Midazolam GTT

  1. Quick question for my critical care folks.....

    What is your typical rates that you run midazolam gtts? I worked an agency shift last night and my patient was on 20mg/hour of midazolam and they said that was the norm for them that their docs didn't particularly mind. I had him down to 11mg/hr and off his levophed when I left and his neuro assessment/behavior was no different on 11 vs 20/hr.

    What's your standard?
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  3. by   detroitdano
    Depends what conditions are going as well (i.e. alcohol withdrawal) but if it's simply for sedation/comfort while being intubated, it seems the norm that no more than 4 mg/hr of Versed is enough to keep your average patient cozy.

    Our docs usually go with fentanyl/midazolam for the continuous sedation protocol and write "titrate to MAAS of 3." Sometimes they need 11 mg/hr, but for most people that will have them snowed. I've seen people climbing out of the bed on 20 and 200 and needing Propofol, and I've seen other people with a MAAS of 1 after 2 and 20. Everyone responds differently.

    Like you, I always try and keep them on the least amount possible, not just enough to make my shift easy. Day shift has a habit of keeping people snowed since they can falsely document a MAAS of 3 and pull it off. On nights when we need to do weaning trials at 0500 or 0600 and the patient's MAAS is 1 and they're on a heavy dose of sedatives, it's kinda hard for them to be making proper Vt's lol.
  4. by   meandragonbrett
    Thanks, I was starting to wonder if my facilities where I am staff is just mean to us or what. LOL. After about 7 or 8mg/hour we switch drugs.
  5. by   detroitdano
    We will keep following the MAAS protocol even if they need 7-8 mg/hr, but mostly because our only other sedation protocol adds lorazepam in instead of midazolam. They are in the process of creating a fentanyl/propofol protocol finally, I can't wait.

    If someone is failing to keep a MAAS <3 with <20 mg/hr of midazolam we will usually bug the docs to stop it and write to keep using fentanyl and titrate propofol per doctor's orders, usually starting at 5 mcg/kg/min. The first time you see how effective it is in practice for people failing to remain sedated on midazolam, it's a site to behold lol.
  6. by   NotReady4PrimeTime
    I work in a PICU and our infusions are of course all weight-based, but our policy is a maximum of 6 mcg/kg/min, which in an average teenager weighing 70 kg could amount to 25 mg/hr. We don't see that dose very often, but we see 4 mcg/kg/min or 16.8 mg/hr for the same 70 kg patient fairly frequently. But let's not talk about how we wean them...
  7. by   catshowlady
    Ours run at 0.02mg/kg/hr to 0.12mg/kg/hr. We titrate for a Ramsey score of 3. If they need more sedation, we add something else - often propofol.

  8. by   Bubbles_RN
    Well we have a scale usually 2 - 10 mg/hr with the option for the docs to write higher end points as required.

    Although if we can't maintain a RASS of -1/-2 with high dose versed/fentanyl we usually look at adding something else.
  9. by   sunnycalifRN
    our max rate is 10 mg/hr.

    some of our narc tolerant patients have been on 500 mcg/hr fentanyl and 10 mg/hr versed and they are still arousable!! And, their BP is fine.
  10. by   WalkieTalkie
    Our sedation form says to titrate it for a goal of RASS -3... it also says something to the effect of "patients requiring more than 16 mg/hr may need additional forms of sedation."

    That being said, I've had patients on 20+ mg/hr. Often times with these patients we will add on propofol at a low dose or give them basal dosed analgesia.

    Most patients require anywhere from 2-10 mg/hr, in my experience. Of course, there's always those who are benzo tolerant and it doesn't work at all.
  11. by   CrufflerJJ
    Quote from sunnycalifRN
    our max rate is 10 mg/hr.

    some of our narc tolerant patients have been on 500 mcg/hr fentanyl and 10 mg/hr versed and they are still arousable!! And, their BP is fine.

    I've had (large) patients on 300 mcg/hr of fentanyl, plus 20 mg/hr versed. They were still VERY easily aroused, and would actually fight you when you did an oral temp or instilled eye drops.

    With the grand propofol "shortage" (along with the vanc shortage, and the paralytic shortage, and the xxx shortage), we're using versed/fentanyl a lot more than propofol for sedation.
  12. by   *!*nurse*!*
    Yes...20mg/hr seems a bit high. Our usual dosage is under 10mg/hr...but we have infused more before. Usually we run our versed drips along with fentanyl drips. We also use the MAAS scale to aid us in our titration.
  13. by   tri-rn
    I think ours is 2-12 mg/hr. I'm in a combined adult MICU/SICU. We titrate to a RASS of -2 to -3. Usually run fentanyl with it, propofol sometimes.
  14. by   ONCRN84
    Max is 20mg/hr. We usually have Fentanyl/Versed running and add Propofol if needed.