Maximum IV Midazolam Dose
The maximum single IV bolus dose of midazolam is 10 mg in adults and adolescents, while pediatric patients typically should not exceed 10 mg total dose (0.4-0.6 mg/kg depending on age), with continuous infusions capped at 5 μg/kg/min (0.3 mg/kg/hr) for refractory seizures. 1, 2, 3
Adult Maximum Dosing
- Single bolus maximum: 10 mg for sedation/anxiolysis in most clinical scenarios 1
- The initial dose should never exceed 2.5 mg in healthy adults, with lower doses (1 mg) for elderly or debilitated patients 1
- All doses must be administered slowly over at least 2 minutes, with an additional 2+ minutes to evaluate sedative effect before repeating 1
Pediatric Maximum Dosing by Age
Infants 6 months to 5 years:
- Initial dose: 0.05-0.1 mg/kg IV 1, 4
- Maximum total dose: 0.6 mg/kg (usually not exceeding 6 mg) 1, 4
- Higher doses associated with prolonged sedation and hypoventilation risk 1
Children 6 to 12 years:
- Initial dose: 0.025-0.05 mg/kg IV 1, 4
- Maximum total dose: 0.4 mg/kg (usually not exceeding 10 mg) 1, 4
- Prolonged sedation risk increases with higher doses 1
Adolescents 12 to 16 years:
- Dosed as adults with maximum usually not exceeding 10 mg 1
- Some patients may require higher than standard adult doses but total should remain ≤10 mg 1
Maximum Continuous Infusion Rates
- Loading dose for refractory seizures: 0.15-0.20 mg/kg IV 2, 3
- Starting infusion rate: 1 μg/kg/min (0.06 mg/kg/hr) 2, 3, 5
- Maximum infusion rate: 5 μg/kg/min (0.3 mg/kg/hr) 2, 3, 5
- Titrate by increments of 1 μg/kg/min every 15 minutes until seizures stop 2, 3
Critical Dose Modifications
- Reduce all doses by 30-50% when combined with opioids or other CNS depressants 1, 6
- Patients with hepatic impairment require dose reduction due to decreased clearance 3, 5
- Obese pediatric patients should have doses calculated based on ideal body weight, not actual weight 1
- Elderly patients (>60 years) require lower initial doses and slower titration 1
Safety Monitoring Requirements
- Continuous pulse oximetry monitoring is mandatory regardless of dose 1, 2
- Immediate availability of resuscitative equipment (bag/valve/mask, intubation equipment) required 1
- Flumazenil must be immediately available to reverse respiratory depression 2, 5, 7
- For pediatric patients, a dedicated observer separate from the proceduralist should monitor throughout 1
Common Pitfalls to Avoid
- Never administer rapid IV push - always give over 2-3 minutes minimum to prevent oversedation and hypotension 1, 3
- Do not exceed 10 mg total dose in routine sedation - higher doses dramatically increase respiratory depression risk 1, 8
- Respiratory depression risk is highest when midazolam is combined with fentanyl or other opioids 1, 6, 9
- Watch for paradoxical agitation in young children, which may prompt inappropriate dose escalation 2, 5
- In neonates, avoid rapid injection as severe hypotension and seizures have been reported 1