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Underdosing of midazolam in emergency endotracheal intubation
Mark J Sagarin1, Erik D Barton, John C Sakles
1Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA.
Objectives:
To determine whether midazolam, when used as an induction agent for emergency department (ED) rapid-sequence intubation (RSI), is used in adequate and recommended induction doses (0.1 to 0.3 mg/kg), and to compare the accuracy of the dosing of midazolam for ED RSI with the accuracy of dosing of other agents.
Methods:
The authors conducted a systematic query of a prospectively collected database of ED intubations using the National Emergency Airway Registry data, gathered in 11 participating EDs over a 16-month period. A data form completed at the time of emergency department intubation (EDI) enabled analysis of patients' ages, weights, and indications for EDI, as well as the techniques and drugs used to facilitate EDI. Data were analyzed to determine whether midazolam is used in recommended doses during RSI. Patients intubated with midazolam alone were compared with patients who received other induction agents for RSI.
Results:
Of 1,288 patients entered in the study, 1,023 (79%) underwent RSI. Of the 888 RSI patients with an age recorded, midazolam was used as the sole induction agent in 140 (16%). The mean (+/-SD) dosages of midazolam used in RSI were 2.6 (+/-1.7) mg in children (age < or = 18) and 3.7 (+/-2.5) mg in adults (age > or =19); the mean (+/-SD) dosages by weight were 0.08 (+/-0.04) mg/kg in children and 0.05 (+/-0.03) mg/kg in adults. More than half (56%) of the children, and nearly all (92%) of the adults, received dosages lower than the minimum recommended dosage (0.1 mg/kg). Of patients who received barbiturates, only 21% of children and 21% of adults received a dose lower than the minimum recommended. When combined with another induction agent, midazolam was dosed similarly to when it was used alone: mean adult doses were 3.1 (+/-1.2) mg and 0.04 (+/-0.02) mg/kg.
Conclusions:
Underdosing of midazolam during ED RSI is frequent, and appears to be related to incorrect dosage selection, rather than to a deliberate intention to reduce the dose used.
Insights
Midazolam is frequently underdosed during emergency department rapid-sequence intubation (RSI), with most patients receiving less than the recommended dose. This underdosing appears to be due to incorrect dosage selection, not intentional dose reduction.
Area of Science:
- Emergency Medicine
- Pharmacology
- Critical Care
Background:
- Rapid-sequence intubation (RSI) is a critical procedure in emergency departments (EDs).
- Midazolam is a common induction agent used in ED RSI.
- Ensuring appropriate dosing of induction agents is crucial for patient safety and procedural success.
Purpose of the Study:
- To evaluate the adequacy of midazolam dosing for ED RSI.
- To compare midazolam dosing accuracy with other induction agents.
- To identify patterns in midazolam underdosing during ED RSI.
Main Methods:
- Systematic review of prospectively collected National Emergency Airway Registry data.
- Analysis of 1,023 RSI cases from 11 EDs over 16 months.
- Comparison of midazolam doses (mg/kg) against recommended ranges (0.1-0.3 mg/kg).
Main Results:
- Midazolam was used as the sole induction agent in 16% of RSI cases.
- Mean weight-based midazolam doses were 0.08 mg/kg in children and 0.05 mg/kg in adults, below the recommended 0.1 mg/kg.
- 56% of children and 92% of adults received sub-therapeutic midazolam doses.
Conclusions:
- Underdosing of midazolam during ED RSI is common.
- The frequent underdosing is attributed to incorrect dosage selection.
- This highlights a need for improved midazolam dosing protocols in emergency settings.