Alright you guys, welcome back to another video lesson from ICU Advantage. My name is Eddie Watson, and my goal is to give you guys the confidence to succeed in the ICU by making these complex critical care subjects easy to understand. I truly hope that I'm able to do just that.
and if I am, I do invite you to subscribe to the channel down below. When you do, make sure you hit that bell icon and select all notifications so you never miss out when I release a new lesson. All right, now real quick before we get started, I just wanted to remind you guys again about the pre-order opportunity for my new program that I'm very excited about called ICU Advantage Academy. So many of you have actually come to YouTube and my channel to learn and really grow your knowledge base simply to become a better practitioner and to do better for your patients. which is absolutely amazing.
But now I'm actually working to become an approved provider of CE credits. And through ICU Advantage Academy, you'll have the opportunity to earn CE credits for watching all of these videos that I made, as well as ones that I do in the future. Now, in addition to that, you're also going to be watching these videos without the interruption of ads.
You're going to have access to audio only versions of each video. as well as access to the lesson notes for each one as well. So the Academy is going to be officially launching March 15th, but if you pre-order lifetime membership before then, you're going to save 50% off the launch price.
So don't miss out on a great deal on opportunity for really a lifetime worth of learning and CE credits for a limited time price. All right, so in this lesson, we are talking about Madazalam, also goes by the trade name Versed. So just a quick history and background.
This medication was initially synthesized in 1975 by Walser and Fry at Hoffman LaRoche Incorporated, and this is actually a Swiss pharmaceutical company. And this was actually a favorable drug opposed to some 35 other-ish benzodiazepines that are currently used in healthcare due to its water solubility and really being less likely to cause thrombophlebitis. And then...
anticonvulsant properties of midazolam were studied in the 1970s, but it really wasn't recognized as an appropriate treatment for status epilepticus until the 1990s. So midazolam is a benzodiazepine that's often used for the induction of anesthesia and to produce conscious sedation. For its therapeutic actions, it's believed that it works by binding GABA receptors and really potentiating the effects of endogenous GABA, which is a major inhibitory neurotransmitter in the central nervous system. Thus, it depresses the central nervous system. It also works to suppress the spread of seizure activity as well.
Now, for indications, it promotes perioperative sedation, anxiolysis, anesthesia induction, or amnesia. It's also used for the treatment of status epileptic. and adults.
And typically in critical care setting, we're either using it for procedural sedation or for ongoing continuous sedation in our intubated and ventilated patients. As for some contraindications, obviously hypersensitivity to the drug is going to be one. We do want to use caution in older adults or patients who are debilitated, those really with uncompensated acute illness, heart failure, respiratory, renal, or hepatic disease. And those with increased risk of falls. And then benzodiazepines are associated with paradoxical reactions.
So sometimes it can actually lead to agitation, aggressive behavior, as well as involuntary movements. Now, as for our adverse effects, so again, system by system. For the central nervous system, so one potential effect is going to be over sedation, obviously drowsiness, amnesia, seizures potentially. those involuntary movements, paradoxical behaviors, and excitement. For the cardiovascular system, we can see variations in our patient's heart rate and blood pressure, although hypotension is actually going to be less common and typically less severe when we're comparing this to a medication like propofol.
Now for ENT, nystagmus is something that we can see. For GI, nausea and vomiting can potentially come about. And then for our respiratory system, Big ones are going to be decreased respiratory rate, decreased oxygen sats, and apnea.
So as far as our common concentrations go, this medication does come in a PO form in a syrup. And typically you can see that in a 2 mg per ml in like a 100 ml bottle. Or they do have some single-use cups of 10 mg and 5 mg.
5 mLs, so again another 2 mg per mL concentration. For IV push, the most common concentration is going to be a 1 mg per mL concentration, so 2 mg, 2 mLs, 5 mg, and 5 mLs. That said, I believe there is some formulation in which is a 5 mg per mL concentration.
Now for continuous sedation, typically, again, we're going to see a 1 mg per mL concentration. something like 50 milligrams and 50 mLs or 100 milligrams and 100 mLs. Now for our common dosing, I'm going to primarily focus on the IV form of this medication. For IV pushes, the dose really depends greatly on the patient's clinical condition as well as their potential tolerance to the medication as well as their size. But a push dose of one to two milligrams is pretty common, but we certainly can also give larger doses as well.
For the IV infusion, we can give a little bit of a push dose of one to two milligrams. So for example, if Again, really kind of depends on the use here, but for sedation, we're typically going to start out at around two milligrams per hour and then titrate for a rascal. And ideally here, our max is going to be 10 milligrams per hour.
That said, some of you guys are probably thinking that I'm crazy by saying that because you've seen it go much higher. And this is absolutely the case, especially for things like status epilepticus, if they've got a brain injury and elevated ICPs. If we're doing proning and paralytic therapy, as well as other things in there as well. So we definitely can see higher doses than the 10 milligrams per hour. Now for our pharmacokinetics, again, for our IV administration, onset's pretty quick, anywhere from 90 seconds to five minutes.
Typically, it tends to be on the lower end of this, more towards 90 seconds. The peak is anywhere from five to seven minutes. And the duration is typically less than two hours. That said...
with cirrhosis, we can see this actually go up to six hours. And the reason for this is it is metabolized primarily in the liver and the gut, and it gets metabolized into four main metabolites, all of which have various roles in the effect of midazolam. And then these metabolites do get excreted in the urine.
Now, as far as our antidote goes, we do have an antidote for this called Flamazenil, also goes by the name Ramazacon. And here the dose is going to be 0.2 milligrams IV push. Now for our nursing considerations, now again this should only be administered by someone who's been specifically trained and has the knowledge when using this medication as a sedative for procedural sedation. So we want to make sure that the antidote, Ramazacon, Flamazanil, should really be readily available in the event that we do have over sedation, which can lead to impaired respiratory status and depression. That said, we also want to make sure we've got rescue equipment nearby.
Again, typically not an issue in the ICU, but things like our code cart, bag valve mask, suctioning can be really important as well if we're dealing with this. Make sure that you are monitoring your patient's blood pressure, heart rate and rhythm, their respirations, their airway integrity, and then make sure we've got a continuous pulse ox, especially if we're doing the conscious sedation or procedural sedation. And then just be aware that individuals that have underlying hepatic impairments and cirrhosis, that they may metabolize this drug slower, leading to a prolonged duration of the drug, as opposed to those who have normal hepatic function.
As well as we do also want to be using decreased dosing in patients who have renal failure, and here typically we're looking at a 50% decrease in the dose size. And then finally, for any relevant laboratory studies, there actually aren't any identified with this medication. And that is going to be our review of Medazolam, aka Versed.
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