What is the recommended dose of midazolam (Benzodiazepine) drip for status epilepticus?

Midazolam Infusion Dosing for Status Epilepticus

For refractory status epilepticus, administer an IV loading dose of 0.15-0.20 mg/kg of midazolam, followed by a continuous infusion starting at 1 mcg/kg/min (0.06 mg/kg/hr), increasing by 1 mcg/kg/min increments every 15 minutes until seizures stop, up to a maximum of 5 mcg/kg/min (0.3 mg/kg/hr). 1

Loading Dose Protocol

• Administer 0.15-0.20 mg/kg IV as a bolus when status epilepticus is refractory to standard first-line benzodiazepines (lorazepam or diazepam) 2, 1
• If additional boluses are needed before starting the infusion, give 0.1-0.3 mg/kg increments up to a cumulative dose of 0.6 mg/kg 3
• 90% of patients who respond to bolus therapy do so with cumulative doses ≤0.3 mg/kg 3

Continuous Infusion Titration

• Start infusion at 1 mcg/kg/min (0.06 mg/kg/hr) immediately after the loading dose 2, 1
• Increase by 1 mcg/kg/min every 15 minutes if seizures persist 2, 1
• Maximum infusion rate: 5 mcg/kg/min (0.3 mg/kg/hr) 2, 1
• Continue infusion for 24 hours after seizure cessation before attempting to wean 1

Adjusting Ongoing Infusions

If a patient is already receiving midazolam and experiences breakthrough seizures:

• Give a bolus equal to or double the hourly infusion dose 1
• Order bolus doses every 5 minutes as needed for ongoing seizures 1
• If two boluses are required within one hour, double the infusion rate 1

Alternative Route When IV Access Unavailable

• IM midazolam: 0.2 mg/kg (maximum 6 mg per dose) 2
• May repeat every 10-15 minutes if needed 2
• In adults, 15 mg IM has shown 84% efficacy (36/43 episodes controlled) 4

Critical Safety Considerations

Respiratory Monitoring

• Prepare for respiratory support before administration regardless of route 2, 1
• Increased apnea risk when combined with other sedatives 2, 1
• Continuous oxygen saturation monitoring is mandatory 2, 1
• In one pediatric study, only 1 of 34 patients required supplemental oxygen and bag-valve-mask ventilation 3

Timing is Critical

• Effectiveness decreases significantly when initiated >3 hours after seizure onset 5
• Early administration (within 1 minute of bolus) achieved 88% seizure cessation in prospective studies 3
• In a multicenter retrospective study, overall efficacy was 64.5%, but notably lower with delayed treatment 5

Common Pitfalls to Avoid

• Do NOT use flumazenil to reverse respiratory depression unless life-threatening, as it will precipitate seizure recurrence 2, 1
• Do NOT delay treatment waiting for EEG confirmation—clinical cessation of motor symptoms is sufficient to assess response 3
• Do NOT forget to address underlying causes (hypoglycemia, hyponatremia, hypoxia, CNS infection) concurrently 1
• Do NOT use doses lower than 0.15 mg/kg for the loading dose—lower doses are ineffective for refractory status epilepticus 2

Pharmacokinetic Considerations

• Elimination half-life is approximately 1 hour in children 3
• Clearance is notably higher in infants (2010 mL/h/kg in a 10-month-old vs. 423-1220 mL/h/kg in older children), which may require higher maintenance doses 3
• Mean effective infusion rate in pediatric studies was 0.22 mg/kg/hr (approximately 3.7 mcg/kg/min) 6