From the Guidelines
Midazolam (Versed) is not the preferred agent for rapid sequence intubation (RSI) in critically ill adults, as etomidate or ketamine may be more suitable due to their favorable hemodynamic profiles 1. When considering RSI, the choice of induction agent is crucial, and the goal is to minimize the risk of hypotension and other complications.
- The use of midazolam for RSI is possible, but it may not be the best option due to its potential to cause hypotension, especially in hemodynamically unstable patients.
- Etomidate and ketamine are often preferred in critically ill patients due to their more favorable cardiovascular profiles, as they are less likely to cause significant hypotension 1.
- A study published in 2023 found that there is no significant difference in mortality or the incidence of hypotension between etomidate and other induction agents, including midazolam, in critically ill adults undergoing RSI 1.
- The dose of midazolam for RSI is typically 0.1-0.3 mg/kg IV, and it should be administered immediately before the paralytic agent, such as rocuronium or succinylcholine.
- It is essential to be cautious when using midazolam in elderly patients, those with liver or kidney dysfunction, or hemodynamically unstable patients, as it may cause hypotension, and have vasopressors ready to counteract potential blood pressure drops.
- The choice of induction agent for RSI should be based on the individual patient's medical history and clinical situation, and the operator's experience and preference should also be considered 1.
From the FDA Drug Label
USUAL PEDIATRIC DOSE (NON-NEONATAL) It should be recognized that the depth of sedation/anxiolysis needed for pediatric patients depends on the type of procedure to be performed. To initiate sedation, an intravenous loading dose of 0.05 to 0. 2 mg/kg administered over at least 2 to 3 minutes can be used to establish the desired clinical effect IN PATIENTS WHOSE TRACHEA IS INTUBATED. (Midazolam should not be administered as a rapid intravenous dose.)
The FDA drug label does not provide specific guidance on rapid sequence intubation using Versed (midazolam). However, it does mention that midazolam should not be administered as a rapid intravenous dose. For patients whose trachea is intubated, an intravenous loading dose of 0.05 to 0.2 mg/kg administered over at least 2 to 3 minutes can be used to establish the desired clinical effect.
- Key points:
- Midazolam should be titrated slowly to the desired clinical effect.
- The dose of midazolam must be reduced in patients premedicated with opioid or other sedative agents.
- Higher risk or debilitated patients may require lower dosages.
- Assisted ventilation is recommended for pediatric patients who are receiving other central nervous system depressant medications such as opioids. 2
From the Research
Rapid Sequence Intubation Using Versed
- The use of Versed (midazolam) in rapid sequence intubation (RSI) is not explicitly mentioned in the provided studies as a preferred or commonly used induction agent 3, 4, 5, 6, 7.
- However, the studies discuss various induction agents used in RSI, including etomidate, ketamine, and propofol 3, 4, 6, 7.
- Etomidate and ketamine are the most commonly used induction agents due to their favorable hemodynamic profiles 4, 6, 7.
- A systematic review and meta-analysis compared ketamine and etomidate for RSI and found that ketamine probably increases hemodynamic instability but decreases the need for vasopressors and adrenal suppression 7.
- The selection of induction agents and neuromuscular blockers in RSI depends on various factors, including patient-specific factors, half-life, and adverse effect profiles 3, 4.
- There is no direct evidence in the provided studies to support the use of Versed as an induction agent in RSI, but the studies provide information on the general principles of RSI and the selection of medications 3, 4, 5, 6, 7.