IV Benzodiazepines for Acute Anxiety

Recommended IV Benzodiazepines and Dosing

Administer slowly over approximately 2 minutes to avoid pain at the IV site 1
The American Academy of Pediatrics recommends adult dosing: 0.05-0.15 mg/kg IV (maximum single dose: 5 mg) for lorazepam 2
Lorazepam has a slower onset but longer duration of action compared to diazepam 3
Adult dosing: 0.05-0.10 mg/kg IV over 2-3 minutes (maximum single dose: 5 mg) for midazolam 4

Monitor continuously: Oxygen saturation, respiratory rate, and blood pressure throughout administration 5, 4
Slow IV push: Administer over 2-3 minutes to minimize respiratory depression and pain at injection site 4, 1
Have reversal agent ready: Flumazenil should be immediately available for life-threatening respiratory depression 3, 6
Prepare for respiratory support: Be ready to provide ventilation assistance, as apnea risk increases significantly when combined with other sedative agents 5, 4

Reduce initial dose by 50%: Start with 0.05-0.1 mg/kg for lorazepam due to decreased drug metabolism in elderly patients 7
Higher risk of respiratory depression and hypotension in elderly patients 7

Highest risk: When combining benzodiazepines with opioids or other sedatives, the risk of respiratory depression increases 5, 6
Rapid IV administration increases apnea risk 1
Agitation or excitement may occur, especially in younger children and elderly patients, as a paradoxical reaction to benzodiazepines 4, 7
If paradoxical reaction occurs, discontinue benzodiazepine and consider alternative sedation 4
May occur with rapid administration or in hemodynamically unstable patients, hypotension is a concern 2, 7
Monitor blood pressure continuously during administration 7
Benzodiazepines potentiate effects of other CNS depressants 5
Elderly patients on multiple medications are at highest risk for interactions 7
Reverses respiratory depression but also reverses anxiolytic effects, flumazenil should be used with caution 3, 6
Contraindicated in tricyclic antidepressant overdose, as it may induce seizures 6
Use with extreme caution in patients with seizure disorders 6
Duration of action shorter than most benzodiazepines, re-sedation may occur with flumazenil 6