Midazolam Infusion for Refractory Generalized Tonic-Clonic Seizures

Monitoring and Administration

Continuous pulse oximetry is mandatory throughout infusion, and monitoring for respiratory depression is crucial, which can occur up to 30 minutes after administration, with flumazenil immediately available for reversal 1, 2
The American College of Cardiology and other guideline societies recommend reducing initial dose by at least 20% in patients over 55 years or with hepatic/renal impairment, and reducing midazolam dose by at least 20% when co-administered with opioids due to synergistic respiratory depression risk 1, 2

For elderly and debilitated patients, as well as patients on concurrent CNS depressants, the guideline society recommends starting with lower infusion rates and titrating cautiously, with a reduction of midazolam dose by at least 20% 1, 2
The European Society of Cardiology notes that midazolam ablates sympathetic tone and can cause vasodilation, bradycardia, and low cardiac output in hemodynamically unstable patients 3

For breakthrough seizures during infusion, the guideline society recommends administering bolus doses equal to 1-2 times the hourly infusion rate every 5 minutes as needed; if 2 boluses are required within 1 hour, double the infusion rate 2
The British Medical Journal states that benzodiazepines should not be first-line for prolonged ICU sedation due to increased delirium risk and worse outcomes compared to propofol or dexmedetomidine 4, 2