Children and elderly individuals or those with a history of alcohol abuse and individuals with a history of aggressive behavior or anger are at increased risk of paradoxical effects.
After nighttime administration of midazolam, residual 'hangover' effects, such as sleepiness and impaired psychomotor and cognitive functions, may persist into the next day.
Intravenous midazolam is indicated for procedural sedation (often in combination with an opioid, such as fentanyl), for preoperative sedation, for the induction of general anesthesia, and for sedation of people who are ventilated in critical care units.
It is the most popular benzodiazepine in the intensive care unit (ICU) because of its short elimination half-life, combined with its water solubility and its suitability for continuous infusion.
Bolus injections should be avoided due to the increased risk of cardiovascular depression, as well as neurological complications.
Oral midazolam is indicated for the short-term treatment of moderately severe insomnia in people who have not reacted adequately to other hypnotics, and who have persistent trouble in falling asleep.
Paradoxical behavior is often not recalled by the patient due to the amnesia-producing properties of the drug.
Midazolam infusions may induce tolerance and a withdrawal syndrome in a matter of days.In the final stages of end-of-life care, midazolam is routinely used at low doses via subcutaneous injection to help with agitation, myoclonus, restlessness or anxiety in the last hours or days of life.At higher doses during the last weeks of life, midazolam is considered a first line agent in palliative continuous deep sedation therapy when it is necessary to alleviate intolerable suffering not responsive to other treatments, Paradoxical excitement occasionally occurs with benzodiazepines, including a worsening of seizures.Withdrawal symptoms can sometimes resemble a person’s underlying condition.Gradual reduction of midazolam after regular use can minimise withdrawal and rebound effects.