Names and pronunciation
(mid′ay-zoe-lam) Nayzilam (nasal spray)
Source page 888
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Individual generic drug information
Extracted information for midazolam only.
(mid′ay-zoe-lam) Nayzilam (nasal spray)
Source page 888
Func. class.: Anxiolytic
Source page 888
Chem. class.: Benzodiazepine, short-acting Controlled Substance Schedule IV
Source page 888
ACTION: Depresses subcortical levels in CNS; may act on limbic system, reticu- lar formation; may potentiate γ-aminobutyric acid (GABA) by binding to specific benzodiazepine receptors
Source page 888
USES: Preoperative sedation, general anesthesia induction, sedation for diag- nostic endoscopic procedures, intuba- tion, anxiety Unlabeled uses: Acute agitation, cocaine, methamphetamine intoxication, palliative/end-of-life sedation, rapid sequence intubation, status epilepticus
Source page 888
Extracted information for midazolam only.
CONTRAINDICATIONS: Preg- nancy, hypersensitivity to benzodiazepines, acute closed-angle glaucoma, epidural/ intrathecal use Precautions: Breastfeeding, children, geriatric patients, COPD, HF, chronic renal failure, chills, debilitated patients, hepatic disease, shock, coma, alcohol intoxication, status asthmaticus
Source page 888
Black Box Warning: Neonates (con- tains benzyl alcohol), IV administration, respiratory depression/insufficiency, specialized care setting, experienced clinician, coadministration with other CNS depressants, abrupt discontinuation, hypotension Black Box Warning: Do not use rapid injection in neonates Y-site compatibilities: Abciximab, acet- aminophen, alemtuzumab, alfentanil, amikacin, amiodarone, anidulafungin, argatroban, atracurium, atropine, aztreo- nam, benzotropine, calcium gluconate, ceFAZolin, cefotaxime, cefOXitine, cef- TRIAXone, cimetidine, ciprofloxacin, CISplatin, clindamycin, cloNIDine, cya- nocobalamin, cycloSPORINE, DACTINo- mycin, digoxin, diltiaZEM, diphenhydrA MINE, DOCEtaxel, DOPamine, doxycycline, enalaprilat, EPINEPHrine, erythromycin, esmolol, etomidate, etopo- side, famotidine, fentaNYL, fluconazole, folic acid, gatifloxacin, gemcitabine, gen- tamicin, glycopyrrolate, granisetron, heparin, hetastarch, HYDROmorphone, hydrOXYzine, inamrinone, isoproterenol, labetalol, lactated Ringer’s, levoFLOXa- cin, lidocaine, linezolid, LORazepam, magnesium, mannitol, meperidine, methadone, methyldopa, methylPRED- NISolone, metoclopramide, metoprolol, M metroNIDAZOLE, milrinone, morphine, nalbuphine, naloxone, niCARdipine, nitroglycerin, nitroprusside, norepineph- rine, ondansetron, oxacillin, oxytocin, PACLitaxel, palonosetron, pancuronium, papaverine, phytonadione, piperacillin, potassium chloride, propranolol, prot- amine, pyridoxine, raNITIdine, remifent- anil, sodium nitroprusside, succinylcho- line, SUFentanil, teniposide, theophylline, thiotepa, ticarcillin, tobramycin, vanco- mycin, vasopressin, vecuronium, verap amil, voriconazole, zoledronic acid Black Box Warning: Should be used only in a specialized care setting by those trained in use Black Box Warning: Respiratory de- pression/insufficiency: apnea, respira- tory depression may be increased in geri- atric patients • Assistance with ambulation until drowsy period ends • Immediate availability of resuscitation equipment, O2 to support airway; do not give by rapid bolus • Beers: avoid in older adults with de- lirium or at high risk for delirium; assess frequently for confusion, delirium; de- gree of amnesia in geriatric patients may be increased • Pregnancy/breastfeeding: do not use in pregnancy; avoid use in breastfeeding, excreted in breast milk
Source pages 888, 889, 890
SIDE EFFECTS CNS: Retrograde amnesia, headache, paresthesia, chills, paradoxic reactions CV: Hypotension, PVCs, nodal rhythm, cardiac arrest EENT: Nystagmus, blurred vision GI: Nausea, vomiting, hiccups INTEG: Urticaria; pain, swelling, pruritus at inj site; rash RESP: Coughing, apnea, respiratory depression
Source page 889
INTERACTIONS Increase: hypotension—antihyperten- sives, opiates, alcohol, nitrates Increase: extended half-life—CYP3A4 inhibitors (cimetidine, erythromycin, raNITIdine), adjust dose if needed Increase: respiratory depression—other CNS depressants, alcohol, barbiturates, opi- ate analgesics, verapamil, ritonavir, indina- vir, fluvoxaMINE, protease inhibitors Decrease: midazolam metabolism— CYP3A4 inducers (azole antifungals, the- ophylline), adjust dose if needed Drug/Herb Increase: sedation—kava, valerian Decrease: midazolam effect—St. John’s wort Drug/Food Increase: (PO) midazolam effect— grapefruit juice, do not use together
Source page 890
TREATMENT OF OVERDOSE: Flumazenil, O2 HIGH ALERT
Source page 890
Extracted information for midazolam only.
DOSAGE AND ROUTES • Use lean body weight for obese patient Preoperative sedation/amnesia induction • Adult/child ≥12 yr: IM 0.07-0.08 mg/ kg ½-1 hr before general anesthesia • Child 6 yr-12 yr: IV 0.025-0.05 mg/ kg; total dose of 0.4 mg/kg may be nec- essary • Child 6 mo-5 yr: IV 0.05-0.1 mg/kg; total dose of 0.6 mg/kg may be necessary Induction of general anesthesia • Adult >55 yr: (ASA I/II) IV 150-300 mcg/kg over 30 sec; (ASA III) IV limit dose to 250 mcg/kg (nonpremedi- cated) or 150 mcg/kg (premedi- cated) • Adult <55 yr: IV 200-350 mcg/kg over 20-30 sec; if patient has not received premedication, may repeat by giving 20% of original dose; if patient has re- ceived premedication, reduce dose by 50 mcg/kg • Child: no safe and effective dose estab- lished; however, doses of 50-200 mcg/kg IV have been used Continuous infusion for mechanical ventilation (critical care) • Adult: IV 0.01-0.05 mg/kg over sev- eral min; repeat at 10- to 15-min inter- vals until adequate sedation, then 0.02- 0.10 mg/kg/hr maintenance; adjust as needed • Child: IV 0.05-0.2 mg/kg over 2-3 min then 0.06-0.12 mg/kg/hr by cont infusion; adjust as needed • Neonate: IV 0.03 mg/kg/hr, titrate using lowest dose Status epilepticus (unlabeled) • Child and infant >2 mo: IV 0.15 mg/ kg then CONT IV 1 mcg/kg/min, titrate upward q5min until seizures con- trolled
Source pages 888, 889
Available forms: Inj 1, 5 mg/mL (pre- servative free); injection 1 mg/mL, 5 mg/ mL; syr 2 mg/mL; nasal spray 5 mg
Source page 889
Administer: • Store at room temperature; protect from light PO route (syrup) • Press-in-bottle adaptor (PIBA) Re- move cap of press-in bottle adapter, push adapter into neck of bottle; close with cap; remove cap, insert tip of dispenser, insert into adapter; turn upside-down, withdraw correct dose; place in mouth IM route • IM deep into large muscle mass IV route • May be given diluted or undiluted 1 mg/mL or 5 mg/mL (undiluted) or 0.03-3 mL (diluted) • After diluting with D5W or 0.9% NaCl, give over 2-5 min (conscious sedation) or over 30 sec (anesthesia induction) Continuous IV infusion route • Dilute in 0.9% NaCl or D5W to 0.5-1 mg/mL, dose is calculated on patient’s weight and use
Source page 889
Extracted information for midazolam only.
Assess: • B/P, pulse, respirations during IV; emergency equipment should be nearby • Inj site for redness, pain, swelling
Source page 890
Evaluate: • Therapeutic response: induction of sedation, general anesthesia
Source page 890
CLINICAL CONSIDERATIONS
Source page 890
Patient and caregiver information: • That amnesia occurs; that events may not be remembered; to give with instruc- tions • To avoid driving, other hazardous ac- tivities until effects are known • Reason for product, expected results
Source page 890
Extracted information for midazolam only.
PHARMACOKINETICS Protein binding 97%; half-life 1-5 hr, metabolized in liver; by CYP3A4 to metabolites excreted in urine; crosses placenta, blood-brain barrier PO: Onset 10-30 min IM: Onset 15 min, peak ½-1 hr, duration 2-3 hr IV: Onset 1.5-5 min, onset of anesthesia 1½-2½ min, duration 2 hr
Source pages 889, 890
Filter the extracted dose blocks for this individual drug.
• Adult/child ≥12 yr: IM 0.07-0.08 mg/ kg ½-1 hr before general anesthesia
Candidate age grouping · source pages 888, 889
• Adult >55 yr: (ASA I/II) IV 150-300 mcg/kg over 30 sec; (ASA III) IV limit dose to 250 mcg/kg (nonpremedi- cated) or 150 mcg/kg (premedi- cated)
Candidate age grouping · source pages 888, 889
• Adult <55 yr: IV 200-350 mcg/kg over 20-30 sec; if patient has not received premedication, may repeat by giving 20% of original dose; if patient has re- ceived premedication, reduce dose by 50 mcg/kg
Candidate age grouping · source pages 888, 889
• Adult: IV 0.01-0.05 mg/kg over sev- eral min; repeat at 10- to 15-min inter- vals until adequate sedation, then 0.02- 0.10 mg/kg/hr maintenance; adjust as needed
Candidate age grouping · source pages 888, 889