All right, you guys. Welcome back to another video lesson from ICU Advantage. My name is
Eddie Watson and my goal is to give you guys the confidence to succeed in the ICU by
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All right, so in this lesson we are talking about Midazolam also goes
by the trade name verse Ed. So just a quick history and background. This medication was
initially synthesized in 1975 by Walser and Fry at Hoffman LAROCHE Incorporated,
and this is actually a Swiss pharmaceutical company.
And this was actually a favorable drug opposed to some, you know, 35 other ish benzodiazepines
that are currently used in healthcare due to its water solubility and really being less likely to
cause thrombophlebitis and then anticonvulsant. Properties of midazolam were studied in the 1970s,
but it really wasn't recognized as an appropriate treatment for status epilepticus until the 1990s.
So Midazolam is a benzodiazepine that's often used for the induction of anesthesia
and to produce conscious sedation for its therapeutic actions. It's believed
that it works by binding GABA receptors and really potentiating the effects of
endogenous gaba, which is a major inhibitory neurotransmitter in the central nervous.
Thus, it depresses the central nervous system. It also works to suppress the spread of seizure
activity as well. Now for our indications, it promotes perioperative sedation, anxiolysis,
anesthesia induction, or amnesia. It's also used for the treatment of status epilepticus
in adults and typically in critical care setting, we're either using it for procedural
sedation or for ongoing continuous sedation in our intubated and ventilated patients.
As for some contraindications, obviously hypersensitivity to the
drug is gonna be. We do want to use caution in older adults or patients
who are debilitated. Those really with uncompensated acute illness,
heart failure, respiratory, renal, or hepatic disease and those with increased
risk of falls. And then benzodiazepines are associated with paradoxical reactions.
So sometimes it can actually lead to agitation, aggressive behavior as well as involuntary move.
now, as for our adverse effects, so again, system by system for the central nervous
system. So one potential effect is gonna be over sedation. Obviously drowsiness,
amnesia, seizures, potentially those involuntary movements, paradoxical behaviors and excitement.
For the cardiovascular system, we can see variations in our patients' heart rate and
blood pressure. Although hypotension is actually gonna be less common and
typically less severe when we're comparing this to a medication like propofol. Now,
for E N T nystagmus is something that we can see. For GI, nausea and
vomiting can potentially come about. And then for our respiratory system,
big ones are gonna be decreased respiratory rate, decreased oxygen, SATs, and apnea.
So as far as our common concentrations go this medication does come in a PO form in
a a syrup. And, and typically you can see that in a two milligram per ml in like a Hunter ML bottle.
Or they do have some single use cups of 10 milligrams in 5 MLs. So again,
another 2 milligram per ML concentration for IV push. The most common concentration is gonna be
a one milligram per ML concentration, so two milligrams, two mls, five milligrams, and five
mls. That said I believe there is some formulation in which is a five milligram per ML concentration.
Now for continuous sedation, typically again, we're gonna see a 1 mg per ml concentration.
Something like 50 mg in 50 MLs, or a 100 mg in 100 MLs. now for our common dosing,
I'm gonna primarily focus on the, IV form of this medication for IV pushes.
The dose really depends greatly on the patient's clinical condition
as well as their potential tolerance to the medication, as well as their size.
But a push dose of one to two milligrams is pretty common. But we certainly can't
also give larger doses as. For the IV infusion again, really kind of depends on the use here,
but for sedation we're typically gonna start out at around two milligrams per hour and
then titrate for a rascal. And ideally here our max is gonna be 10 milligrams per hour.
That said, some of you guys are probably thinking that I'm crazy by
saying that cause you've seen it go much higher. And this is absolutely the case,
especially for things like status epilepticus. If they've got a brain injury and elevated ICPs,
if we're doing proning and paralytic therapy, as well as other things in there as well.
So we definitely can see higher doses than the 10 milligrams per hour. now for our pharmacokinetics,
again, for our IV administration, onsets pretty quick, anywhere from 90 seconds to to
five minutes. Typically it tends to be on the lower end of this, more towards 90 seconds. The
peak is anywhere from five to seven minutes, and the duration is typically less than two hours.
That said, with cirrhosis, we can see. This actually go up to six hours. And the
reason for this is it is metabolized primarily in the liver and the gut,
and it gets metabolized into four main metabolites, all of which have various
roles in the effect of midazolam. And then these metabolites do get excreted in the urine.
Now, as far as our antidote goes, we do have an antidote for this called omano,
also goes by the name Zicon, and here the dose is gonna be 0.2 milligrams iv. now for our nursing
considerations. Now again, this should only be administered by someone who's been specifically
trained and has the knowledge when using this medication as a sedative for procedural sedation.
So we wanna make sure that the, the antidote, Ramas Flumazenil should
really be readily available in the event that we do have over sedation,
which can lead to impaired respiratory status and depression. That said, we also wanna make sure
we've got rescue equipment nearby. Again, typically not an issue in the ICU U, but.
You know, things like our code cart, bag, valve mask suctioning can be really important as well
if we're, we're dealing with this, make sure that you are monitoring your patient's blood pressure,
heart rate and rhythm, their respirations, their airway integrity, and then make sure we've got a
continuous pulse oxs, especially if we're doing the conscious sedation or procedural sedation.
And then just be aware that individuals that have underlying hepatic impairments
and cirrhosis that they may metabolize this drug slower leading to a prolonged
duration of the drug as opposed to those who have normal hepatic function. As well
as we do also want to be using decreased dosing in patients who have renal failure.
And here, typically we're looking at a 50% decrease in the dose. And then finally, for
any relevant laboratory studies, there actually aren't any identified with this medication.
And that is gonna be our review of Midazolam aka ved. So I hope that you guys found this
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