Midazolam Infusion for Status Epilepticus

Dosing Protocol

The American Academy of Pediatrics recommends an IV loading dose of 0.15-0.20 mg/kg of midazolam for refractory status epilepticus, followed by a continuous infusion starting at 1 mg/kg per minute and increasing by 1 mg/kg per minute increments every 15 minutes as needed, up to a maximum of 5 mg/kg per minute until seizures stop 1, 2, 3
IV loading dose: 0.15-0.20 mg/kg, administered immediately upon determination that status epilepticus is refractory to standard first-line therapies 1, 3
Continuous infusion should start at 1 mg/kg per minute and increase by increments of 1 mg/kg per minute every 15 minutes, with a maximum dose of 5 mg/kg per minute 1, 2, 3

IM administration of midazolam: 0.2 mg/kg (maximum: 6 mg per dose), which may be repeated every 10-15 minutes as needed 1, 2, 3

Increased incidence of apnea when midazolam is combined with other sedative agents, requiring preparation for respiratory support regardless of administration route 1, 2, 3
Continuous oxygen saturation monitoring is essential when administering midazolam for status epilepticus 1, 3

Flumazenil may be administered to reverse life-threatening respiratory depression caused by midazolam, but it will also reverse the anticonvulsant effects and may precipitate recurrence of seizures 1, 2, 3

First-line therapy: Standard benzodiazepines (lorazepam, diazepam), followed by second-line therapy with phenytoin/fosphenytoin, valproate, or levetiracetam, and finally midazolam infusion for refractory status epilepticus 4, 5
The European Federation of Neurological Societies recommends anesthetic doses of midazolam, propofol, or barbiturates for status epilepticus refractory to benzodiazepines and phenytoin 4, 5

Concurrent treatment of underlying causes of status epilepticus (hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection) is essential when administering midazolam 4, 6

Si el paciente ya está recibiendo una infusión de midazolam y se vuelve sintomático, es razonable administrar una dosis en bolo igual o el doble de la dosis de infusión por hora, según la Sociedad de Medicina Intensiva, con una recomendación basada en evidencia de nivel moderado 7
Las dosis en bolo de midazolam IV deben ordenarse cada 5 minutos según sea necesario, según la Sociedad de Medicina Intensiva, con una recomendación basada en evidencia de nivel moderado 7
Si un paciente recibe dos dosis en bolo en una hora, es razonable duplicar la velocidad de infusión, según la Sociedad de Medicina Intensiva, con una recomendación basada en evidencia de nivel moderado 7