Intranasal Midazolam Falls Short in Pediatric ED Procedures

TOPLINE:

Nearly half of the children receiving intranasal midazolam for laceration repair in the emergency department (ED) exhibited extreme procedural anxiety. Younger age, reduced sociability, and extremity lacerations were significantly associated with a poor response to the medication.

METHODOLOGY:

• A cross-sectional study evaluated 102 children (mean age, 4.7 years; 40% girls; 85.3% with facial lacerations) who received intranasal midazolam prior to undergoing laceration repair in the ED.
• Registered nurses administered midazolam (5 mg/mL) at 0.2 mg/kg, up to a total dose of 6 mg, using an intranasal mucosal atomization device.
• Procedural anxiety was assessed using the modified Yale Preoperative Anxiety Scale; scores ≥ 72.91 indicated extreme anxiety, and these patients were identified as intranasal midazolam nonresponders.

TAKEAWAY:

• Overall, 45.1% of children showed extreme procedural anxiety and were identified as intranasal midazolam nonresponders.
• Age, temperament, laceration location, and the interval between midazolam administration and procedure initiation were significantly associated with midazolam response.
• Younger age (odds ratio [OR], 0.79; P = .034) and extremity lacerations (OR, 8.04; P = .009) were associated with an increased likelihood of nonresponse, whereas a more sociable temperament (OR, 0.28; P = .002) was associated with a decreased likelihood of nonresponse.

IN PRACTICE:

“Study results highlight the variability in children’s anxiety response to intranasal midazolam during laceration repair in the ED. The high rate of nonresponse to intranasal midazolam has important implications for clinical practice. Current findings suggest that factors such as child age and temperament play a significant role in intranasal midazolam effectiveness, underscoring the need for tailored, multimodal strategies,” the authors wrote.

SOURCE:

The study was led by Sarah R. Martin, PhD, Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine. It was published online on February 3, 2025, in Academic Emergency Medicine.

LIMITATIONS:

The cross-sectional design limited causal inferences about the effectiveness of intranasal midazolam. The study utilized a lower dose, which may have contributed to nonresponse and could limit generalizability. Provider discretion in administering intranasal midazolam may have introduced selection bias, potentially affecting response rates. The sample was limited to children aged 2-12 years, excluding those admitted as inpatients, which may have limited generalizability to younger children or those with more severe injuries.

DISCLOSURES:

This study received funding from the National Institute of Child Health and Human Development. Two authors reported receiving support from the National Institutes of Health. One author reported serving as a consultant for Edwards Lifesciences and Mend and being the president of the American College of Perioperative Medicine.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.