What is the recommended intravenous diazepam (Valium) dosing for an adult, including for status epilepticus and procedural sedation?

IV Diazepam (Valium) Dosing for Adults

For most adult indications, IV diazepam is dosed at 5-10 mg initially, administered slowly at a rate of 5 mg per minute, with repeat doses every 3-4 hours as needed. 1

General Administration Principles

• Administer slowly at 5 mg per minute (1 mL per minute) to minimize respiratory depression and cardiovascular complications 1
• Use large veins; avoid small veins on the dorsum of the hand or wrist 1
• Facilities for respiratory assistance must be readily available before IV administration 1
• Do not mix or dilute with other solutions or drugs 1

Indication-Specific Dosing

Status Epilepticus and Severe Recurrent Convulsive Seizures

• Initial dose: 5-10 mg IV (preferred route over IM) 1
• May repeat every 10-15 minutes if necessary, up to a maximum of 30 mg 1
• If needed, therapy may be repeated in 2-4 hours, though residual active metabolites persist and require consideration 1
• Exercise extreme caution in patients with chronic lung disease or unstable cardiovascular status 1

Important caveat: While diazepam is effective, lorazepam (2 mg IV) is likely superior for out-of-hospital status epilepticus, with better seizure termination rates (59.1% vs 42.6%) and similar safety profiles 2. However, diazepam remains a reasonable alternative when lorazepam is unavailable.

Procedural Sedation (Endoscopy)

• Titrate IV dosage to desired sedative response (e.g., slurred speech) immediately prior to procedure 1
• Generally 10 mg or less is adequate 1
• Up to 20 mg IV may be given, particularly when concomitant narcotics are omitted 1
• The initial induction dose is 5-10 mg over 1 minute, with additional doses at 5-minute intervals if required 3
• In general, 10 mg IV is sufficient for most endoscopic procedures, though up to 20 mg may be necessary if a narcotic is not coadministered 3

Moderate Anxiety Disorders

• 2-5 mg IM or IV, repeat in 3-4 hours if necessary 1

Severe Anxiety Disorders

• 5-10 mg IM or IV, repeat in 3-4 hours if necessary 1

Acute Alcohol Withdrawal

• 10 mg IM or IV initially, then 5-10 mg in 3-4 hours if necessary 1

Muscle Spasm (Local Pathology, Cerebral Palsy, Tetanus)

• 5-10 mg IM or IV initially, then 5-10 mg in 3-4 hours if necessary 1
• For tetanus, larger doses may be required 1

Preoperative Medication

• 10 mg IM (preferred route) before surgery 1

Cardioversion

• 5-15 mg IV within 5-10 minutes prior to procedure 1

Special Population Adjustments

Elderly or Debilitated Patients

• Use lower doses (usually 2-5 mg) and slow dose titration 1
• Dose reduction is required in debilitated or elderly patients 3

Concomitant Sedative Use

• Reduce diazepam dose when other sedative drugs are coadministered 1
• The respiratory depressant effect is synergistic when benzodiazepines are combined with opioids 3

Critical Safety Considerations

Respiratory Depression

• The major side effect is dose-dependent respiratory depression from suppression of central ventilatory response to hypoxia and hypercapnea 3
• More likely in patients with underlying respiratory disease or those receiving combinations of benzodiazepine and opioid 3
• Monitor oxygen saturation continuously 3
• Have flumazenil available to reverse life-threatening respiratory depression, though note it will also reverse anticonvulsant effects and may precipitate seizures 3

Other Adverse Effects

• Coughing, dyspnea, and cardiovascular instability may occur 3
• Rapid infusion may cause hypotension and bradycardia 3

Overdose Management

• Manifestations include somnolence, confusion, coma, and diminished reflexes 1
• Monitor respiration, pulse, and blood pressure 1
• Flumazenil is indicated for reversal but carries seizure risk, particularly in long-term benzodiazepine users 1