Midazolam: pro or con

Midazolam is a near default drug when it comes to Australian anaesthesia, even for brief procedures with propofol. A survey by Padmanabahn and Leslie (Anaesthesia & Intensive Care, May 2008) reported that 75% of respondents use midazolam with propofol, and usually with fentanyl.

But for brief procedures like endoscopy, local anaesthetic surgery, oocyte retrieval, and curetttage it seems there is usually no value in using midazolam in the induction of sedation/anaesthesia, and indeed it only slows the time to full recovery. The endoscopy literature has a lot of comparisons between propofol and midazolam which demonstrate this, and that will not surprise most. Seifert and others (Aliment Pharmacol Ther 2000; 14: 1207±1214.) looked at the use of midazolam with propofol versus propofol alone for ERCP. A mean of 2.9 mg midazolam was used when it was used, and the recovery to clear conversation those patients was 6 minutes longer and the PARS was better in the propofol alone group even at 30 min. There were no differences in recall or the tolerating the ERCP.

Although a difference of minutes may not seem much from the perspective of the individual patients care, these types of cases are often clustered in sizeable groups which can place quite a demand on a facility and its staff. Even if midazolam only contributed an average of an extra 20 minutes for patients to walk out the door it means that a busy facility that deals with, say, 15 of these cases has 300 extra patient-minutes on the recovery trolleys and chairs, but with no measureable intraoperative benefit. The ampoule of midazolam can be quite expensive.