What is the recommended dose of midazolam (Versed) for a 28kg male for procedural sedation?

Midazolam Dosing for a 28 kg Pediatric Patient

For procedural sedation in a 28 kg child, administer midazolam 0.05-0.1 mg/kg IV (1.4-2.8 mg) given slowly over 2-3 minutes, with the ability to titrate up to a total dose of 0.4 mg/kg (11.2 mg) based on clinical response. 1, 2

Age-Specific Dosing Algorithm

Based on weight alone, this child could be 6-12 years old, which determines the dosing strategy:

For children 6-12 years of age:

• Initial dose: 0.025-0.05 mg/kg IV (0.7-1.4 mg for 28 kg child) 2
• Administer over 2-3 minutes 1, 2
• Wait 2-3 minutes after each dose to evaluate sedative effect before repeating 2
• Maximum total dose: 0.4 mg/kg (11.2 mg for 28 kg child), though usually does not exceed 10 mg 2, 3

For children 6 months-5 years of age (if younger than expected for weight):

• Initial dose: 0.05-0.1 mg/kg IV (1.4-2.8 mg for 28 kg child) 2
• Maximum total dose: 0.6 mg/kg (16.8 mg for 28 kg child), though usually does not exceed 6 mg 2

Critical Titration Requirements

Midazolam takes approximately three times longer than diazepam to achieve peak EEG effects, making the 2-3 minute wait between doses non-negotiable. 2 This is the most common dosing error—administering repeat doses too quickly leads to oversedation and respiratory depression.

• Titrate slowly with small increments until appropriate sedation level achieved 2
• Higher doses are associated with prolonged sedation and increased risk of hypoventilation 2
• The combination of fentanyl and midazolam is effective for procedural sedation but requires extreme caution 4

Dose Reduction Requirements

If the patient has received opioids or other sedatives, reduce the midazolam dose significantly. 2 The American Academy of Pediatrics warns of synergistic respiratory depression when midazolam is combined with opioids, requiring particular vigilance. 1

Essential Safety Monitoring

Continuous oxygen saturation monitoring is mandatory, as respiratory depression is the most serious adverse event. 5, 1 In one Class I study, oxygen desaturation occurred in 11.6% of patients receiving midazolam for procedural sedation. 4

• Have flumazenil (0.01 mg/kg) immediately available to reverse life-threatening respiratory depression 1
• Ensure qualified personnel trained in pediatric airway management are present throughout 1
• Be prepared to provide bag-valve-mask ventilation 2
• Monitor for hypotension, particularly with rapid administration 5

Common Pitfalls to Avoid

Do not calculate dose based on actual body weight if the child is obese—use ideal body weight instead. 2 This prevents overdosing in overweight children.

Avoid the temptation to give repeat doses before waiting the full 2-3 minutes for peak effect. 2 This leads to stacking doses and unpredictable deep sedation.

Younger children (under 6 years) generally require higher mg/kg doses than older children and may require closer monitoring. 2 However, paradoxical agitation may occur, especially in younger pediatric patients. 1

Alternative Route Considerations

Intramuscular midazolam (0.1-0.15 mg/kg, up to 0.5 mg/kg for anxious patients) can be used if IV access is not yet established, though this does not prolong emergence from general anesthesia. 2 The total IM dose usually does not exceed 10 mg. 2

Intranasal midazolam at 0.2-0.3 mg/kg is appropriate only for anxiolysis and mild sedation, not for painful procedures requiring deep sedation. 1 In one study, intranasal midazolam at 0.5 mg/kg showed only 54% physician satisfaction versus 88% with IV ketamine/midazolam for laceration repair. 1

Comparative Efficacy Evidence

Midazolam alone was significantly less effective than pentobarbital for CT sedation in one Class II randomized trial, with only 19% successful scans with midazolam versus 97% with pentobarbital. 4 For painful procedures, the combination of fentanyl and midazolam is more effective than midazolam alone. 4