Hypotension midazolam

Pentobarbital is commonly loaded at a dose of 10 to 15 mg/kg over 1 to 2 hours, followed by a continuous infusion of 0.5 to 4 mg/kg per hour. Therapy can be tapered off after 12 to 24 hours of seizure control as evident on the EEG.35 One metaanalysis reported a lower incidence of treatment failure with pentobarbital (3%) when compared to midazolam (21%) or propofol (20%), although the risk of hypotension requiring vasopressor therapy was higher when pentobarbital was used.36 This relative efficacy for pentobarbital must be considered... 

A metaanalysis showed that among patients refractory to GCSE, pentobarbital had a 92% response rate, compared to midazolam (80%) and propofol (73%). Breakthrough seizures were least common with pentobarbital (12%, compared with propofol [15%] and midazolam [51%]). Hypotension was more common with midazolam and propofol. 

T effects OF amiodarone, astemizole, atorvastadn, barbiturates, bepridil, bupropion, cerivastatin, cisapride, clorazepate, clozapine, clarithromycin, desipramine, diazepam, encainide, ergot alkaloids, estazolam, flecainide, flurazepam, indinavir, ketoconazole, lovastatin, meperidine, midazolam, nelfinavir, phenytoin, pimozide, piroxicam, propafenone, propoxyphene, quinidine, rifabutin, saquinavir, sildenafil, simvastatin, SSRIs, TCAs, terfenadine, triazolam, troleandomycin, zolpidem X effects W/ barbiturates, carbamazepine, phenytoin, rifabutin, rifampin, St. John s wort, tobacco X effects OF didanosine, hypnotics, methadone, OCPs, sedatives, theophylline, warfarin EMS T Effects of amiodarone, diazepam, midazolam and BBs, may need X- doses concurrent use of Viagra-type drugs can lead to hypotension X- effects of warfarin concurrent EtOH use can T adverse effects T glucose ODs May cause an extension of adverse SEs symptomatic and supportive Rivasrigmine (Exelon) [Cholinesterase Inhibitor/Anri ... 

Sedation Avoidance of doses inducing respiratory sedation and hypotension is recommended Agents such as midazolam with a rapid onset and offset of action are preferred... 

The safety of benzodiazepines in neonates has been assessed in a retrospective chart review of 63 infants who received benzodiazepines (lorazepam and/or midazolam) as sedatives or anticonvulsants (57). Five infants had hypotension and three had respiratory depression. In all cases of respiratory depression, ventilatory support was initiated or increased. Significant hypotension was treated with positive inotropic drugs in two cases. Thus, respiratory depression and hypotension are relatively common when benzodiazepines are prescribed in these patients. However, both depression and hypotension could also have been due to the severe underlying illnesses and concomitant medications. Matched controls were not studied. 

In 27 children with refractory generalized convulsive status epilepticus, midazolam 0.2 mg/kg as a bolus followed by 1-5 (mean 3.1) micrograms/kg/minute as a continuous infusion achieved complete control of seizures in 26 children within 65 minutes (14). There were no adverse effects, such as hypotension, bradycardia, or respiratory depression. In one patient with acute meningoencephalitis, status epilepticus could not be controlled. Five patients died of the primary disorders, one with progressive encephalopathy. 

The incidence of hypotension with the use of midazolam for pre-hospital rapid-sequence intubation of the trachea has been assessed in a retrospective chart review of two aeromedical crews (19). The rapid-sequence protocols were identical, except for the dose of midazolam. Both crews used 0.1 mg/kg, but one crew had a maximum dose of 5 mg imposed. This meant that patients over 50 kg received lower doses of midazolam they also had a higher incidence of hypotension. This relation was also present in patients with traumatic brain injury, implying that cerebral perfusion could be compromised at a critical time in those without dosage restriction. 

Several adverse effects have been reported with the combined use of fentanyl and midazolam, including chest wall rigidity, making ventilation with a bag and mask impossible (SEDA-16, 79). In neonates, hypotension can occur (SEDA-16, 80), and respiratory arrest in a child and sudden cardiac arrest have been reported (SEDA-16, 80). However, in one study there were no cardiac electrophy-siological effects of midazolam combined with fentanyl in subjects undergoing cardiac electrophysiological studies (SEDA-18, 80). 

Davis DP, Kimbro TA, Vilke GM. The use of midazolam for prehospital rapid-sequence intubation may be associated with a dose-related increase in hypotension. Prehosp Emerg Care 2001 5(2) 163-8. 

Hypotension has occurred in neonates given midazolam and fentanyl... 

All narcotics are expected to have this problem. The most common side effects demonstrated with narcotics include decreased gastrointestinal motility and risk of hypotension. Lorazepam is the preferred sedative agent in the absence of pain owing to its fast onset of action, its lack of hemodynamic toxicities, and its low risk of metabolite accumulation in comparison with diazepam. Midazolam continuous infusion is a reasonable altemative, although more costly and requiring additional fluid, which may be detrimental in a patient predisposed to PDA. Muscle paralysis has been used to reduce ventilator fighting and the consequent comphcations. However, its role in RDS has diminished owing to adverse effects (e.g., edema and hypoventilation). If paralysis is induced, assessment of sedation and seizures is confounded. Consequently, concurrent phenobarbital serum concentrations of 40 mg/L are recommended. Independent of... 

Midazolam. Give 0.05 mg/kg (up to 0.35 mg/kg for anesthesia induction) IV over 20-30 seconds (usual adult doses vary 1 mg to maximum of 5 mg given in increments of 2.5 mg every 2 minutes lower dose in geriatric patients with maximum at 3.5 mg) or 0.07-0.1 mg/kg IM. Repeat after 10-20 minutes if needed. Continuous infusions have also been used to maintain effect with initial rates of 0.02-0.1 mg/kg/h (usual adult dose 1-7 mg/h children 1-2 mcg/kg/min) and then titrated to effect. Caution There have been several reports of respiratory arrest and hypotension after rapid intravenous injection, especially when midazolam is given in combination with opioids. Prolonged continuous infusion may lead to persistent sedation after the dmg is discontinued because midazolam accumulates in tissues. 

A. Additive effect with other CNS depressants that may result in lower propofol dosage requirements if given concomitantly. Through its inhibition of cytochrome P-450, propofol may increase levels of midazolam, diazepam, and other opiates such as sufentanyl and alfentanyl, causing respiratory depression, bradycardia, and hypotension. 

In general the combined use of benzodiazepines with atfentanil or fentanyl is synei istic but may also result in additive effects on respiratory depression and/or hypotension. A pharmacokinetic study found that fentanyl reduced the metabolism of midazolam. Retrospective evidence suggests that midazolam can increase the dose requirement of sufentanil, but midazolam did not alter the analgesic efficacy of fentanyl in healthy subjects. 

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