What sleeping medication can be given to a patient with nothing by mouth (NPO) status?

From the Guidelines

For a patient who is NPO and requesting a sleeping medication, I would recommend using midazolam 0.5-1 mg/h IV as the initial dose, which can be titrated to effect, with a usual effective dose range of 1-20 mg/h, as it is a short-acting benzodiazepine with a rapid onset of action and is often prescribed for palliative sedation 1.

Key Considerations

• Midazolam can be administered intravenously or subcutaneously, making it a versatile option for patients who are NPO.
• The medication has a rapid onset of action, which is beneficial for patients who are experiencing distress or discomfort.
• It is essential to start with the lowest effective dose and monitor the patient closely for adverse effects, such as respiratory depression, particularly in elderly patients or those with sleep apnea.
• The patient's condition and preferences regarding sedation should be regularly reassessed, and the dose of midazolam can be titrated down to re-establish lucidity if desired.

Administration and Monitoring

• Midazolam can be administered as a continuous infusion, with a starting dose of 0.5-1 mg/h, and the dose can be adjusted as needed to achieve the desired level of sedation.
• The patient's vital signs, including respiratory rate and oxygen saturation, should be closely monitored during the administration of midazolam.
• It is crucial to have a plan in place for managing potential adverse effects, such as paradoxical agitation or withdrawal, and to have access to an antagonist, such as flumazenil, if needed 1.

From the FDA Drug Label

For preoperative sedation/anxiolysis/amnesia (induction of sleepiness or drowsiness and relief of apprehension and to impair memory of perioperative events).The recommended premedication dose of midazolam for good risk (ASA Physical Status I & II) adult patients below the age of 60 years is 0.07 to 0. 08 mg/kg IM (approximately 5 mg intramuscular) administered up to 1 hour before surgery.

For a patient who is strict NPO (nothing by mouth) and requesting a sleeping medication, midazolam can be given intramuscularly. The recommended dose is 0.07 to 0.08 mg/kg (approximately 5 mg intramuscular) for good risk adult patients below the age of 60 years, administered up to 1 hour before the procedure. However, the dose must be individualized and reduced when administered to patients with chronic obstructive pulmonary disease, other higher risk surgical patients, patients 60 or more years of age, and patients who have received concomitant narcotics or other CNS depressants 2.

From the Research

Patient Request for Sleeping Medication while NPO

• Patients who are NPO (nil per os) and requesting sleeping medication pose a challenge, as the goal is to minimize the risk of aspiration while also ensuring the patient's comfort and safety.
• According to the study 3, NPO guidelines have become increasingly permissive, allowing for the ingestion of clear fluids up to two hours before elective surgery.

Benzodiazepine Options

• Benzodiazepines, such as midazolam and lorazepam, are commonly used for sedation and anxiety relief, but their use in NPO patients requires careful consideration.
• The study 4 discusses the pharmacologic differences between lorazepam and midazolam, and provides dosage guidelines for conversion equivalencies.
• Midazolam has been shown to be effective for off-label uses, including sedation and anxiety relief, but its use should be carefully monitored due to its potential for adverse reactions and drug-drug interactions 5.

Administration and Dosage

• The study 6 found that benzodiazepines, particularly midazolam and lorazepam, are frequently underdosed in patients with status epilepticus.
• The study 5 notes that the duration of action of benzodiazepines is strongly dependent on the duration of administration, and that midazolam has the shortest recovery profile followed by lorazepam and diazepam.
• When administering benzodiazepines to NPO patients, it is essential to start with a low dose and titrate slowly to minimize the risk of adverse reactions and ensure the patient's safety.

Alternative Strategies

• The study 7 suggests that continuing the patient's home oral antiepileptic drug regimen, when possible, can help minimize the frequency of seizures during hospitalizations.
• Alternative strategies, such as administration of intravenous antiepileptic drugs or temporary administration of benzodiazepines, may also be considered, but their effectiveness and safety should be carefully evaluated on a case-by-case basis.