Midazolam Does Not Work Until It Is Given

Most of us have seen patients on midazolam. Some of us might’ve had some for minimally invasive procedures. The patient doesn’t remember anything and it’s possible they have the same conversation over. The patient doesn’t remember anything and they have the same

oh.

Right.

Anyhow, we had a gentleman who went into VF. He kept his output (he was monitored with both arterial line and ECG) but it was fading. He DID keep his alertness, however. We were very fast with the defibrillator. A senior registrar (who was on scene) proceeded to do what you do…charged, apologised “I’m very sorry sir…!”

And Zapped.

Followed by a cry of “SOMEBODY GET HIM MIDAZOLAM!!!”

And Zapped again.

He reverted, we got him the midazolam, can’t actually remember whether he needed to be intubated…but he remembered everything…and the first thing he did say was “CAN YOU PLEASE NEVER DO THAT AGAIN?”

In anaesthetics, we had a patient who had had his induction dose of proposal, suxemethonium, and fentanyl. We intubated him reasonably promptly, and as the anaesthetic nurse I set out to help the scout nurse with positioning the patient. The anaesthetist answered his telephone. The patient didn’t like us moving him. Pressure alarms went off on the ventilator…the whole thing. The anaesthetist gave more propofol, we positioned the patient, the surgeon started the procedure…the patient jumped, the anaesthetist rapidly sedated the patient with more propofol and told the surgeon “it was OK, they’ve had some midazolam”.

Except the patient hadn’t yet been given any.

Hence the tip: MIdazolam does not work until it has been given.

Midazolam is wonderful drug in for use in critical care. In small doses, it is relatively short acting. It is painlessly administered intranasally (equivalent dosage for I.V.  – good for kiddies) and usable IV or via deep I.M. (obviously not as painlessly). It has a small number of incompatibilities in solutions and is good for procedural sedation, long term ICU sedation and as a second line treatment for status epilepticus.

It’s not perfect – it can cause respiratory depression or arrest and should be used with caution with intoxicated patients – it is metabolised in the liver via CYP3A4 (of the CYP450 family of oxidising enzymes) so drunk patients may have a prolonged duration of action.

This is NOT an administration guide for a medication. Clinicians should use their own judgement and adhere to relevant policies.