JULY 1989, VOL. 50, NO 1 AORN JOURNAL

Midazolam: Saint or Sinner?

n the past, many perioperative nurses watched I the administration of midazolam (Versed@) to a patient undergoing a prolonged endoscopic procedure with some degree of trepidation. Monitoring equipment included a manual blood pressure cuff and rarely an electrocardiogram (ECG). Occasionally, a nasal oxygen supply also was used. Today, an automatic blood pressure recorder, a respiratory monitor, an ECG, and oxymetry are used. These, along with appropriate lighting, allow a quick clinical assessment.

The role of the perioperative nurse in the use of midazolam varies. It may include administering the medication and monitoring the patient's vital signs. This is important because midazolam can lower the blood pressure, particularly in patients who are extremely apprehensive or agitated. Also, patients who have essential hypertension may experience hypotension after an intravenous (IV) injection of the medication. Without proper monitoring, a drop in blood pressure may go unnoticed. If such a decrease is severe, as it often is in the elderly, vasopressers and/or IV fluids may be indicated.

It was quite predictable that midazolam would replace diazepam (Valium@). Occasional patient resistance to sedation, even with high doses of diazepam; a relatively long half-life with prolonged drowsiness or stupor; and side effects such as confusion, frequent thrombophlebitis, and occasional respiratory depression precipitated the change.' Even though the two medications are structural siblings, their effects are quite different with respect to end-point and titration of drug. Midazolam limits recall and may provide sedation. Diazepam acts as a skeletal muscle relaxant, limits recall, and may provide sedation.

Intravenous midazolam has a shorter half-life (1.2 to 2 hours), which generally allows patients undergoing outpatient procedures to be released within two to three hours after surgery. Throm- bophlebitis is an infrequent occurrence, and

discomfort upon injection is minimal. Amnesia may occur in more than 80% of patients with dosages ranging from 30 to 60 mcglkg (approx- imately 2 to 4 mg)?

In this dosage range, however, the patient is cooperative, answers questions, and when left alone will sleep soundly. Doubling the dosage increases the amnesic quality very little, however, it increases respiratory depression. This effect is enhanced when midazolam is administered with narcotics or sedatives. If the desired result is to render the patient unconscious, midazolam may be inappropriate. This dosage also produces a degree of analgesia because of central nervous system depression, but this probably is not a rationale for using midazolam.

The reason for increased monitoring of the patient receiving midazolam and undergoing endoscopy is related to abuse of the drug as an anesthetic agent rather than as a relaxant and amnesic agent. Respiratory depression and death have occurred when midazolam was used in heavy doses or in elderly or physiologically compromised patients.3 An Ambu bag with oxygen source generally provides sufficient respiratory assistance. An anesthesia machine and readily available personnel may provide greater assurances in case they are needed.

The use of hypnotics and sedatives are the hallmarks of the philosophy of medical care during the last 50 to 60 years. The search for a drug that produces amnesia, analgesia, and sleep in one injection, pill, or suppository has been elusive. Every orifice has been used, every combination

J. Russell Eubanks, Jr, MD, i~ codirector of anesthesia services, Thomas Hospital, Fairhope, Ala, and associate clinical professor of anesthesia, University of South Alabama School of Medicine, Mobile. He earned his medical degree at the University of Arkansas, Little Rock.

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attempted with little consistent success. Benzodiazepines were introduced in 1933.4 The

first clinically used benzodiazepine was chlordi- azepoxide, which relaxed muscles and had a taming effect on a number of animal species. By the mid-l970s, more than 2,000 benzodiazepines had been synthesized and evaluated. These included muscle relaxants, anxiety-reducing agents, sedatives, and amnestics, and were used singularly or in combination.

Midazolam can be administered by physicians or nurses. It is used as an intravenous or intramuscular prernedication. Given intramuscu- larly, a 5 mg dose is common, but this method of administration is less predictable than IV administration. It also can be used as an induction agent in the operating room.

Endoscopies and closed reductions are accomp- lished easily with this medication. These proce- dures should be performed in the operating room or similar locations where personnel can provide for oxygenation, proper monitoring, and resuscitation.

The perioperative nurse must be careful when caring for patients receiving midazolam. Poor lighting, faulty equipment, or an attempt to hurry through the procedures may lead to disaster. All health care providers should appreciate medica- tions for their side effects as well as their effects. Midazolam is not the final answer, but it is the drug presently being used.

J. RUSSELL EUBANKS, JR, MD

Notes 1. F Soloman et al, “Sleeping pills, insomnia, and

medical practice,” The New England Journal of Medicine 300 (April 5, 1979) 803-808.

2. Physicians Desk Reference (Oradell, N J Medical Economics Co, Inc, 1982) 1752-1753.

3. B L Beattie, E M Sellers, “Psychoactive drug use in the elderly: The pharmacokinetics,” Psychosomatics

4. A Srnity, M D Rawlins, “Benzodiazepines,” British Medical Journal 2 (Aug 13, 1977) 447.

5. E Costa, P Greengard, Mechanism of Action of Bemodiazepines (New York City: Raven Press, 1975)

20 (July 1979) 474-479,

131-151.

Survey Shows Nursing Executives Have Clout A survey of nursing executives, who were initially surveyed in 1986, shows that they now manage a wide range of hospital services, partici- pate at the executive level, and are better edu- cated and paid, according to the March 10, 1989, issue of Modern Healthcare. The survey was conducted by the American Organization of Nurse Executives, Chicago, and Witt Associates, an executive search firm, Oak Brook, Ill.

The results show that nursing plays an impor- tant role in quality and profitability of patient care. To reflect their new status, nurses are receiving better salaries, bonuses, titles, and pre- requisites. Two thirds of the respondents have the title vice president. In hospitals with 250 or more beds, the top nurse executive receives nearly $68,000. The average annual nurse executive salary at hospitals with 150 to 250 beds is slightly more than $55,000.

The majority of nurse executives manage sev- eral patient care services such as ORs (75%), emergency services (68%), and ambulatory care (51%). Compared to the 1986 survey, these per- centages are lower. The study also shows that nurse executives are more involved with budgets and marketing. In 1988,72% said they had de- veloped cost-containment measures, 58% had developed new programs, and 21% had become involved in product line management.

The number of respondents to the survey was 471, or 31%.

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