Intranasal midazolam delivery procedure
Basic Intranasal Midazolam
Delivery Materials:
1. Syringe and needle/needleless device to
draw up the medication
2. Atomizer
3. Midazolam of appropriate concentration for
nasal medication delivery
 High concentration - Low volume
 5 mg/ml generic midazolam or
 Compounded in pharmacy to 25
mg/ml (revise all dose volume
calculations
Procedure:
1. Aspirate the proper volume of midazolam
required to treat the patient (0.2 to 0.3 mg/kg
for seizures, 0.5 mg/kg for sedation) – (an
extra 0.1 ml of medication should be drawn
up to account for the dead space within the
atomizer at the end of the procedure.)
2. Twist off/remove the syringe from the
needle/needleless device
3. Attach the atomizer tip via Luer lock
mechanism – it twists into place.
 Slip Luer is also effective as long as the
tip is firmly seated on the syringe tip and
you hold it against the patients nose
while delivering
4. Using your free hand to hold the crown of
the head stable, place the tip of the atomizer
snugly against the nostril aiming slightly up
and outward (towards the top of the ear on
the same side- this photo in error).
5. Briskly compress the syringe plunger to
deliver half of the medication into the
nostril.
6. Move the device over to the opposite nostril
and administer the remaining medication
into that nostril.
Intranasal medications and doses based on published literature
Clinical Scenario
Intranasal Medication and
Important reminders
dose
Pain control
Sufentanil 0.5 to 0.7 ug/kg
 Always monitor for respiratory depression
Fentanyl 2.0 ug/kg
 Use lower sufentanil dose in elderly
 Only use a device that can very accurately deliver an exact
Diamorphine 0.1 mg/kg (in
U.K.)
Ketamine 0.5 to 1 mg/kg
Sedation
dose of medication.
 Titration is possible every 15 minutes, consider oral
medications at 15-20 minutes to kick in as I.N. wears off
Midazolam 0.5 mg/kg
 Always monitor for respiratory depression
Sufentanil 1.0 to 1.5 ug/kg
 Combination therapy probably more effective than single
drug therapy but greater respiratory risk so use less of each.
Seizures
Fentanyl 1.5 to 3.0 ug/kg
 Titration is possible
Ketamine 10 mg/kg
 Midazolam burns for 30 seconds and is only minor sedation
Dexmedetomidine 2-3 ug/kg
 Dexmed does not burn, onset is 20 min, lasts > 1 hour
Midazolam 0.2 to 0.3 mg/kg
 ALWAYS use the concentrated form of midazolam: 5 mg/ml
(use 10 mg in teenagers and
 Deliver immediately to allow absorption to occur while you
adults)
Opiate overdose
Naloxone 2 mg (2 ml)
support airway
 ALWAYS use the concentrated form of naloxone: 1 mg/ml
 Deliver immediately to allow absorption to occur while you
support airway.
Epistaxis
Oxymetazoline 1.0 – 2.0 ml
to affected nostril
 Blow nose to remove all clots from nostril prior to delivery of
the medication.
(Add lidocaine 4% if
 Spray 1-2 ml of medication up effected nostril(s)
cautery to be done)
 Soak a cotton swab with oxymetazoline and insert into nose
 Pinch nose for 5-10 minutes then re-examine and cauterize,
repeat or use thrombin if necessary
 Send patient home with oxymetazoline bottle to use TID
Nasal procedures
Lidocaine 4% (plus
 Spray both the nose (1.5 ml) and the throat (3.0 ml).
(NG tube, Fiberoptics,
oxymetazoline in nose)
 Wait 3 minutes for full anesthetic effect before doing the
NP airway, Nasal
intubation)
procedure. Repeat half dose if necessary.
General Comments:

Prior to using a nasal medication, inspect the nostril for significant amounts of blood or mucous discharge. Presence of
these will limit medication absorption. Suctioning the nasal passage prior to delivery and/or alternated delivery options
should be considered.

Always deliver half the medication dose up each nostril. This doubles the available mucosal surface area (over a single
nostril) for drug absorption and increases rate and amount of absorption.

Always use the MOST concentrated form of the medication available – dilute forms are less effective (example – use
midazolam 5 mg per ml, not 1 mg per ml). If you have a compounding pharmacy and can get the concentrations such
that the nasal volumes are 0.2 to 0.3 ml per nostril this would be ideal and may require slightly lower dosing.

Do not use more than ½ to 1 ml of medication per nostril (0.2 to 0.3 is the ideal volume). If a higher volume is
required, apply it in two separate doses allowing a few minutes for the former dose to absorb.

For small volume doses of medication, be aware that most delivery devices have a “dead space” in the applicator tip
where some of the medication will remain. Be sure to take that dead space into account when calculating the volume
of medication to be administered.

Titration to effect is probably possible for selected situations where time is not critical. If inadequate clinical effect is
present after 5 to 15 minutes, re-administering a second dose may be effective.

Midazolam burns for 30-45 seconds – forewarn the parents that the child will initially cry (but nothing like they will
cry with a shot). It also only causes mild sedation/anxiolysis and lasts about 30 minutes

Dexmedetomidine sedation is deeper than midazolam, has slower onset (20 min) and longer sedation

Sufentanil is extremely potent. Monitoring with pulse oximetry is imperative.

Both fentanyl and sufentanil pain control effects begin wear off at about 45 minutes to an hour. It is nice to the patient
to give them an oral drug at about 15-20 minutes since this will then kick in about the time the nasal drug is wearing
off. Another option is simply repeating the nasal drug.
Therapeutic
Intranasal Drug Delivery
Needleless treatment options for medical problems
Intranasal sedation protocol:
General points:
 Midazolam, ketamine, dexmedetomidine and sufentanil are the most commonly used
sedative medications for IN delivery.
o Midazolam results in mild somnolence with resultant reduction in anxiety and
probably amnesia. It will not make the patient unconscious.
o Be aware that midazolam causes some nasal burning for 30-45 seconds
when administered.
o In small children you should administer lidocaine 2% or 4% - 0.2 ml per
nostril 5 minutes prior to the midazolam to stop the burning.
o Sufentanil will also cause deeper sedation and in doses over 1.5 mcg/kg has been
noted to cause respiratory depression.
o Dexmedetomidine takes longer to take effect (20 minutes) and lasts longest of all
(over 1 hour).
 Combination therapy with midazolam plus either sufentanil or ketamine may work better
than any of the medications alone
 Newer data discussed above suggests that IN dexmedetomidine may be the best option
for sedation if more than just mild sedation is needed and prolonged affect is required
(also slower onset of action).
 Reasonable IN starting dose:
o Midazolam 0.4 to 0.5 mg/kg
 Use the lower dose for minor, non-painful procedures such as radiographic
imaging
 Use the higher dose for better sedation prior to procedures such as
laceration repair
o Ketamine 10 mg/kg
o Sufentanil 1 to 1.5 mcg/kg (this is a higher dose than required for pain control
and increases the risk for respiratory depression)
o Dexmedetomidine 2-3 mcg/kg
o Combined dosing:
 Midazolam plus sufentanil: 0.2 to 0.3 mg/kg of midazolam plus 0.75 to 1
mcg/kg of sufentanil




 Midazolam plus ketamine: 0.2 to 0.3 mg/kg of midazolam plus 5 mg/kg of
ketamine
Use only concentrated midazolam (5 mg/ml) and ketamine formulations
Be sure to monitor oxygen saturation in all patients
Ideal volume is 0.3 to 0.5 ml per nostril, maximum is 1 ml per nostril, more will just run
out nose.
Nasal naloxone and flumazenil can be used as reversal agents
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