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Reversible neurologic abnormalities associated with prolonged intravenous midazolam and fentanyl administration

I Bergman1, M Steeves, G Burckart

  • 1Department of Pediatrics, University Health Center of Pittsburgh, Pennsylvania.

The Journal of Pediatrics
|October 1, 1991
PubMed

Insights

Infants sedated with midazolam and fentanyl may develop encephalopathy. Careful monitoring and dosing are crucial for prolonged use in pediatric intensive care units.

Area of Science:

  • Pediatric Neurology
  • Neonatal Intensive Care
  • Pharmacology

Background:

  • Prolonged sedation is common in neonatal intensive care units (NICUs) for critically ill infants.
  • Midazolam, a benzodiazepine, is frequently used for intravenous sedation.
  • Concomitant use of analgesics like fentanyl is standard practice.

Observation:

  • Three infants developed encephalopathy following 4-11 days of midazolam and fentanyl sedation.
  • Symptoms included poor social interaction, decreased visual attention, dystonic postures, and choreoathetosis.
  • These symptoms resolved within 5 days to 4 weeks after sedation cessation.

Findings:

  • A retrospective review of 45 infants revealed 5 cases (11.1%) with definite or possible neurologic sequelae after prolonged midazolam infusion.
  • Neurologic sequelae were associated with younger age, female gender, low serum albumin, and concurrent aminophylline use.
  • All affected infants received concomitant intravenous fentanyl therapy.

Implications:

  • The observed encephalopathy may be a benzodiazepine withdrawal syndrome or related to prolonged receptor agonism.
  • Other potential causes include combined toxic, metabolic, or infectious insults in the NICU setting.
  • This highlights the need for cautious dosing, monitoring, and discontinuation strategies for intravenous midazolam in infants and children.

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