Based on the pharmacokinetic parameters and reported clinical experience in preterm and term midazolam in neonates , continuous IV infusion of midazolam should be initiated at a rate of 0.0005 to 0.001 mg/kg/mm (0.5 to 1 mcg/kg/min).
IV loading doses should not be used with midazolam in neonates ; rather the infusion may be run more rapidly for the first several hours to establish therapeutic plasma levels.
Hypotension may be observed in patients who are critically ill and in preterm and term infants, particularly those receiving fentanyl and or when midazolam in neonates is administered rapidly.
Midazolam is water soluble and therefore not generally painful on intravenous administration . It should be noted that because of its water solubility, it takes three times as long to reach a peak EEG effect as the more fat-soluble diazepam.
The clinical importance of this is that one should wait at least 3 minutes between intravenous doses to avoid “stacking” of effect.
The shorter elimination half-life (∼2 hours) of midazolam in neonates than diazepam (∼18 hours) offers an advantage for use as a premedicant in children.
Midazolam is the only benzodiazepine approved by the Food and Drug Administration for use in neonates; in this population the half-life is much longer (6 to 12 hours).
In addition, severe hypotension has been reported with midazolam in neonates after bolus administration, and the potential for this problem is apparently increased in neonates also receiving fentanyl.
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