Midazolam for induction: yes or no?

[soorg]

I stopped using midaz as part of my induction drugs about three years ago; patients seem to wake up a little faster, and are less groggy.

Can anyone else comment on their experience? Use it or not?

IMO, it just doesn't make sense to have to draw up another drug that doesn't do much for my induction, but can prolong emergence. I know everyone has the whole spiel about it being protective against awareness, but that is rare, and I doubt a measly 2 mg of midaz would be enough to prevent awareness.
It makes sense to use it in holding if a patient is freaking out, but other than that, I see it being overused like crazy.

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[Mman]

To me, it's a premedication to be given in preop holding. Helps ease anxiety, helps decrease chances of awareness. But that's be given 15-30 minutes before rolling in the OR. Not much point IMHO of giving it with induction in the OR unless it's part of a gentle induction on a sick heart patient.

 

[gasp]

I think its a great drug. Most pt's need some since surgery in general gives them anxiety. Even if you think it does not help with intra-op awareness (I think even 2mg does), it definitely makes it so most people don't remember rolling into the OR or anything after. It does not help you with induction per say but it decreases your MAC so one can argue that it does help with induction/intra-op/post-op in terms of requiring less of other drugs and gas. There are however times when I avoid using it like if someone is very old and already has cognitive problems. When you say it prolngs your emergence, how do you know that it is specifically the Midazolam?

 

[pgg]

I think it's the most overused drug in the OR. For anxious patients, it's great. Most don't need it and are better off without it.

 

[Bertelman]

To me, it's a premedication to be given in preop holding. Helps ease anxiety, helps decrease chances of awareness. But that's be given 15-30 minutes before rolling in the OR. Not much point IMHO of giving it with induction in the OR unless it's part of a gentle induction on a sick heart patient.

You only need about 2 min for that stuff to hit. I used to push it when I went to get the Pt., and by the time we had lines untangled and kisses to family, they were feeling it.

 

[proman]

2mg of midazolam gives a healthy patient 20 min of amnesia. I like to use it for induction, in case of post induction instability and the chance of using minimal anesthetic during that time. I have essentially eliminated it from use for cardiac patients. I'm more likely to use it in younger and sympathetically revved up patients.

 

[Mman]

You only need about 2 min for that stuff to hit. I used to push it when I went to get the Pt., and by the time we had lines untangled and kisses to family, they were feeling it.

Yes, that's the minimum time. Our patients are premedicated well before leaving to go to the OR. Waiting until the last minute to give it adds no benefit and for anxious patients leaves them feeling anxious in preop for longer.

 

[proman]

Yes, that's the minimum time. Our patients are premedicated well before leaving to go to the OR. Waiting until the last minute to give it adds no benefit and for anxious patients leaves them feeling anxious in preop for longer.

I think it hits faster. I'd say about 1 min from bolus injection. When remidazolam comes out (the ultra short acting benzo) we'll probably find that more useful.

 

[narcusprince]

I stopped using it only for female anxious young patients. Def prolongs emergence. My wakeups are so much smoother without versed.

 

[slunk]

I recall that a bit of midazolam during a case can reduce the risk of nausea postop according to some meta-analysis. It was a while ago when I read this.

 

[Planktonmd]

I did not know that Midazolam was part of the "induction" of anesthesia!
I thought it was a premedication for anxiolysis.
The only people I saw giving Midazolam at induction were CRNA's for some CRNA specific indications.

 

[Arch Guillotti]

I did not know that Midazolam was part of the "induction" of anesthesia!
I thought it was a premedication for anxiolysis.
The only people I saw giving Midazolam at induction were CRNA's for some CRNA specific indications.

I agree with this. I think it is fine to give some to the average patient preoperatively. I think it is stupid to give it as part of the induction although a couple of nurses I work with like to do it. A couple of times I have seen the nurse give some midazolam after the induction. I think that if you are giving it
as a means of preventing recall then you are not doing something right.

 

[badasshairday]

Never seen it used for induction. Always just for premedication in holding areas just before we start to wheel the patient back.

 

[soorg]

I think it's useless to give it once you're in the OR.
It's almost pointless at that time, bc the pt's already freaking out
at that time. Definitely should be given in holding.

 

[Bertelman]

Yes, that's the minimum time. Our patients are premedicated well before leaving to go to the OR. Waiting until the last minute to give it adds no benefit and for anxious patients leaves them feeling anxious in preop for longer.

There is definitely a benefit to doing it prior to wheeling into the OR, even if it is just before you leave. Patients are anxious about the surgery, not pre-op holding. I would give it before their anxiety hit the critical peak as we rolled into the OR.

Depending on the logistics of your institution it is not always feasible to give it 30 min prior to OR time. Patients need to be consented, marked, etc. My policy is no benzo until all the paperwork is completed and confirmed. Sometimes that doesn't happen until minutes before we roll. In that case, I spend a couple extra minutes with the patient to reassure them. That's my anxiolysis.

And if a CRNA hands me a syringe of midaz in my stack of induction drugs, I throw it on the cart and tell them it's too late for that.

 

[proman]

I've had a patient who told me she had recall after a previous induction. It was legit recall too, so while I don't think it's a mandatory part of induction it can have utility as part of induction. I use my charming personality and witty discourse for anxiolysis preop

 

[lushmd]

I have essentially eliminated it from use for cardiac patients.

Why?

 

[periopdoc]

Rarely use it.

-pod

 

[jwk]

... but it decreases your MAC...

It does? How?

 

[MTGas2B]

I think it's the most overused drug in the OR. For anxious patients, it's great. Most don't need it and are better off without it.

Agreed. For some it seems so dogmatic. I try to get my residents to give it for a reason not as routine.


On the iPhone

 

[Sonny Crocket]

I know some people that use midazolam as a back up against awareness should it occur. I don't really use it most of the time, but if you are really concerned about awareness it might be something to consider.

 

[Oggg]

I stopped giving it in the outpatient center. Our super orthopod does a 15min knee arthroscopy and patients have no pain postop after he does he local injection. I give toradol, but no fent and no midaz. They need more PPF and more sevo for sure. Of course I give midaz for blocks.

 

[Bertelman]

Of course I give midaz for blocks.

I rarely do that, at least not for femorals (I give fentanyl). Pre-op nurses gasp at each other when I say no, probably mumble about me being some barbarian when I leave.

 

[oldguy55]

I did not know that Midazolam was part of the "induction" of anesthesia!
I thought it was a premedication for anxiolysis.
The only people I saw giving Midazolam at induction were CRNA's for some CRNA specific indications.

This.

It's an anxiolytic, not an induction drug. For many patients there is nothing terribly distressing about actually seeing the inside of an operating room.

I regularly have to tell the CRNAs not to give it ("to prevent awareness") after delivery during a stat, general anesthetic C-section. After propofol and several minutes of sevo you're concerned the patient might be awake?

I suspect some of them sneak it in anyway. Grrrr.

 

[sevoflurane]

If you haven't given 10mg of Versed + .2 Mac of Gas... at least try it sometime for the experience. Pretty darn smooth. Especially when you are gowned up putting in lines and have your hands tied up. A lot of old timers do their inductions that way in the cardiac room.

Not my preference, but I've done it enough not to hate it, and still do it from time to time.

100 mcgs of sufenta and 5 mg of midaz usually gets me through a cardiac case. I see nothing inherently wrong with that. Usually 2 of Vitamin V in preop, 1 more once they hit the OR table before starting the a-line and the last 2 right after going on.

 

[sevoflurane]

I agree that versed is overused.
2mg of versed can get in the way with quick cases (bladder biopsies, stent removals, ERCPs, Trigger fingers, perc pinnings, t&a's, etc, etc.).

 

[Planktonmd]

If you haven't given 10mg of Versed + .2 Mac of Gas... at least try it sometime for the experience. Pretty darn smooth. Especially when you are gowned up putting in lines and have your hands tied up. A lot of old timers do their inductions that way in the cardiac room.

Not my preference, but I've done it enough not to hate it, and still do it from time to time.

100 mcgs of sufenta and 5 mg of midaz usually gets me through a cardiac case. I see nothing inherently wrong with that. Usually 2 of Vitamin V in preop, 1 more once they hit the OR table before starting the a-line and the last 2 right after going on.

There is nothing wrong with Benzo or Benzo + Opiate induction if you are using the Benzo as an induction agent.
There is nothing wrong also with giving a Benzo as an anxiolytic BEFORE you take the patient to the OR or to facilitate a pre-op procedure.
But adding 2 mg of Midazolam to a potent induction agent like Propofol ( which is also an excellent amnestic) in the hopes of "preventing" awareness is a little silly and has nurse logic written all over it.

 

[sevoflurane]

Agreed.
Happy gobble gobble y'all.

 

[Arch Guillotti]

There is nothing wrong with Benzo or Benzo + Opiate induction if you are using the Benzo as an induction agent.
There is nothing wrong also with giving a Benzo as an anxiolytic BEFORE you take the patient to the OR or to facilitate a pre-op procedure.
But adding 2 mg of Midazolam to a potent induction agent like Propofol ( which is also an excellent amnestic) in the hopes of "preventing" awareness is a little silly and has nurse logic written all over it.

this

 

[gasp]

It does? How?

Of course it does. Anything you use to give you sedation will be decreasing your requirement for gas/narcs.. etc. Midazolam is no different.

Also there are many people saying Midazolam is not an induction agent but it can be if you chose to use it as one. Obviously 2mg is not going to induce an adult since the induction dose of Midazolam is 0.1mg/kg. I have never done it myself but it would do the trick if you had nothing else available. Waking up that pt is a different story though.

 

[RxBoy]

I stopped using midaz as part of my induction drugs about three years ago; patients seem to wake up a little faster, and are less groggy.

Use it for most cardiac patients
4-6 mg Versed
200-400 mcg fentanyl
8-10 mg vec
Bag with high MAC sevo

No prop
Tube
Smooth as can be.

 

[bostonblaz]

I use it for blocks and I use it for macs. 2 of v, 100 of fent, 4 of zofran and the rest of a 10cc syringe filled with propofol puts down most people under the age of 70 and then start the pump at 85 mcg/kg/min and everyone is happy.

 

[IveGotTwins]

Do those of you who use it for blocks use it when a patient has to be upright and somewhat cooperative? Paravertebral, spinal, epidural, etc.?

 

[proman]

Why?

I hate to say it but Sol is right. Seeing all my patients post op, the difference between midaz and no midaz is really alarming. The no midaz patients are much more alert and interactive. There are a few papers that support that too. The use of high dose fentanyl is antiquated, as is the use of high dose midazolam for cardiac surgery. It all predates the use of volatile anesthetic during CPB. High dose fentanyl was first used (like 100 mcg/kg) because they thought the volatile anesthetic was too much of a myocardial depressant. That was the sole anesthetic, no wonder cardiac surgery had a high rate of recall. Since we now know that volatiles aren't that bad for the heart, and have some protective effects, the opioid and benzo doses should be reduced. I rarely give more than 500 mcg of fentanyl for the case either. But, what do I know, I apparently think like a nurse

 

[jwk]

Of course it does. Anything you use to give you sedation will be decreasing your requirement for gas/narcs.. etc. Midazolam is no different.

Also there are many people saying Midazolam is not an induction agent but it can be if you chose to use it as one. Obviously 2mg is not going to induce an adult since the induction dose of Midazolam is 0.1mg/kg. I have never done it myself but it would do the trick if you had nothing else available. Waking up that pt is a different story though.

Midaz was released in the mid 80's, and was available in 5mg/cc 10 cc vials. We tried using it for inductions when it first became available. We quickly found out that the "recommended" induction dose of 0.5mg/kg was just a tad high. Waking up after getting a 35mg bolus of midaz was painful - to us.

 

[periopdoc]

JWK. Thanks for sharing things like this. I like hearing the unsanitized version of anesthetic history that you don't get in the books.

- pod

 

[IlDestriero]

We do PO midazolam for most of the kids. I would prefer more parent present inductions and a better wake up, but I'm in the minority. Sometimes I give some flumazenil if they're light weights and slow to wake in the ASC, or if they're having a bad case of emergence delirium. I've been doing that more and more.

 

[Deanmonster]

I use it occasionally in addition to propofol for burst suppression. Seems to help get over the edge.

 

[Sublimazing]

We use it IM to reduce the amount of ketamine in our darts

 

[G-Man82]

There is nothing wrong with Benzo or Benzo + Opiate induction if you are using the Benzo as an induction agent.
There is nothing wrong also with giving a Benzo as an anxiolytic BEFORE you take the patient to the OR or to facilitate a pre-op procedure.
But adding 2 mg of Midazolam to a potent induction agent like Propofol ( which is also an excellent amnestic) in the hopes of "preventing" awareness is a little silly and has nurse logic written all over it.

I was in an annoying bladderstim insertion case in an obese patient. Surgeon wanted the patient awake enough to answer questions when the stim was turned on, but the patient also had to be prone. And of course the surgeon wanted minimal motion. . Anyway, pt was obese, so my plan was to run a light propofol drip with 25 mcg boluses of fentanyl as needed just for comfort and some amnesia. I wanted to avoid Midaz completely in this obese OSA patient if I was already using prop and fentanyl. CRNA comes in to take over and questioned why I didn't use midaz. I said propofol already is a strong amnestic, so I don't need midaz. CRNA response: "Oh. I didn't know propofol was amnestic." Wait, what?

 

[pgg]

I was in an annoying bladderstim insertion case in an obese patient. Surgeon wanted the patient awake enough to answer questions when the stim was turned on, but the patient also had to be prone. And of course the surgeon wanted minimal motion. . Anyway, pt was obese, so my plan was to run a light propofol drip with 25 mcg boluses of fentanyl as needed just for comfort and some amnesia. I wanted to avoid Midaz completely in this obese OSA patient if I was already using prop and fentanyl. CRNA comes in to take over and questioned why I didn't use midaz. I said propofol already is a strong amnestic, so I don't need midaz. CRNA response: "Oh. I didn't know propofol was amnestic." Wait, what?

Fentanyl doesn't provide amnesia. If your propofol drip was light enough for the patient to answer questions, it probably wasn't providing amnesia, either.

A better answer to the CRNA might have been "amnesia isn't one of my goals for this case" ... 'cause you know she gave some midazolam as soon as you walked out the room.

 

[G-Man82]

I'd re-read my paragraph after posting and wanted to rephrase that sentence about the fentanyl and propofol with amnesia and comfort but it slipped my mind after I was called out to do an epidural on a G12 p9 at 5 cm who they for some reason had on a pitocin infusion. But that's another story. I had propofol running at 40 mcg/kg/min, which I was hoping would provide some degree of amnesia. I used the fentanyl boluses occasionally to supplement for patient comfort because their 50-50 mix of 0.5% bupivicaine and 1% lido wasn't doing the trick despite approaching toxic levels. Out of curiosity though, when I saw the pt later on (after my preop break) she responded to my question that she did not remember answering any questions. Maybe that much propofol was just enough? No midaz documented on the record.