training innovations buccal midazolam training slideshare

Buccal MidazolamJuly 2015

Tutor: Patrick Doyle

© Training Innovations Ltd 2015 Last updated: 21.07.15

LD ESN June 2009

Learning Outcomes

By the end of the session candidates will:• Be able to recognise prolonged and serial

seizures and respond appropriately• Be able to describe the appropriate conditions

required to participate in the administration of Buccal Midazolam

• Be able to demonstrate through simulation the procedure for administering Buccal Midazolam

© Training Innovations Ltd 2015

National Institute for Clinical Excellence(NICE)

• NICE recommends Buccal Midazolam as the first-line treatment in children, young people and adults with prolonged or repeated seizures in the community and

• Only used in those people who have had a previous episode of prolonged or serial convulsive seizures NICE (2012)


LD ESN June 2009

What is Midazolam?

• Is the pharmaceutical name for this drug, from a family of similar drugs called Benzodiazepines

• Other names and formulations for Midazolam include Hypnoval and most commonly Buccolam and Epistatus

• Buccolam comes in pre-filled syringes• Epistatus comes in a bottle with empty syringes• Midazolam is licensed as a sedative and is used in

hospitals and clinics before clinical procedures. • In the brain it acts as an effective anti epileptic© Training Innovations Ltd 2015

LD ESN June 2009

How was Midazolam developed for use?

• Used as a sedative since 1988• Used in epilepsy since 1997• Community use developed in paediatric services/

school age children• Gradual introduction in to adult learning disability• Now the most common form of rescue medication• Recommendations for use in NICE, included in most

formularies


Why do we use Midazolam?

• We know that early treatment for seizures is more effective preventing SE

• We may be preventing brain damage even death• We may be preventing other poor health (e.g

aspiration infection)• Prevents disruption, decreasing hospitalisation• Best outcomes for individual, family and carer


LD ESN June 2009

How Does Midazolam Work?

• Slowly dripped into nasal/buccal cavity• Absorbed through mucosal skin surfaces• Good blood supply to these areas• Travels via the heart and lungs to the brain• Dampens down seizure activity


LD ESN June 2009

Indications for use

• Midazolam is prescribed where the individual has a history of seizures which are prolonged/ serial , most commonly with people who also have LD

• Prolonged seizures are around 5 minutes for tonic clonic seizures. Serial seizures occur one after the other with no recovery between

LD ESN June 2009

Indications for Use contd.

• Midazolam is used as a rescue medication early on in the development of the seizure/s to try to prevent status epilepticus, improve outcome from seizure/s and quality of life

• Status Epilepticus is a continued state of seizure lasting for 30 minutes.


Care Plan

• Each individual should have an epilepsy care plan.• Care plans should include details of individual such as:• Type of epilepsy – if known• Types of seizure• Details of prescribed treatment• Details of who is responsible for monitoring /reviewing

epilepsy• Details of any known aura• Known triggers• Usual length of seizure• Mental state during recovery etc


Protocol

The Prescribing doctormust provide a clear protocol

for the use of rescue medication in prolonged or repeated (serial) convulsive seizures


This Protocol must include:-

• Details of service user (name, DOB, age, address)• Details of the prescribing doctor and start date.• When to give medication (i.e. when seizure is prolonged , 5

minutes or more, repeated/cluster)• The dose of medication prescribed and the route of

administration.• Time to allow for drug to take effect (e.g.6 –10 minutes)• Details of any second dose – when to give and time to allow

for drug to take effect.• Time allowed between doses and maximum dose in 24 hours• What to do if rescue medication is not effective


Protocol continued

• The protocol should be reviewed annually by the prescribing doctor.

• The protocol should be kept with the medication for the specific individual

• Consider copying / reducing / laminating the protocol to make it easier to take out with person.

• The protocol must be checked before each administration of Midazolam


Buccolam

• Does not require special storage – do not refrigerate or freeze

• Buccolam has a shelf life of 18 months (please check expiry date)

• Buccolam is to be administered into the buccal cavity

• Buccolam is prescribed off-license for over 18’s


Epistatus Midazolam Buccal Liquid

• 10mg (base) in 1ml sugar-free syrup• Indication• Treatment of prolonged or repeated (serial) seizures, which are

likely to progress to Status Epilepticus, by buccal administration• Presentation• Box (with instructions for use on one panel) containing:• 30ml amber glass bottle (large enough to hold firmly) with a

safety closure• 5ml of liquid (sufficient to deliver 4 x 1ml doses)• 4 x 1ml oral syringes (syringes without needles)• Patient information leaflet


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Epistatus Midazolam Buccal Liquid

Storage of the Pack

• Store the pack upright at 15-25°C.• The cap must be replaced immediately after use

otherwise the liquid will evaporate and some of the Midazolam will precipitate. (This will be exhibited as white particles in the liquid.)

• The pack must be discarded if the solution is not clear.

• The last 1ml of solution MUST NOT BE USED, the pack should be returned to the pharmacist.


LD ESN June 2009

Possible Adverse Effects

• Depression of respiratory effort• Restlessness• Severe drowsiness (possibly for several hours)• Memory loss• May irritate nasal passages or cause discomfort to

gums• Over use can cause dependence and be ineffective• Recovery rates vary

Contra-Indications & Precautions

• Hypersensitivity and acute narrow angle glaucoma.

• The safety of Midazolam in pregnancy has not been established.

• Dental Care• The solution has a pH of 5.0 – 5.5 which is

mildly acidic• (as acidic as vinegar), it is also sugar-free.


Buccal Midazolam: Following onset

• Note the time the seizure starts• Follow the individuals protocol to see how

long to wait before giving Midazolam• Decide to give Midazolam• Check Midazolam package to ensure:• Dose, expiry date, route, time interval, name

and correct medication


Buccal Midazolam: Drawing up

• Ensure syringe plunger is pushed all the way down syringe

• Insert syringe into bottle and tip whole bottle upside down

• Following the protocol draw the required amount of liquid into syringe and replace the cap on the bottle


• Point syringe to back of mouth on insertion then angle downwards into the buccal cavity

• Administer approximately half the dose buccal cavity on one side of the mouth.

• Then administer the residual liquid into the buccal cavity on the other side of the mouth.

• If that is not possible, then administer the whole dose to the buccal cavity on one side of the mouth

• Do not administer the dose below the tongue since the teeth may clamp shut and break the syringe in the mouth

Buccal Midazolam: Administration

The Buccal Cavity: between cheek and gums


Buccal Midazolam: Post Administration• Stay with the individual until the seizure has stopped• Note the time the seizure stops• Stay with the person until they have returned to usual

functioning• Be aware that individual may be at risk of respiratory depression,

so will need close observation for several hours.• Assist the person to dress or tidy themselves (remember: they

may have been incontinent) • Document the seizure in the notes or care plan, etc

Consideration must be given to:• Recording amount• Recording use• Recording outcome in the epilepsy care plan


Onset & Duration of Action

Onset of Action• Initial effects become apparent after

approximately five minutes. About 80% of seizures are terminated within ten minutes

Duration of Action• The patient may be drowsy for several hours

after administration and may be protected from recurring seizures for up to four hours


It is vital that Buccal Midazolam is administered according to the Guidelines because

prolonged convulsive epileptic seizures are potentially life threatening


Convulsive Status Epilepticus

• A continuous Tonic Clonic seizure or repeated Tonic Clonic seizures lasting 30 minutes

• This can be life threatening and requires medical attention


Non Convulsive Status Epilepticus

Any seizure can develop into status• Complex partial status relatively common in

Learning disability. • This condition can be difficult to diagnose,

consciousness is often impaired but not lost completely.

• Can continue for long periods. • Can adversely affect health in vulnerable people

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Ethical Issues

• Duty Of Care

• Consent

• Invasive

• Fear of Legal Action

“When Midazolam is prescribed there should be no unreasonable barriers to its use”

Joint Epilepsy Council for the UK and Ireland


• Any questions?• Please take some time to complete the course evaluation - Thank

you…• PowerPoint slides available at: www.slideshare.net/TInnovations

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