Conscious Sedation

Question 1

What is the preparation for flumazenil

Answer 1

5 mL ampule, 100 mg/mL

Question 2

For flumazenil what is the dose given by intravenous injection.

Answer 2

200 µg over 15 seconds then 100 µg at 62 second intervals

Question 3

State the class/family of drugs to which the most commonly used intravenous sedation agent belongs.

Answer 3

Benzodiazepines

Question 4

Is midozalam a trade or generic name?

Answer 4

Trade

Question 5

What other name is Midozalam known by?

Answer 5

Hypnoval

Question 6

For answer above, is this name a trade or generic one?

Answer 6

Generic

Question 7

In what year was Midozalam available in the United Kingdom?

Answer 7

1983

Question 8

State the half life of midozalam.

Answer 8

1 to 4 hours. Approximately 5 mg of drugs will be eliminated from the body within five hours.

Question 9

What schedule of controlled drug is Midozalam classified as?

Answer 9

Schedule III controlled substance.

Question 10

Midozalam is available in what presentations?

Answer 10

Clear liquid: 10 mg in 5ml
10 mg in 2ml
5 mg in 5ml

Question 11

From the presentations that Midozalam are available in, which one should be used for best practice?

Answer 11

5 mg in 5 mls.

Question 12

What does the blue dot stamped on the ampoule represent?

Answer 12

It signifies a place that should be held for ease of opening.

Question 13

What colour is Midozalam?

Answer 13

Clear liquid.

Question 14

How should Midozalam be stored when not in use?

Answer 14

In a controlled drug cabinet, which is locked, made of metal and fixed to the wall. When required it should be signed in and out of the drug cabinet and by two members of staff who have authorisation to do so. An inventory/record of stock must be kept with documentation being held for two years.

Question 15

What are the routes of administration for Midozalam?

Answer 15

Intravenously, per-nasal and buccally (transmucosal)

Question 16

What is the pH of midozalam?

Answer 16

PH of 3.4.

Question 17

State five advantages of providing a patient with intravenous sedation using Midozalam.

Answer 17

Anxyolitic, hypnotic, anticonvulsant, muscle relaxant and anterograde amnesia. They produce sedation. It has a rapid onset with a pronounced effect and is short acting. It can be titrated to produce a desired effect to reflect individual patients needs and are water soluble. As a patient’s vein is continually maintained, drugs can be provided in the event of an emergency or the patient becomes over sedated. Patient recovery time is quicker than oral or intramuscular drugs. Nausea and vomiting rarely occur. It reduces the gag reflex slightly.

Question 18

State five disadvantages of providing a patient with intravenous sedation using midozalam.

Answer 18

Venepuncture is Mandatory. Training is necessary to undertake venepuncture and it requires great skill. Venepuncture sites can cause problems. A sedation nurse must be available at all times. Midozalam can cause respiratory depression and minimal cardiovascular depression. Due to the rapid onset of midozalam, its actions and it’s more pronounced affects, the risk of potential complications is elevated. No analgesia is provided. Elderly and paediatric patients occasionally experience paradoxical affects. Appointment times must be longer to allow for patient’s recovery period. Consent must be taken, with patients complying with rigid pre and post-operative instructions.

Question 19

If a patient had an allergic reaction to Midozalam, how would the reaction be managed?

Answer 19

The administration of the midozalam would be stopped, the patient’s airway maintained, oxygen provided and adrenaline administered. As the patient will have an indwelling cannula, the intravenous concentration of adrenaline can be provided, which is 0.5 mL 1:10,000. However, not all healthcare settings will have adrenaline in that concentration therefore 0.5 mL 1:1000 intramuscular adrenaline will be provided. Alternatively an EpiPen can be used.

Question 20

What information can be found stamped on an ampoule of midozalam?

Answer 20

Drug name, concentration, batch number and expiry date.

Question 21

What is the recommended titration of Midozalam to a patient who is deemed an American Society of Aneastheologists medical fitness classification 1 (ASA1).

Answer 21

Initial bolus 2 mg over 30s. Observe patient response for two minutes. After two minutes a further 0.5-1 mg is administered until the level of sedation required has been achieved. The usual dose is between 2.5 and 7.5 mg.

Question 22

How is the amount of midozalam administered to a patient calculated.

Answer 22

It is based on their age.

Question 23

What is the recommended titration of midozalam for an elderly patient?

Answer 23

Initial bolus to be as low as 1 to 1.5 mg. The total amount may not need to exceed 3.5 mg. It is important to observe an elderly patient for longer after the first bolus before administering any more midozalam to avoid over sedation

Question 24

Why are the titrations of midozalam less and periods of observation longer for an elderly patient?

Answer 24

Elderly patients are more sensitive to Midozalam as the arm brain time is much slower than that of a younger patient. This means if Midozalam was titrated in the same way, an elderly patient would be more likely to become over-sedated. This is because it takes longer for the initial bonus to reach the brain.

Question 25

What is the appropriate onset of action time for midazolam?

Answer 25

1 to 3 minutes.

Question 26

Side effects of Midazolam

Answer 26

Minimal cardiovascular effects
Respiratory effects
Hiccoughs
Coughing
Headaches
Drowsiness
Nausea and vomiting
Loss of inhibitions 
Restlessness
Irritation at cannula site (however midozalam is water soluble and it is not common for the patient to experience any irritation)

Question 27

Name some special precautions and some contra indications of the use of Midozalam

Answer 27

Pregnancy and the nursing mother
Liver or kidney impairment
The elderly
Children
Allergy to benzodiazepines 
Alcohol and drug abuse
Cardiorespiratory disorders
Analgesics and Midazolam 
Erythromycin
Saint Johns wort

Question 28

What is another name for propofol?

Answer 28

Diprivan

Question 29

What is another name for diazepam

Answer 29

Valium