ICU Advantage Lecture Notes

Introduction

• Presenter: Eddie Watson
• Goal: Simplify complex critical care subjects for ICU success.
• Invitation to subscribe to the channel for updates on new lessons.

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Topic: Midazolam (Versed)

History and Background

• Synthesized in 1975 by Walser and Fry at Hoffman LaRoche Inc. (Swiss pharmaceutical company).
• Favorable due to water solubility and less thrombophlebitis risk.
• Recognized for treating status epilepticus in the 1990s.

Therapeutic Actions

• Benzodiazepine used for anesthesia induction and conscious sedation.
• Works by binding GABA receptors and enhancing effects of endogenous GABA.
• Suppresses seizure activity spread.

Indications

• Perioperative sedation, anxiolysis, anesthesia induction, amnesia.
• Treatment of status epilepticus in adults.
• Used in critical care for procedural sedation and continuous sedation in intubated/ventilated patients.

Contraindications

• Hypersensitivity to the drug.
• Caution with older adults, debilitated patients, those with uncompensated acute illness, heart failure, respiratory, renal, or hepatic disease.
• Increased fall risk and potential paradoxical reactions (agitation, aggression, involuntary movements).

Adverse Effects

• Central Nervous System: Over-sedation, drowsiness, amnesia, potential seizures, involuntary movements.
• Cardiovascular: Heart rate and blood pressure variations; less common/severe hypotension compared to propofol.
• ENT: Nystagmus.
• Gastrointestinal: Nausea and vomiting.
• Respiratory: Decreased respiratory rate, oxygen saturation, and potential apnea.

Concentrations and Dosing

• PO Form: 2 mg/mL syrup, 100 mL bottle, single-use 10 mg, and 5 mg cups.
• IV Push: Common concentration 1 mg/mL.
• Continuous Sedation: 1 mg/mL, e.g., 50 mg/50 mL or 100 mg/100 mL.
• Dosing: Varies by clinical condition, tolerance, and patient size. Typical IV push: 1-2 mg. Infusion starts at 2 mg/hour, max 10 mg/hour (can be higher for specific conditions).

Pharmacokinetics

• Onset: 90 seconds to 5 minutes.
• Peak: 5 to 7 minutes.
• Duration: Less than 2 hours (up to 6 with cirrhosis).
• Metabolized in liver and gut, excreted in urine.

Antidote

• Flumazenil (Ramazacon): 0.2 mg IV push.

Nursing Considerations

• Administered by trained personnel only.
• Antidote and rescue equipment should be readily available.
• Monitor blood pressure, heart rate, respirations, airway integrity, and continuous pulse oximetry.
• Adjust dosing for patients with hepatic impairment or renal failure (50% dose reduction).
• No specific laboratory studies required.

Conclusion

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