Section 13 · Monograph
Midazolam (continuous infusion)
Reviewed Nov 2026FDA label
VersedBenzodiazepine
- Forms
- IV: 1, 5mg/mL
- Dose
- Refractory status epilepticus (off-label): 0.2mg/kg IV load, then 0.1-2mg/kg/h | ICU sedation: 0.02-0.1mg/kg/h
- MOA
- ↑GABA-A Cl- channel frequency
Black Box Warning
- Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma and death
- Respiratory depression and respiratory arrest can occur — must be given only in settings with continuous monitoring and resuscitative equipment
- Abuse, misuse and dependence; withdrawal reactions after prolonged use
Indications
- Sedation of intubated and mechanically ventilated patients (continuous infusion)FDA-labeled
- Preoperative sedation, anxiolysis and amnesia; induction of anesthesiaFDA-labeled
Off-Label Uses
- Refractory status epilepticus (continuous infusion)Off-label
Mechanism of Action
- Benzodiazepine that enhances GABA-A receptor chloride channel opening frequency; short-acting with an active alpha-hydroxy metabolite that can accumulate in prolonged infusions
Full Dosing
Adult / usual
- Refractory status epilepticus (off-label): 0.2mg/kg IV loading dose, then 0.1-2mg/kg/h titrated to seizure suppression on EEG
- ICU sedation: 0.02-0.1mg/kg/h (often 1-7mg/h), titrated to sedation goal
Renal
- Reduce doses with renal impairment, hypoalbuminemia and CYP3A4 inhibitors
Contraindications
- Acute narrow-angle glaucoma
- Known hypersensitivity to midazolam
Drug Interactions
- CYP3A4 inhibitors (azoles, macrolides, protease inhibitors) markedly raise levels
- Opioids and other CNS depressants: profound sedation
- Enzyme inducers (carbamazepine, phenytoin) lower levels
Adverse Effects
- Respiratory depression and hypotension
- Tachyphylaxis and accumulation (prolonged sedation after long infusions)
- Delirium and paradoxical agitation
- Dependence and withdrawal
Monitoring Parameters
- Continuous respiratory and hemodynamic monitoring
- Continuous EEG for status epilepticus
- Daily sedation interruption where appropriate
Pregnancy & Lactation
- Neonatal sedation or withdrawal possible with late-pregnancy exposure
- Excreted in milk; monitor infants