f anesthesia or during treatment in a critical care setting.

datives (see dosage and administration), it should be used for sedation/anxiolysis/amnesia only in the presence of personnel skilled in early detection of hypoventilation, maintaining a patent airway, and supporting ventilation. when used for sedation/anxiolysis/amnesia, midazolam should always be titrated slowly in adult or pediatric patients. adverse hemodynamic events have been reported in pediatric patients with cardiovascular instability; rapid intravenous administration should also be avoided in this population (see dosage and administration for complete information). risks from concomitant use with opioids concomitant use of benzodiazepines, including midazolam, and opioids may result in profound sedation, respiratory depression, coma, and death. if a decision is made to use midazolam concomitantly with opioids, monitor patients closely for respiratory depression and sedation (see precautions, drug interactions). risk of respiratory adverse events serious cardiorespiratory adverse events have occurred after administration of midazolam. these have included respiratory depression, airway obstruction, oxygen desaturation, apnea, respiratory arrest and/or cardiac arrest, sometimes resulting in death or permanent neurologic injury. there have also been rare reports of hypotensive episodes requiring treatment during or after diagnostic or surgical manipulations particularly in adult or pediatric patients with hemodynamic instability. hypotension occurred more frequently in the sedation studies in patients premedicated with a narcotic. individualization of dosage midazolam must never be used without individualization of dosage particularly when used with other medications capable of producing central nervous system depression. see dosage and administration for complete information. other adverse events reactions such as agitation, involuntary movements (including tonic/clonic movements and muscle tremor), hyperactivity and combativeness have been reported in both adult and pediatric patients. these reactions may be due to inadequate or excessive dosing or improper administration of midazolam; however, consideration should be given to the possibility of cerebral hypoxia or true paradoxical reactions. should such reactions occur, the response to each dose of midazolam and all other drugs, including local anesthetics, should be evaluated before proceeding. reversal of such responses with flumazenil has been reported in pediatric patients. concomitant use of central nervous system depressants concomitant use of barbiturates, alcohol or other central nervous system depressants may increase the risk of hypoventilation, airway obstruction, desaturation, or apnea and may contribute to profound and/or prolonged drug effect. narcotic premedication also depresses the ventilatory response to carbon dioxide stimulation. debilitation and comorbid considerations higher risk adult and pediatric surgical patients, elderly patients and debilitated adult and pediatric patients require lower dosages, whether or not concomitant sedating medications have been administered. adult or pediatric patients with copd are unusually sensitive to the respiratory depressant effect of midazolam. pediatric and adult patients undergoing procedures involving the upper airway such as upper endoscopy or dental care, are particularly vulnerable to episodes of desaturation and hypoventilation due to partial airway obstruction. adult and pediatric patients with chronic renal failure and patients with congestive heart failure eliminate midazolam more slowly (see clinical pharmacology). because elderly patients frequently have inefficient function of one or more organ systems and because dosage requirements have been shown to decrease with age, reduced initial dosage of midazolam is recommended, and the possibility of profound and/or prolonged effect should be considered. injectable midazolam should not be administered to adult or pediatric patients in shock or coma, or in acute alcohol intoxication with depression of vital signs. particular care should be exercised in the use of intravenous midazolam in adult or pediatric patients with uncompensated acute illnesses, such as severe fluid or electrolyte disturbances. risk of intra-arterial injection there have been limited reports of intra-arterial injection of midazolam. adverse events have included local reactions, as well as isolated reports of seizure activity in which no clear causal relationship was established. precautions against unintended intra-arterial injection should be taken. extravasation should also be avoided. the safety and efficacy of midazolam following nonintravenous and nonintramuscular routes of administration have not been established. midazolam should only be administered intramuscularly or intravenously. return to full cognitive function midazolam is associated with a high incidence of partial or complete impairment of recall for the next several hours. the decision as to when patients who have received injectable midazolam, particularly on an outpatient basis, may again engage in activities requiring complete mental alertness, operate hazardous machinery or drive a motor vehicle must be individualized. gross tests of recovery from the effects of midazolam (see clinical pharmacology) cannot be relied upon to predict reaction time under stress. it is recommended that no patient operate hazardous machinery or a motor vehicle until the effects of the drug, such as drowsiness, have subsided or until one full day after anesthesia and surgery, whichever is longer. for pediatric patients, particular care should be taken to assure safe ambulation. usage in pregnancy an increased risk of congenital malformations associated with the use of benzodiazepine drugs (diazepam and chlordiazepoxide) has been suggested in several studies. if this drug is used during pregnancy, the patient should be apprised of the potential hazard to the fetus. withdrawal symptoms of the barbiturate type have occurred after the discontinuation of benzodiazepines (see drug abuse and dependence). usage in preterm infants and neonates rapid injection should be avoided in the neonatal population. midazolam administered rapidly as an intravenous injection (less than 2 minutes) has been associated with severe hypotension in neonates, particularly when the patient has also received fentanyl. likewise, severe hypotension has been observed in neonates receiving a continuous infusion of midazolam who then receive a rapid intravenous injection of fentanyl. seizures have been reported in several neonates following rapid intravenous administration. the neonate also has reduced and/or immature organ function and is also vulnerable to profound and/or pro-longed respiratory effects of midazolam. exposure to excessive amounts of benzyl alcohol has been associated with toxicity (hypotension, metabolic acidosis), particularly in neonates, and an increased incidence of kernicterus, particularly in small preterm infants. there have been rare reports of deaths, primarily in preterm infants, associated with exposure to excessive amounts of benzyl alcohol. the amount of benzyl alcohol from medications is usually considered negligible compared to that received in flush solutions containing benzyl alcohol. administration of high dosages of medications (including midazolam) containing this preservative must take into account the total amount of benzyl alcohol administered. the recommended dosage range of midazolam for preterm and term infants includes amounts of benzyl alcohol well below that associated with toxicity; however, the amount of benzyl alcohol at which toxicity may occur is not known. if the patient requires more than the recommended dosages or other medications containing this preservative, the practitioner must consider the daily metabolic load of benzyl alcohol from these combined sources (see warnings and precautions, pediatric use). pediatric neurotoxicity published animal studies demonstrate that the administration of anesthetic and sedation drugs that block nmda receptors and/or potentiate gaba activity increase neuronal apoptosis in the developing brain and result in long-term cognitive deficits when used for longer than 3 hours. the clinical significance of these findings is not clear. however, based on the available data, the window of vulnerability to these changes is believed to correlate with exposures in the third trimester of gestation through the first several months of life, but may extend out to approximately three years of age in humans (see precautions, pregnancy and pediatric use and animal toxicology and/or pharmacology). some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. these studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.

nd warnings). reactions such as agitation, involuntary movements, hyperactivity and combativeness have been reported in adult and pediatric patients. should such reactions occur, caution should be exercised before continuing administration of midazolam (see warnings). midazolam injection should only be administered im or iv (see warnings). care should be taken to avoid intra-arterial injection or extravasation (see warnings). midazolam injection may be mixed in the same syringe with the following frequently used premedications: morphine sulfate, meperidine, atropine sulfate or scopolamine. midazolam, at a concentration of 0.5 mg/ml, is compatible with 5% dextrose in water and 0.9% sodium chloride for up to 24 hours and with lactated ringer’s solution for up to 4 hours. both the 1 mg/ml and 5 mg/ml formulations of midazolam may be diluted with 0.9% sodium chloride or 5% dextrose in water. monitoring patient response to sedative agents, and resultant respiratory status, is variable. regardless of the intended level of sedation or route of administration, sedation is a continuum; a patient may move easily from light to deep sedation, with potential loss of protective reflexes. this is especially true in pediatric patients. sedative doses should be individually titrated, taking into account patient age, clinical status and concomitant use of other cns depressants. continuous monitoring of respiratory and cardiac function is required (i.e., pulse oximetry). adults and pediatrics: sedation guidelines recommend a careful presedation history to determine how a patient’s underlying medical conditions or concomitant medications might affect their response to sedation/analgesia as well as a physical examination including a focused examination of the airway for abnormalities. further recommendations include appropriate presedation fasting. titration to effect with multiple small doses is essential for safe administration. it should be noted that adequate time to achieve peak central nervous system effect (3 to 5 minutes) for midazolam should be allowed between doses to minimize the potential for oversedation. sufficient time must elapse between doses of concomitant sedative medications to allow the effect of each dose to be assessed before subsequent drug administration. this is an important consideration for all patients who receive intravenous midazolam. immediate availability of resuscitative drugs and age- and size-appropriate equipment and personnel trained in their use and skilled in airway management should be assured (see warnings). pediatrics: for deeply sedated pediatric patients a dedicated individual, other than the practitioner performing the procedure, should monitor the patient throughout the procedure. intravenous access is not thought to be necessary for all pediatric patients sedated for a diagnostic or therapeutic procedure because in some cases the difficulty of gaining iv access would defeat the purpose of sedating the child; rather, emphasis should be placed upon having the intravenous equipment available and a practitioner skilled in establishing vascular access in pediatric patients immediately available.

amuscular administration: administration of im midazolam to elderly and/or higher risk surgical patients has been associated with rare reports of death under circumstances compatible with cardiorespiratory depression. in most of these cases, the patients also received other central nervous system depressants capable of depressing respiration, especially narcotics (see dosage and administration). the following additional adverse reactions were reported subsequent to intravenous administration as a single sedative/anxiolytic/amnestic agent in adult patients: pediatric patients the following adverse events related to the use of iv midazolam in pediatric patients were reported in the medical literature: desaturation 4.6%, apnea 2.8%, hypotension 2.7%, paradoxical reactions 2.0%, hiccough 1.2%, seizure-like activity 1.1% and nystagmus 1.1%. the majority of airway-related events occurred in patients receiving other cns depressing medications and in patients where midazolam was not used as a single sedating agent. neonates for information concerning hypotensive episodes and seizures following the administration of midazolam to neonates (see boxed warning, contraindications, warnings and precautions). other adverse experiences, observed mainly following iv injection as a single sedative/anxiolytic/amnesia agent and occurring at an incidence of <1.0% in adult and pediatric patients, are as follows: respiratory: laryngospasm, bronchospasm, dyspnea, hyperventilation, wheezing, shallow respirations, airway obstruction, tachypnea cardiovascular: bigeminy, premature ventricular contractions, vasovagal episode, bradycardia, tachycardia, nodal rhythm gastrointestinal: acid taste, excessive salivation, retching cns/neuromuscular: retrograde amnesia, euphoria, hallucination, confusion, argumentativeness, nervousness, anxiety, grogginess, restlessness, emergence delirium or agitation, prolonged emergence from anesthesia, dreaming during emergence, sleep disturbance, insomnia, nightmares, athetoid movements, seizure-like activity, ataxia, dizziness, dysphoria, slurred speech, dysphonia, paresthesia special senses: blurred vision, diplopia, nystagmus, pinpoint pupils, cyclic movements of eyelids, visual disturbance, difficulty focusing eyes, ears blocked, loss of balance, light-headedness integumentary: hive-like elevation at injection site, swelling or feeling of burning, warmth or coldness at injection site hypersensitivity: allergic reactions including anaphylactoid reactions, hives, rash, pruritus miscellaneous: yawning, lethargy, chills, weakness, toothache, faint feeling, hematoma image2.jpg image3.jpg