Midazolam for intubation (Have U used midaz. anaesthesia?)

[sihi]

Hi!

Have you used Midazolam to induce anesthesia for intubation pre-hosp. without using muscle relaxants?

It means you have breathing patient who must be intubated and mechanically ventilated. Midazolam in doses 0,2-0,35 mg/kg. And no use of relaxant (Succinylcoline).

If you did Midaz. anestesia, please describe situation, how midazolam had effect on reflexes, blood pressure, spontaneous breathing.

Thanks

[chbare]

Midazolam is IMHO a suboptimal medication for emergent pre-hospital intubation when used as an induction agent. It has a slow onset, long duration and is associated with haemodynamic complications. I've never used midazolam as a sole agent for medication facilitated intubation, therefore I have little anecdotal evidence to add other than the well known properties of midazolam.

[Kiwiology]

As chbare points out, midazolam is a very sub optimal medicine for intubating people; we used to have midazolam facilitated intubation in the 1990s but it was withdrawn after it was shown to have a very high mortality rate. Pouring midazolam into somebody until they are unconscious enough to accept a tube will more than likely destroy their blood pressure and we know hypotension is linked to secondary brain injury.

The Metropolitan Ambulance Service in Melbourne, Australia uses fentanyl and midazolam in reasonably high doses for RSI. They noted that while Intensive Care Paramedic RSI improves the functional outcome of patients the Paramedic RSI group of patients who were given fentanyl and midazolam suffered a concerning number of cardiac arrests and included the administration of these medicines to patients who had no recordable blood pressure. See here http://www.ncbi.nlm.nih.gov/pubmed/21107105

In New Zealand we use fentanyl and ketamine, an excellent anaesthetic and one with near ideal cardiovascular risk profile. Midazolam 0.05mg/kg is used for patients who have a neurogenic cause for coma i.e. are already unconscious and who do not have shock or hypotension.

I'm also totally against intubating people without using a muscle relaxant (take your pick; we use suxamethonium and vecuronium but rocuronium is probably acceptable as a sole agent)

I would recommend fentanyl, ketamine and a paralytic of your choice, again sux and vec in combo are acceptable but roc is probably OK as a sole agent

Oh and it also goes without saying that electronic capnography and physiologic monitoring and all that good stuff must be mandatory

[Paramagic]

We use fentanyl and midazolam as our routine agents for induction (with suxamethonium for paralysis). Generally speaking they work well, however, as the others have said, midazolam on it's own (or fentanyl + midazolam without paralytic agents) is very much sub-optimal.

I like the regime Kiwi describes, ketamine for anyone with hypotension or potential for hypotension, midazolam + fentanyl for people whose brain has already exploded and who have a BP of eleventybillion over 90. And rocuronium would be my choice of paralytic.

Midazolam and morphine make a nice infusion for ongoing sedation and analgesia though, they are needed in lower doses so there are less issues with hypotension.

[Kiwiology]

I am very biased towards everybody should be getting ketamine, ketamine is an excellent anaesthetic at the dosages used in RSI (1.5mg/kg) and I have doubts that 0.05mg/kg midazolam actually produces sufficient amnesia; even if they are only personally ill conceived doubts I would prefer to give somebody ketamine rather than midazolam and know they are totally anaesthetised and unaware vs. is that person who is paralysed and getting a tube rammed down their gob aware of this shit what if it's just 0.00000001% I knew I should have used ketamine!

[croaker260]

What he said!

Seriously, anesthetic doses for Versed only intubation approach 30 mg or more. We dont even carry that much on a rig. Far better to use the right drugs for the job, than to use a crappy one in large doses.

Of course, if all you have is a hammer in your tool box...then everything is a nail...

[mikeymedic1984]

I always consider it bad medicine to overdose a patient on the wrong airway med, instead of using the right one. Services who do this are doing a shortcut to RSI without having to go through the proper steps of proving that you are competent to do RSI. Do it the right way and remember, patients do not die because you did not intubate them, they die because you did not ventilate them.

[chbare]

I am not sure midazolam is the wrong medication for RSI. Used in appropriate doses in patients where you've weighed risks and benefits, midazolam will work. Especially, with good premedication with fentanyl or other related agent IMHO. Unfortunately, there are no "magic bullet" agents for RSI. Every agent has benefits and every agent has pitfalls. I remain skeptical of using midazolam as a sole agent without a paralytic and possibly pre-medication however. Clearly, I have to admit personal bias with other agents such as etomidate and ketamine.

[SandPitMedic]

Over here, if we are going to intubate a patient with pharmacological assistance, we always use a paralytic if the patient has an intact gag reflex. Under normal circumstances we use 0.3 mg/kg Etomidate, morphine or fentanyl if necessary for analgesia (not for sedation), 0.01 mg/kg Vecuronium as a defasciculating agent, and 1.5 mg/kg Succinylcholine for paralysis. After RSI we use 2.5 - 5 mg Midazolam for continued sedation, and 0.1 mg/kg Vecuronium if we need continued paralysis. We also carry Rocuronium as an additional option.

I agree with the idea that we should be using the correct medications for the procedure, and never too much of the wrong medications. IMHO using the wrong tool for the job (in this case pushing Midazolam until the gag reflex disappears) is always asking for trouble. With that being said, I have heard of people having good success using Midazolam as a sedative instead of Etomidate, in appropriate doses, and still using a paralytic.

Edited May 26, 2012 by SandPitMedic

[Kiwiology]

For patients who are unconscious with poor airway and breathing (i.e. TBI, postictal state, alcohol or GHB poisoning) I don't think fentanyl and midazolam is a bad combination; as I've said I am personally biased towards using ketamine as ketamine provides profound anaesthesia at induction dosages but I'm not convinced 0.05mg/kg midazolam will produce the same level of amnesia; I guess I'm quite scared of the idea that the patient might not be properly anaesthetised.

Patients without significant hypertension or physiology where transient hypertension and cardiac stimulation would be bad should receive fentanyl and ketamine. Midazolam is used instead of ketamine for patients who have significant hypertension as well as for patients with pathology where increased blood pressure and cardiac work would be detrimental

Suxamethonium and vecuronium are in flavour for paralysis in these parts

Edited May 26, 2012 by Kiwiology