Podcast: Play in new window | Download

Subscribe: Apple Podcasts | RSS

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So, a couple of days ago I made a video about, “My mom is not waking up after propofol in ICU, Help!”. And today, I’ve got a question from another reader who says, “My dad is not waking up after midazolam or Versed in ICU, help!”.

So, as I explained a couple of days ago in the other video, propofol is a short-term acting sedative, and midazolam is a long-term acting sedative. Midazolam is also known as Versed. So, when midazolam is being used to patients, depending on how much midazolam they had and for how long they’ve been on midazolam or Versed, they may not wake up quickly. So, sometimes midazolam may be off for a few days and patients may not wake up.

Now this also depends on whether patients had opiates such as morphine or fentanyl. And again, it depends how much they’ve had it. Sometimes patients might be in an induced coma, that’s just an example, after a traumatic brain injury, especially when patients have potential seizures or high intracranial pressures also known as ICP.

They may need lots of midazolam or Versed and lots of morphine or fentanyl. And then hopefully after they get over the high ICPs and the traumatic brain injury slowly and they’re woken up. They may not wake up for a number of days because again, midazolam or Versed is long-acting, and the half-life of midazolam is so much longer compared to propofol. When you switch off propofol, patients most of the time wake up pretty quickly.

So therefore, (A), you need to be patient. (B), you need to find out how much midazolam did your loved one have, because that can be a lot sometimes, and a lot means like 5 to 10 milligrams an hour, potentially, sometimes more. Again, depending on what condition they’re having the Midazolam for, seizure management, traumatic brain injury, just to name a few, where high doses can be used.

Now, also if your loved one is on midazolam or Versed, unlike propofol, it is addictive in nature because it’s a benzodiazepine and if you’re having that combination of midazolam/Versed with morphine or fentanyl as opiates, for an induced coma, and keep in mind, morphine or fentanyl are also addictive in nature, patient might go through withdrawal waking up, and you have to wean midazolam or Versed very slowly, half it every day, for example, so that the patient does not go through withdrawal and the same is applicable for high doses of morphine and fentanyl. Ideally, you wean it down slowly rather than just switching it off so patient doesn’t go cold turkey, really.

So, what if your loved one isn’t waking up after a few days off midazolam and morphine or fentanyl? Well, number of things are similar to propofol. So, if your loved one is in liver failure or in kidney failure, it may simply take more time for the midazolam to be metabolized or excreted from the kidneys. So that could be one reason.

Another reason could be your loved one not waking up is that, God forbid, your loved one may have had a neurological event, i.e. your loved one may have had a stroke, some seizures, and that needs to be ruled out, i.e. if someone in intensive care, after an induced coma, is not waking up for unknown reasons, a CT scan of the brain should be done so that a neurological event can be ruled out.

So, what should happen then if your loved one is going through withdrawal, for example, from midazolam or from morphine or fentanyl? Well, what should be done? As I said, the reduction in doses should be by 50%. If someone is on 10 milligrams an hour of midazolam, maybe the next day it can be reduced to five milligrams an hour and then the next day to 2.5 milligrams an hour and so forth. So that the weaning is gradual.

Now, if withdrawal is real then that needs to be managed. Often what I’ve seen is it can be managed with clonidine or sometimes with Precedex as well to manage the withdrawal because if someone is withdrawing, they might also get confused. And it’s not good if someone is confused in intensive care, especially if you want to wean them off a ventilator because they’ve got to be coherent and cooperative.

So that is my quick tip for today.

I hope that makes sense. If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected].

Also, have a look at our membership for families in intensive care at intensivecaresupport.org . There you have access to me and my team 24-hours a day, and we answer all questions intensive care related in a membership area and via email.

If you want a medical record review, please contact us as well. We review medical records for our clients while they are in ICU in real time or also after ICU, but we recommend for you to have us look at medical records in real time so we can interpret clinical data for you in real time and so that you can understand what’s really happening.

Now, subscribe to my YouTube channel, share the video with your friends and families. Click the like button, click the notification bell and comment below what you want to see next, or what questions and insights you have from this video or what you want to see next.

Thanks for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I’ll talk to you in a few days.

Take care.