-0.1 mg/kg IV initially, up to 0.6 mg/kg total 4
• Ages 6-12 years: 0.025-0.05 mg/kg IV initially, up to 0.4 mg/kg total 4
• Children <6 years may require up to 1 mg/kg orally (maximum 20 mg) 3
• Oral route: 0.5 mg/kg is effective in 76% of children for minor procedures 5

ICU Sedation (Continuous Infusion)

Note: Current evidence strongly favors minimizing benzodiazepine use in ICU due to increased delirium risk compared to propofol or dexmedetomidine 1

When Midazolam is Used

• Loading dose: 0.01-0.05 mg/kg (approximately 0.5-4 mg) given slowly over several minutes 2
• May repeat loading dose at 10-15 minute intervals until adequate sedation achieved 2
• Maintenance infusion: 0.02-0.1 mg/kg/hr (1-7 mg/hr initially) 2
• Alternative recommendation: 2.5-5 mg/hr (0.05-0.1 mg/kg/hr) titrated to light sedation 1
• Adjust infusion rate by 25-50% based on sedation assessment every 1-2 hours 6, 2
• If patient requires 2 bolus doses in one hour, double the infusion rate 3

Anesthesia Induction

Unpremedicated Adults <55 Years

• 0.3-0.35 mg/kg IV over 20-30 seconds, allowing 2 minutes for effect 2
• May use increments of 25% of initial dose if needed 2
• Up to 0.6 mg/kg total may be used in resistant cases (prolongs recovery) 2

Unpremedicated Adults ≥55 Years

• 0.3 mg/kg IV initially 2

Premedicated Adults <55 Years

• 0.25 mg/kg IV over 20-30 seconds 2

Premedicated Adults ≥55 Years

• 0.2 mg/kg IV 2

Patients with Severe Systemic Disease

• 0.15-0.25 mg/kg IV (as little as 0.15 mg/kg may suffice) 2

Seizure Management

Acute Seizures (Pediatric)

• IM: 0.2 mg/kg (maximum 6 mg per dose), may repeat every 10-15 minutes 3

Status Epilepticus (Adult)

• IM: 15 mg as initial dose 7
• IV loading dose: 0.15-0.2 mg/kg (7.5-10 mg), followed by continuous infusion starting at 3 mg/hr (0.06 mg/kg/hr) 1
• For refractory status epilepticus: increase infusion by 1 mg/kg/min increments every 15 minutes (maximum 5 mg/kg/min) until seizures stop 3

Special Population Adjustments

Hepatic or Renal Impairment

• Reduce dose by at least 20% due to decreased clearance 1, 6

Concurrent Opioid Use

• Reduce midazolam dose by at least 20% due to synergistic respiratory depression 1
• When combined with fentanyl, hypoxemia occurs in 92% and apnea in 50% of patients 8

H2-Receptor Antagonist Use

• Reduce dose by 30% due to increased bioavailability 1

Critical Safety Considerations

Respiratory Monitoring

• Respiratory depression can occur up to 30 minutes after administration 1
• Monitor oxygen saturation continuously 6, 9
• Be prepared to provide respiratory support regardless of route 3, 6
• Have flumazenil available for reversal of life-threatening respiratory depression 3, 1, 6

High-Risk Combinations

• Combining midazolam with opioids dramatically increases respiratory depression risk 1, 8
• 78% of midazolam-associated deaths were respiratory in nature; 57% involved concurrent opioid use 8
• When combining with olanzapine, use extreme caution due to risk of oversedation and respiratory depression 3

Common Pitfalls

• Paradoxical agitation may occur, especially in younger children (6% incidence) 3, 5
• Elderly patients have slower peak effect—wait longer between doses 2
• Titrate slowly in patients with COPD or when co-administered with antipsychotics 3
• Flumazenil reverses both respiratory depression AND anticonvulsant effects, potentially precipitating seizures 3, 6

Alternative Routes

Subcutaneous/Intramuscular

• Delirium management: 2.5 mg SC/IV every 1 hour PRN (maximum 5 mg) 3
• Use lower doses (0.5-1 mg) in elderly, frail, or COPD patients, or when co-administered with antipsychotics 3

Oral

• Pediatric procedural sedation: 0.5 mg/kg (onset 15 minutes, effective in 76%) 5
• Produces amnesia in 66% of children 5